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MULTI MODALITY INTERVENTION INFECTION CONTROL (MIMIC) ON KNOWLEDGE AND PRACTICE AMONG

CRITICAL CARE NURSING STAFF IN HOSPITAL USM

AHMAD TAWFIQ S. SABBAH

UNIVERSITI SAINS MALAYSIA

2021

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MULTI MODALITY INTERVENTION INFECTION CONTROL (MIMIC) ON KNOWLEDGE AND PRACTICE AMONG

CRITICAL CARE NURSING STAFF IN HOSPITAL USM

by

AHMAD TAWFIQ S. SABBAH

Thesis submitted in fulfilment of the requirement for the degree of

Doctor of Philosophy

October 2021

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ACKNOWLEDGEMENT

In the name of ALLAH, the Most Gracious and the Most Merciful

All praises to ALLAH for the completion of my PhD thesis. I thank ALLAH for all the blessing, patience and strength that have been showered on me throughout my study. I would like to honestly thank my supervisors, as I was fortunate to have two supervisors, Dr. Rohani Ismail, who have taken over the supervision duties after the retirement of Assoc. Prof. Dr. Rehanah Mohd. Zain, for their support, understanding, patience, the contribution of their time throughout the research and for providing constructive motivation to complete this thesis. Thanks extended to my co- supervisors, Assoc. Prof. Dr. Siti Suraiya Md Noor, and Assoc. Prof. Dr. Mahaneem Binti Mohamed, and co-researcher Ms. Norazliah Hj. Samsudin, for their helpful advice, valuable comments and suggestions. My deepest gratitude goes to all my family members for their encouragement, support and supplications. I would like to express my special gratitude and thanks to my beloved wife and my lovely kids who have been standing by me through all my moments of happiness and sadness, my fits of pique and impatience. I would like to extend my thanks to the Dean, Admin Staff, and graphic designers at the School of Health Sciences and School of Medical Sciences, Universiti Sains Malaysia. I would also like to express my gratitude to the Director of the Hospital USM and to the staff of the Hospital Infections and Epidemiology Control Unit and Nursing Department, and to all the sisters and staff nurses in the Hospital USM who have participated in the study. My sincere thanks to the RUI grant, USM, for granting me financial support to carry out my study (RUI grant No.: 1001.PPSK.8012373). May ALLAH shower the above cited personalities with blessings and prosperity in their lives.

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TABLE OF CONTENTS

ACKNOWLEDGEMENT ... ii

TABLE OF CONTENTS ... iii

LIST OF TABLES ... xiv

LIST OF FIGURES ... xvii

LIST OF SYMBOLS ... xix

LIST OF ABBREVIATIONS ... xx

LIST OF APPENDICES ... xxiv

ABSTRAK ... xxv

ABSTRACT ... xxvii

CHAPTER 1 INTRODUCTION ... 1

1.1 Background of the Study ... 1

1.2 Types of Healthcare-Associated Infections (HAIs) ... 2

1.2.1 Ventilator-Associated Pneumonia (VAP) ... 2

1.2.2 Central Line-Associated Bloodstream Infection (CLABSI) ... 2

1.2.3 Catheter-Associated Urinary Tract Infections (CAUTI) ... 3

1.2.4 Surgical Site Infections (SSI) ... 3

1.3 Problem Statement ... 7

1.4 Study Area ... 9

1.5 The Rationale of the Study ... 10

1.6 Significance of the Study ... 12

1.6.1 Infection Control Education Program (ICEP) ... 12

1.6.2 Infection Control Monitoring System (ICMS)... 13

1.6.3 Infection Control Supportive Environment (ICSE) ... 13

1.6.4 Evidence-based and Theory-based MIMIC module ... 14

1.7 Objectives ... 14

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1.7.1 The General Objective ... 14

1.7.2 The Specific Objectives ... 14

1.7.2(a) Phase I- Retrospective Study ... 15

1.7.2(b) Phase II- MIMIC Module ... 15

1.7.2(c) Phase III – Interventional Study ... 15

1.8 Research Questions ... 15

1.8.1 Phase I- Retrospective Study ... 15

1.8.2 Phase II- MIMIC Module ... 16

1.8.3 Phase III – Interventional Study ... 16

1.9 Research Hypotheses ... 16

1.10 Operational Definitions ... 17

1.10.1 Intensive Care Unit ... 17

1.10.2 Critical Care Nursing ... 17

1.10.3 Healthcare-Associated Infections ... 17

1.10.4 Prevalence of HAI ... 17

CHAPTER 2 LITERATURE REVIEW ... 18

2.1 Introduction ... 18

2.2 Intensive Care Unit ... 18

2.2.1 Critical Care Nurse... 19

2.3 Healthcare-Associated Infections (HAIs) ... 20

2.3.1 Definition of Healthcare-Associated Infections ... 20

2.3.2 Types of Healthcare-Associated Infections ... 21

2.3.2(a) Catheter-Associated Urinary Tract Infections (CAUTI)... 21

2.3.2(b) Central Line-Associated Bloodstream Infections (CLABSI) ... 22

2.3.2(c) Ventilator-Associated Pneumonia (VAP) ... 24

2.3.2(d) Surgical Site Infection (SSI) ... 26

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2.4 Epidemiology of Healthcare-Associated Infections... 28

2.4.1 Impacts of HAIs ... 29

2.4.1(a) Development of MDROs ... 29

2.4.1(b) Mortality ... 30

2.4.1(c) Length of Stay (LOS) ... 30

2.4.1(d) Economic Burden... 31

2.5 Infection Prevention and Control ... 31

2.5.1 Core Components of Infection Prevention and Control... 31

2.5.1(a) Organization of IPC Programs ... 32

2.5.1(b) Technical Guidelines ... 32

2.5.1(c) Human Resources... 32

2.5.1(d) Surveillance of Infections and Assessment of Compliance with IPC Practices ... 32

2.5.1(e) Microbiology Laboratory ... 32

2.5.1(f) Environment ... 32

2.5.1(g) Monitor and Evaluation of Programs ... 32

2.5.1(h) Links with Public Health or other Services ... 33

2.5.2 Infection Prevention and Control Precautions ... 33

2.5.2(a) Infection Prevention and Control Standard Precautions ... 33

2.5.2(b) Infection Prevention and Control Transmission-Based Precautions ... 33

2.5.3 Barriers Toward Compliance with Infection Prevention and Control Practices ... 33

2.5.4 Risk Factors of Healthcare-Associated Infections ... 34

2.5.4(a) Knowledge and Awareness ... 34

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2.5.4(b) Environment ... 36

2.5.4(c) Intensive Care Unit ... 37

2.5.5 Prevention of Healthcare-Associated Infections ... 37

2.5.5(a) A call for Preventive Interventions ... 38

2.5.5(b) Healthcare-Associated Infections Preventive Interventions- Review ... 39

2.6 Intervention Mapping (IM) Protocol ... 51

2.7 Health Behavior Change theories... 52

2.7.1 Health Belief Model (HBM) ... 52

2.7.2 Theory of Planned Behavior (TPB) ... 53

2.7.3 Social Cognitive Theory (SCT) ... 53

2.8 Fuzzy Delphi Method ... 55

2.9 Nurses’ Knowledge and Practice Regarding HAIs Control Measures ... 56

2.9.1 Effect of implemented interventions on knowledge and practice ... 57

2.10 Conceptual Framework of the Study... 58

2.11 Summary ... 63

CHAPTER 3 MATERIALS AND METHOD ... 64

3.1 Introduction ... 64

3.2 Ethical Approval ... 64

3.3 Study-Phase I: Assessment Phase ... 66

3.3.1 Identifying HAIs Prevalence ... 66

3.3.1(a) Study Design ... 66

3.3.1(b) Population and Sample ... 67

3.3.1(b)(i) Target Population ... 67

3.3.1(b)(ii) Sampling Frame ... 67

3.3.1(b)(iii) Source Population ... 67

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3.3.1(c) Subject Criteria... 67

3.3.1(c)(i) Inclusion Criteria ... 67

3.3.1(c)(ii) Exclusion Criteria ... 68

3.3.1(d) Sample Size Determinations ... 68

3.3.1(e) Sampling Method ... 68

3.3.1(f) Variables ... 68

3.3.1(g) Research Tools ... 68

3.3.1(h) Data Collection Procedure ... 69

3.3.1(i) Statistical Analysis ... 69

3.3.2 Assessment of Infection Control System ... 71

3.3.2(a) Study Design ... 71

3.3.2(b) Population and Sample ... 71

3.3.2(c) Sample Size Determination ... 71

3.3.2(d) Sampling Method ... 72

3.3.2(e) Variables ... 72

3.3.2(f) Research Tools ... 72

3.3.2(g) Data Collection Procedure ... 73

3.3.2(h) Statistical Analysis ... 79

3.3.3 Flowchart of Study-Phase I ... 80

3.4 Study-Phase II: Developing and Validating of MIMIC Module ... 81

3.4.1 Developing MIMIC Module ... 81

3.4.1(a) Intervention Mapping (IM) Protocol ... 82

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3.4.1(a)(i) Step 1: Needs Assessment ... 83

3.4.1(a)(ii) Step 2: Setting of Objectives ... 85

3.4.1(a)(iii) Step 3: Program Design ... 90

3.4.1(a)(iv) Step 4: Program Development ... 92

3.4.1(a)(v) Step 5: Program Implementation ... 92

3.4.1(a)(vi) Step 6: Evaluation Plan ... 95

3.4.2 Validating MIMIC Module ... 97

3.4.2(a) Fuzzy Delphi Method (FDM)- Content Validity ... 97

3.4.2(a)(i) Step 1: Selection of Experts ... 98

3.4.2(a)(ii) Step 2: An Expert Questionnaire ... 99

3.4.2(a)(iii) Step 3: Dissemination of the MIMIC Module and the Validation Forms ... 101

3.4.2(a)(iv) Step 4: Conversion of Likert Scale to Fuzzy Scale ... 103

3.4.2(a)(v) Step 5: Threshold Value (d) ... 104

3.4.2(a)(vi) Step 6: Percentage Value of the Experts’ Agreement ... 105

3.4.2(a)(vii) Step 7: Defuzzification Process ... 106

3.4.2(b) Statistical Analysis ... 106

3.4.2(c) Flowchart of Study-Phase II... 108

3.5 Study-Phase III: Intervention Phase ... 109

3.5.1 Pilot Study-Internal Consistency Reliability... 109

3.5.1(a) Study Design ... 109

3.5.1(b) Population and Sample ... 110

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3.5.1(b)(i) Target Population ... 110

3.5.1(b)(ii) Sampling Frame ... 110

3.5.1(b)(iii) Source Population ... 110

3.5.1(c) Subject Criteria... 111

3.5.1(c)(i) Inclusion Criteria ... 111

3.5.1(c)(ii) Exclusion criteria ... 111

3.5.1(d) Sample Size Determinations ... 111

3.5.1(e) Sampling Method ... 111

3.5.1(f) Variables ... 112

3.5.1(g) Research Tools ... 112

3.5.1(h) Data Collection Procedure ... 114

3.5.1(i) Statistical Analysis ... 116

3.5.2 MIMIC Module Implementation ... 118

3.5.2(a) Study Design ... 118

3.5.2(b) Population and Sample ... 119

3.5.2(b)(i) Target Population ... 119

3.5.2(b)(ii) Sampling Frame ... 119

3.5.2(b)(iii) Source Population ... 119

3.5.2(c) Subject Criteria... 119

3.5.2(c)(i) Inclusion Criteria ... 119

3.5.2(c)(ii) Exclusion Criteria ... 119

3.5.2(d) Sample Size Determinations ... 120

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3.5.2(e) Sampling Method ... 120

3.5.2(f) Variables ... 121

3.5.2(f)(i) Independent Variable ... 121

3.5.2(f)(ii) Dependent Variable ... 121

3.5.2(g) Research Tools ... 122

3.5.2(g)(i) Assessment Tool (Questionnaire) ... 122

3.5.2(g)(ii) MIMIC Module ... 122

3.5.2(h) Data Collection Procedure ... 122

3.5.2(h)(i) Pre-Intervention Assessment ... 123

3.5.2(h)(ii) Intervention- MIMIC Module ... 124

3.5.2(h)(iii) Post-Intervention Assessment ... 134

3.5.2(i) Statistical Analysis ... 135

3.5.2(j) Flowchart of Study-Phase III ... 137

CHAPTER 4 RESULTS ... 138

4.1 Introduction ... 138

4.2 Study-Phase I: Assessment Phase ... 138

4.2.1 Identifying HAIs Prevalence ... 138

4.2.2 Assessment of Infection Control System ... 144

4.2.2(a) Infection Control Workshops and Training Programs ... 144

4.2.2(b) Visual Reminders ... 147

4.2.2(c) HAI-Related Forms ... 149

4.2.2(d) Infection Control Informative Resources... 151

4.2.2(e) HAI-Related Statistics Tool ... 153

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4.3 Study-Phase II: Developing and Validating of MIMIC Module ... 155

4.3.1 Developing MIMIC Module ... 155

4.3.1(a) Infection Control Education Program (ICEP) ... 155

4.3.1(b) Infection Control Monitoring System (ICMS) ... 157

4.3.1(c) Infection Control Supporting Environment (ICSE) ... 161

4.3.2 Validating MIMIC Module ... 164

4.3.2(a) Nursing Guide to Infection Prevention and Control ... 164

4.3.2(b) ICMS Manual ... 169

4.3.2(c) ICMS-Monitoring Forms ... 173

4.3.2(d) ICMS-Statistical Tool ... 176

4.3.2(e) ICSE Manual ... 179

4.3.2(f) ICSE-Posters ... 182

4.3.2(g) ICSE-Brochures ... 185

4.3.3 Summary ... 188

4.4 Study-Phase III: Intervention Phase ... 189

4.4.1 Pre-Intervention Test... 189

4.4.1(a) Response Rate ... 189

4.4.1(b) Demographic Details of the Adult Critical Care Nurses Responded ... 189

4.4.1(c) Pre-Intervention Knowledge Scores and Levels ... 191

4.4.1(d) Pre-Intervention Practice Scores and levels ... 193

4.4.2 Study Intervention “MIMIC Module” ... 195

4.4.3 Post-Intervention Test ... 198

4.4.3(a) Response Rate ... 198

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4.4.3(b) Post-Intervention Knowledge Scores ... 198

4.4.3(c) Post-Intervention Practice Scores ... 200

4.4.4 Impact of the MIMIC Module ... 201

4.4.4(a) One-way Repeated Measures ANOVA ... 202

4.4.4(a)(i) Assumptions of One-way Repeated Measures ANOVA ... 203

4.4.4(b) Impact of MIMIC Module on Knowledge Scores ... 206

4.4.4(c) Impact of MIMIC Module on Practice Scores ... 210

CHAPTER 5 Discussion ... 215

5.1 Study-Phase I: Assessment Phase ... 217

5.1.1 Identifying HAIs Prevalence ... 217

5.1.2 Assessment of Infection Control System ... 220

5.2 Study-Phase II: Developing and Validating of MIMIC Module ... 225

5.2.1 Developing MIMIC Module ... 225

5.2.2 Validating MIMIC Module ... 229

5.3 Study-Phase III: Intervention Phase ... 232

5.3.1 Pre-Intervention Assessment... 232

5.3.2 Post-Intervention Assessment ... 237

5.3.3 Strengths and Limitations of the Study ... 241

5.3.3(a) Strengths of the Study ... 241

5.3.3(b) Limitations of the Study ... 242

CHAPTER 6 CONCLUSION AND FUTURE RECOMMENDATIONS ... 244

6.1 Conclusion ... 244

6.2 Recommendations for Future Research ... 244

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REFERENCES ... 250 APPENDICES

LIST OF PUBLICATIONS

INTELLECTUAL PROPERTY (IP)

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LIST OF TABLES

Page

Table 2.1 Types of Central Lines ... 23

Table 2.2 Ventilator-Associated Pneumonia Diagnoses Criteria ... 25

Table 2.3 Interventional studies characteristics related to HAIs prevention and control ... 42

Table 2.4 Study Characteristics-Southeast Asia ... 49

Table 3.1 Bench marking Points of comprehensive IPC program ... 75

Table 3.2 Bench marking Points of visual reminders scope of topics ... 76

Table 3.3 Bench marking Points of HAI-related forms scope of topics ... 77

Table 3.4 Matrix of Change Objectives (COs) of MIMIC module... 86

Table 3.5 Theory-based methods and practical applications to the MIMIC module ... 91

Table 3.6 MIMIC module theoretical sessions contents ... 94

Table 3.7 The Likert Scale Scoring and Fuzzy Scoring for A Five-Point Scale .... 103

Table 3.8 Average Fuzzy scores for the item ... 104

Table 3.9 Threshold value for the construct... 105

Table 3.10 Schedule of the theoretical session "1" of the MIMIC module ... 127

Table 3.11 Schedule of the theoretical session "2" of the MIMIC module ... 128

Table 3.12 Schedule of the theoretical session "3" of the MIMIC module ... 129

Table 3.13 Schedule of the practical sessions of the MIMIC module ... 131

Table 4.1 One-year prevalence according to HAI type (1 January to 31 December 2019) ... 139

Table 4.2 HAI-causative agents and MDROs proportion in the adult ICUs between January to December 2019 ... 143

Table 4.3 Assessment results of the Infection control system applied in the adult ICUs in context of workshops and training programs ... 146

Table 4.4 Assessment results of the Infection control system applied in the adult ICUs in context of visual reminders ... 148

Table 4.5 Assessment results of the Infection control system applied in the adult ICUs in context of HAI-related forms ... 150

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Table 4.6 Assessment results of the Infection control system applied in the

adult ICUs in context of infection control informative resources ... 152

Table 4.7 Assessment results of the Infection control system applied in the adult ICUs in context of HAI-related statistical reports ... 154

Table 4.8 Infection Control Education Program (ICEP) framework ... 156

Table 4.9 Components of the Infection Control Monitoring System (ICMS) ... 159

Table 4.10 Infection Control Monitoring System (ICMS) framework ... 160

Table 4.11 Components of the Infection Control Supporting Environment (ICSE) ... 162

Table 4.12 Infection Control Supporting Environment (ICSE) framework ... 163

Table 4.13 The Fuzzy Delphi analysis for the Nursing Guide to Infection Prevention and Control validation ... 166

Table 4.14 The Fuzzy Delphi analysis for the ICMS manual validation ... 170

Table 4.15 The Fuzzy Delphi analysis for the ICMS- Monitoring Forms validation ... 174

Table 4.16 The Fuzzy Delphi analysis for the ICMS- Statistical Tool validation ... 177

Table 4.17 The Fuzzy Delphi analysis for the ICSE Manual validation ... 180

Table 4.18 The Fuzzy Delphi analysis for the ICSE-Posters’ validation ... 183

Table 4.19 The Fuzzy Delphi analysis for the ICSE-Brochures’ validation ... 186

Table 4.20 Responses distribution of the pre-intervention questionnaire ... 189

Table 4.21 The distribution of the pre-intervention test respondents according to demographic characteristics (n= 121) ... 190

Table 4.22 Descriptive statistics of adult critical care nurses’ pre-intervention knowledge scores (n=121) ... 191

Table 4.23 Pre-intervention knowledge score levels among adult critical care nurses in the adult ICUs toward IPC precautions (n=121) ... 192

Table 4.24 Descriptive statistics of adult critical care nurses’ pre-intervention practice scores (n=121) ... 193

Table 4.25 Pre-intervention practice score levels among adult critical care nurses toward HAIs preventive measures (n=121)... 194

Table 4.26 The distribution of the adult critical care nurses to the MIMIC module theoretical sessions groups... 195

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Table 4.27 Completion rates of on-lecture room theoretical sessions of the MIMIC module ... 195 Table 4.28 Completion rates of on-site theoretical sessions of the MIMIC

module ... 196 Table 4.29 Descriptive statistics of adult critical care nurses’ post-intervention

knowledge scores (n=121) ... 199 Table 4.30 Post-intervention knowledge score levels among adult critical

care nurses toward IPC precautions (n=121) ... 200 Table 4.31 Descriptive statistics of adult critical care nurses’ post-intervention

practice scores (n=121) ... 200 Table 4.32 Post-intervention practice score levels among adult critical

care nurses toward HAIs preventive measures (n=121)... 201 Table 4.33 Adult critical care nurses' scores means for the pre- and

post-intervention results (n=121) ... 202 Table 4.34 Skewness and kurtosis of the study dependent variables ... 204 Table 4.35 Mean, standard deviation and repeated measures analysis

of variance for MIMIC module effect on knowledge scores (n=121) .. 207 Table 4.36 Mean, standard deviation and repeated measures analysis of

variance for MIMIC module effect on knowledge scores within

the adult ICUs (n=121) ... 209 Table 4.37 Mean, standard deviation and repeated measures analysis

of variance for MIMIC module effect on practice scores (n=121) ... 211 Table 4.38 Mean, standard deviation and repeated measures analysis

of variance for MIMIC module effect on practice scores within the adult ICUs (n=121) ... 213

Table 4.39 Bonferroni post-hoc results of practice scores between the four adult ICUs (n=121) ... 214

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LIST OF FIGURES

Page

Figure 2.1 Superficial incisional SSI criteria (CDC, 2020d) ... 26

Figure 2.2 Deep incisional SSI criteria (CDC, 2020d) ... 27

Figure 2.3 Organ/space SSI criteria (CDC, 2020d) ... 27

Figure 2.4 PRISMA flowchart showing the selection of studies for the integrative review ... 48

Figure 2.5 Factors affecting individual behaviour in perspective of SCT ... 55

Figure 2.6 Conceptual framework of the study ... 62

Figure 3.1 Flowchart of the Study-Phase I ... 80

Figure 3.2 Intervention Mapping (IM) Protocol ... 82

Figure 3.3 Cause and effect diagram of HAIs prevalence ... 84

Figure 3.4 Logic model of the HAIs problem ... 84

Figure 3.5 Fuzzy Delphi Method framework ... 97

Figure 3.6 Section 4 of the MIMIC module assessment questionnaire ... 101

Figure 3.7 OneDrive share folders of MIMIC module ... 102

Figure 3.8 Fuzzy Delphi Analysis Software v2.0 ... 107

Figure 3.9 Flowchart of the Study-Phase II ... 108

Figure 3.10 Online study-questionnaire via Microsoft Forms ... 115

Figure 3.11 Framework of the data collection procedure for the pilot study ... 116

Figure 3.12 One-group pretest-posttest quasi-experimental study variables ... 122

Figure 3.13 Theoretical sessions of MIMIC module ... 126

Figure 3.14 Practical sessions of MIMIC module ... 130

Figure 3.15 Flowchart of the Study-Phase II ... 137

Figure 4.1 Monthly HAIs prevalence (January to December 2019) in the adult ICUs ... 139

Figure 4.2 Monthly CLABSI prevalence (January to December 2019) in the adult ICUs ... 140

Figure 4.3 Monthly CAUTI prevalence (January to December 2019) in the adult ICUs ... 141

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Figure 4.4 Monthly VAP prevalence (January to December 2019) in the

adult ICUs ... 142 Figure 4.5 Monthly SSI prevalence (January to December 2019) in the

adult ICUs ... 142 Figure 4.6 Comparison of knowledge scores mean for the adult critical care

nurses in two points of time, pre- and post-intervention ... 206 Figure 4.7 Comparison of knowledge mean scores for the four adult ICUs in

two points of time, pre- and post-intervention ... 207 Figure 4.8 Means Plot graph of knowledge scores at two points of time for

the selected ICUs ... 208 Figure 4.9 Comparison of practice scores mean for the adult critical care

nurses in two points of time, pre- and post-intervention ... 210 Figure 4.10 Comparison of practice mean scores for the four adult ICUs in

two points of time, pre- and post-intervention ... 211 Figure 4.11 Means Plot graph of practice scores at two points of time for the

selected ICUs ... 212

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LIST OF SYMBOLS

e.g. For example

et al. And others

> More than

< Less than

≥ Equal or more than

≤ Equal or less than

N Sample size

N Population size

& And

% Percentage

= Equal to

P Prevalence

E Degree of precision

Z Critical value of the normal distribution

ηp2 Partial eta squared

(d) Threshold

°C Degree Celsius

H1 Alternative hypothesis

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LIST OF ABBREVIATIONS

ANOVA Analysis of Variance

APIC Association for Professionals in Infection Control and Epidemiology

BBE Bare Below the Elbow

BSI Blood Stream Infection

CAUTI Catheter-Associated Urinary Tract Infection

CCTV Closed Camera Television

CDC Centers for Disease Control and Prevention

CFU Colony-Forming Unit

CI Confidence Interval

CLABSI Central Line-Associated Bloodstream Infection

cmH2O centimetres of water

CNE Continuous Nursing Education

CO Change Objective

CPD Continuing Professional Development

CRA Carbapenem Resistant Acinetobacter

CRA Carbapenem Resistant Acinetobacter

CRE Carbapenem-Resistant Enterobacteriaceae

CVC Central Venous Catheter

ESBL Extended-Spectrum β-Lactamase

ETT Endotracheal Tube

FDM Fuzzy Delphi Method

FiO2 Fraction of Inspired Oxygen

HAI Healthcare-Associated Infection

HCW Healthcare Worker

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HH Hand Hygiene

HIACC Hospital Infection and Antibiotic Control Committee HUSM Hospital Universiti Sains Malaysia

ICAT Infection Control Assessment Tool

ICC Infection Control Committee

ICD Infection Control Doctor

ICEP Infection Control Education Program

ICLN Infection Control Link Nurse

ICMS Infection Control Monitoring System

ICMS-MF Infection Control Monitoring System-Monitoring Forms ICMS-ST Infection Control Monitoring System-Statistical Tool

ICN Infection Control Nurse

ICSE Infection Control Supportive Environment

ICT Infection Control Team

ICU Intensive Care Unit

IM protocol Intervention Mapping Protocol IPC Infection Prevention and Control

IUC Indwelling Urinary Catheter

IV Intravenous

IWP Infection Window Period

KP Klebsiella Pneumoniae

LOS Length of Stay

M Mean

MCO Movement Control Order

MD Mean Difference

MDR-AB Multidrug Resistant Acinetobacter Baumannii MDROs Multidrug Resistance Organisms

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MIMIC Multi-Modality Intervention Infection Control

MMOH Malaysian Ministry of Health

MRSA Methicillin-Resistant Staphylococcus Aureus

MV Mechanical Ventilator

ONCG Oral Nursing Care Guideline

OS Organizational Support

PE Physical Environment

PEEP Positive End-Expiratory Pressure PICC Peripherally Inserted Central Catheter

PO Performance Objective

PPE Personal Protective Equipment

PsA Pseudomonas Aeruginosa

RRR Retrospective Record Review

RCT Randomized Controlled Trial

RP Risk Perception

SCT Social Cognitive Theory

S-CVI Scale Level Content Validity Index.

SD Standard Deviation

SE Self-Efficacy

SPSS Statistical Package for the Social Sciences

SSI Surgical Site Infection

TFN Triangular Fuzzy Numbers

UC Urinary Catheter

USM Universiti Sains Malaysia

UTI Urinary Tract Infection

VAP Ventilator-Associated Pneumonia

VRE Vancomycin-Resistant Enterococci

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WBC White Blood Cells

WHO World Health Organization

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LIST OF APPENDICES

Appendix A Ethical approval to conduct the study Appendix B Participant Informed Consent Form Appendix C Expert Information and Consent Form

Appendix D Director of HUSM permission “Application Form for the Use of Patients’ Data, Laboratory Services and Others at HUSM”

Appendix E CDC permission to use the “Infection Prevention and Control Assessment Tool for Acute Care Hospitals”

Appendix F Permission to use the questionnaire

Appendix G Contact information request for research study-Nursing Department

Appendix H Data release request-Hospital Infections and Epidemiology Control Unit

Appendix I Data collection tool of the HAIs prevalence

Appendix J “Infection Prevention and Control Assessment Tool for Acute Care Hospitals”

Appendix K Questionnaire on Knowledge and Practices of Nurses Regarding Hospital Acquired Infections

Appendix L Agendas of the MIMIC module sessions Appendix M Experts Validation forms

Appendix N Nursing Guide to Infection Prevention and Control Appendix O Infection Control Monitoring System-Monitoring Forms Appendix P Infection Control Monitoring System-Statistical Tool Appendix Q Infection Control Monitoring System-Manual

Appendix R Infection Control Supportive Environment-Manual Appendix S Infection Control Supportive Environment-Brochures Appendix T Infection Control Supportive Environment-Posters

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INTERVENSI KAWALAN INFEKSI PELBAGAI MODALITI (MIMIC) KE ATAS PENGETAHUAN DAN AMALAN DALAM KALANGAN JURURAWAT JAGAAN

KRITIKAL DI HOSPITAL USM

ABSTRAK

Jangkitan dapatan hospital (HAI) adalah masalah kesihatan yang sangat penting dengan kesan yang besar terhadap sektor penjagaan kesihatan di seluruh dunia. Kajian-kajian yang menumpukan kepada pelaksanaan modul multi-modaliti yang diwujudkan kepada jururawat penjagaan kritikal adalah sangat terhad. Tujuan kajian ini adalah untuk menilai kesan modul multi-modaliti terhadap tahap pengetahuan dan amalan jururawat penjagaan kritikal dewasa mengenai pencegahan dan kawalan HAI di Hospital Universiti Sains Malaysia. Kajian ini dijalankan dalam tiga fasa. Fasa pertama melibatkan tinjauan carta retrospektif untuk menilai prevalens HAI. Di samping itu, kajian keratan rentas deskriptif dilakukan untuk menilai sistem pengendalian jangkitan yang diaplikasikan. Fasa kedua pula menumpukan kepada pengembangan modul kawalan jangkitan Multimodaliti pelbagai intervensi menggunakan protokol Intervensi Pemetaan (IM) dan Teori Kognitif Sosial (SCT), serta mengesahkan modul yang dikembangkan menggunakan Kaedah Fuzzy Delphi (FDM). Fasa ketiga terdiri daripada kajian kuasi-eksperimen pretest-posttest satu kumpulan untuk menilai kesan modul yang dikembangkan. Prevalens HAI selama satu tahun adalah 5.84%. Selain itu, penilaian sistem kawalan jangkitan telah mengenal pasti bidang yang perlu dilakukan penambahbaikkan. Modul yang dibangunkan merangkumi tiga intervensi: program pendidikan pengendalian jangkitan, sistem pemantauan pengendalian jangkitan, dan sokongan persekitaran kawalan jangkitan, telah disahkan oleh tujuh panel pakar. Tahap pengetahuan dan

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amalan jururawat penjagaan kritikal dewasa telah dinilai sebanyak dua kali: sejurus sebelum dan tiga bulan selepas intervensi (n = 121); penilaian pra-intervensi menunjukkan bahawa 96.7% daripada responden mempunyai tahap amalan pengetahuan yang sederhana, dengan skor purata 18.68 daripada 30 (SD = 2.255) dan 95% CI [18.27, 19.08]. Dan 79.3% daripada responden mempunyai tahap praktik yang sederhana, dengan skor purata 8.79 daripada 15 (SD = 1.449) dan 95% CI [8.53, 9.05]. Penilaian pasca intervensi menunjukkan bahawa 86% responden mempunyai tahap pengetahuan yang baik, dengan skor purata 25.83 daripada 30 (SD

= 2.151) dan 95% CI [25.44, 26.21]. Bagi tahap amalan, 62% daripada responden mempunyai tahap yang sederhana, dengan skor purata 10.83 daripada 15 (SD = 1.564) dan 95% CI [10.55, 11.11]. Hasil pengukuran berulang sehala ANOVA menunjukkan satu peningkatan yang signifikan dalam skor pengetahuan, F (1, 120) = 632,679, p <.001, ηp2 = .844 dan peningkatan yang signifikan dalam skor amalan, F (1, 120) = 113.089, p <.001, ηp2 = .492. Kesimpulannya, kajian ini telah menyumbang kepada pembentukkan modul intervensi bersepadu yang berkesan dan terbukti dapat meningkatkan pengetahuan dan amalan jururawat penjagaan kritikal dewasa terhadap pencegahan dan kawalan HAI. Ia juga turut membantu untuk memberikan bukti kelebihan protokol IM, SCT, dan FDM dalam membangun dan mengesahkan pencegahan jangkitan dan kawalan intervensi.

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MULTI MODALITY INTERVENTION INFECTION CONTROL (MIMIC) ON KNOWLEDGE AND PRACTICE AMONG CRITICAL CARE NURSING STAFF

IN HOSPITAL USM

ABSTRACT

Healthcare-Associated Infections (HAIs) are a crucial health problem with significant impacts on healthcare sector worldwide. Studies that focused on the implementation of a multi-modality module tailored to critical care nurses are very limited. The aim of this study was to to determine the Healthcare-Associated Infections prevalence and impact of “Multi-Modality Intervention Infection Control”

module on knowledge and practice among critical care nursing staff in Hospital Universiti Sains Malaysia. This study was conducted in three phases. The first phase involved a retrospective record review to assess the prevalence of HAIs. In addition, a descriptive cross-sectional study was conducted to assess the infection control system applied. The second phase focused on developing a multi-modality intervention infection control using the Intervention Mapping (IM) protocol and Social Cognitive Theory (SCT), as well as validating the developed module using the Fuzzy Delphi Method (FDM). The third phase consisted of a one-group pretest- posttest quasi-experimental study to assess the impact of the developed module. The one-year prevalence of HAIs was 5.84%. In addition, the infection control system assessment identified the areas for improvement. The developed module, which includes three interventions: an infection control education program, an infection control monitoring system, and an infection control supporting environment, was validated by a seven-expert panel. The adult critical care nurses’ knowledge and practice levels were assessed in two points in time: immediately before and three

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months after intervention (n=121); the pre-intervention assessment revealed that 96.7% of the respondents had a fair level of knowledge, with a mean score of 18.68 out of 30 (SD= 2.255) and 95% CI [18.27, 19.08]. And 79.3% of the respondents had a fair level of practice, with a mean score of 8.79 out of 15 (SD= 1.449) and 95% CI [8.53, 9.05]. The post-intervention assessment showed that 86% of the respondents had a good level of knowledge, with a mean score of 25.83 out of 30 (SD= 2.151) and 95% CI [25.44, 26.21]. And for the practice level, 62% of the respondents had a fair level, with a mean score of 10.83 out of 15 (SD= 1.564) and 95% CI [10.55, 11.11]. The one-way repeated measures ANOVA results indicated a significant improvement in knowledge scores, F(1, 120)= 632.679, p < .001, ηp2= .844. And a significant improvement in practice scores, F(1, 120)= 113.089, p < .001, ηp2= .492.

In conclusion, this study contributed to the development of a comprehensive module of integrated interventions that have proven to improve the adult critical care nurses’

knowledge and practice toward HAIs prevention and control. And also helped to provide evidence on the advantage of the IM protocol, SCT, and FDM in developing and validating infection prevention and control interventions.

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1 CHAPTER 1 INTRODUCTION

Healthcare sector encounters several challenges that can impact the quality of the services provided and increase the economic burden of healthcare. These challenges require an ongoing effort to overcome them by developing a set of an evidence-based actions and ensuring their implementation. One of the most significant challenges is healthcare-associated infections (aka nosocomial infections), these infections are a global concern impacting many hospitalized patients’ and impeding their treatment plans as well as affecting healthcare workers and unwittingly increasing the risk of diseases transmission across a broad range.

The focus on the HAIs study was traced back to the 1830’s, when the term healthcare associated infection was introduced by James Simpson in England, who called the problem “Hospitalism” (Mourud, 2010). Since then, the healthcare sector still face an increasing prevalence of HAIs that affects the quality of patient care.

This concern is of interest to decision-makers, health administrators, healthcare workers, and patients.

1.1 Background of the Study

Healthcare-Associated Infections (HAIs) are infections acquired when providing health care in a hospital or in any other healthcare facility that first arise 48 hours or more after admission to hospital (Haque et al., 2018). Furthermore, they include occupational infections among healthcare providers (Khan et al., 2017a). The consequences of HAIs can be seen in increasing morbidity and mortality rates, raising the cost of treatment (Masavkar and Naikwadi, 2016) primarily due to prolonged hospital stay (Manoukian et al., 2018), and most critically developing

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causative agents (microorganism) resistant to antibiotics that are used in the treatment of patients (Shoaei et al., 2017). In its fact sheet, WHO reported that the mortality rate and an economic burden are increasing annually due to the high prevalence of HAIs worldwide with 10% of hospitalized patients in developing countries and 7% in developed countries acquiring one of Healthcare-Associated Infections (World Health Organization, 2016b). And more specifically, in Malaysia, the prevalence for HAIs is 13.9% of total hospital admissions (World Health Organization, 2016b).

1.2 Types of Healthcare-Associated Infections (HAIs)

HAIs have four most frequent types (Datta et al., 2014; Ducel et al., 2002; Khan et al., 2017a):

1.2.1 Ventilator-Associated Pneumonia (VAP)

It is a condition of lung infection that occurs 48 hours or longer after tracheal intubation for patients with respiratory difficulties in breathing and receiving mechanical ventilation (Hunter, 2012). VAP is the second most prevalent Healthcare-Associated Infections and the leading cause of high mortality rates among critically ill patients from HAIs (Torres et al., 2017). VAP acquired by 9-27%

of mechanically ventilated patients (Khan et al., 2017b).

1.2.2 Central Line-Associated Bloodstream Infection (CLABSI)

It is an infection that the patient acquired within 48 hours of placement a central venous catheter (CVC) and not related to another site infection (Blot et al., 2014).

CVCs are central lines placed for blood withdrawing; hemodialysis; infusion of blood products, medications, or fluids; or hemodynamic monitoring. CVCs include Peripheral inserted central catheter (PICC), tunneled catheter, non-tunneled catheter,

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and implanted port. CLABSI are deadly infections with the mortality incidence rate of 12-25% (Khan et al., 2017a).

1.2.3 Catheter-Associated Urinary Tract Infections (CAUTI)

It is the most common bacterial infections (40% of HAIs worldwide), associated with the presence of urinary catheter (Tenke et al., 2017). The urinary catheter is inserted via the urethra to the patient's bladder to allow the patient's urine to drain freely from the bladder.

1.2.4 Surgical Site Infections (SSI)

Is an infection occurs after surgery of the organ or surgical incision or space where the surgery took place (Berríos-Torres et al., 2017). SSIs are Healthcare- Associated Infections in 2%–5% of patients undergoing surgery, and the incidence rate could be as high as 20% depending on the surgical procedure (Khan et al., 2017b).

In Southeast Asia, ventilator-associated pneumonia has the highest incidence density (14.7/1000 ventilator day), and for catheter-associated urinary tract infections, and central line-associated bloodstream infections was 8.9/1000 catheter- days, and 4.7/1000 catheter-days, respectively. While the incidence of surgical site infections was 7.8% (Ling et al., 2015).

All hospitalized patients are at risk to acquire one of the Healthcare-Associated Infections, but patients in intensive care units (ICUs) are at higher risk of being infected compared to patients in general wards of the hospital (Edwardson and Cairns, 2019; Khan et al., 2017a). WHO reports that in the ICU, the HAIs prevalence is 30% in high-income countries while in low and middle-income countries the HAIs prevalence is tended to be 2-3 times greater than in high-income countries (World

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Health Organization, 2016b). The key explanation behind the high prevalence of HAIs among patients in ICUs can be referred to using invasive devices in ICUs for the treatment or monitoring of critically ill patients, putting them at greater risk of acquiring catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), central line-associated bloodstream infections (CLABSI) or other infections (Adegboye et al., 2018).

The increasing in Healthcare-Associated Infections rates can be attributed to a number of risk factors, including lack of knowledge of infection prevention and control guidelines and evidence-based practice among healthcare staff; poor hygiene;

lack of resources; inadequate nurse to patient’s ratio; inadequate waste disposal;

follow-up strategies (for health care staff); Immunosuppressed patients; length of stay; prolonged or inadequate use of antibiotics; catheters days (Adegboye et al., 2018; Barker et al., 2017; Khan et al., 2017a).

As the majority of health care staff, nurses are considered as a backbone of the provision of healthcare to patients. They are the first healthcare professionals that patients see and play a significant role in health promotion and disease prevention, an in addition, nursing care is a crucial element of the patients’ care plan. Their adherence extent with infection prevention and control precautions, relying on their evidence-based knowledge level, would either enable them to break the chain and prevent the spread of Healthcare-Associated Infections or be vectors, inadvertently, playing role in the transmission of disease-causing agents to themselves or to patients. Many studies have touched on the significant impact of inadequate knowledge about infection prevention and control precautions among nursing staff on increasing the prevalence of HAIs (Gandhi et al., 2017; Giri et al., 2016;

Kadamwadi, 2016; Marofi et al., 2017).

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Studying nursing, whether at the undergraduate (baccalaureate) or diploma levels, cover a broad variety of subjects, including infection prevention and control, in order to efficiently protect patients and themselves from infections. In addition to the role of the educational institutions, hospitals through Continuous Nursing Education (CNE) provide their nursing staff with programs for the prevention and control of infections. However, the HAIs are still on the increase, and it is becoming necessary to develop a new strategy to tackle this critical problem.

Preventing Healthcare-Associated Infections needs to comply with standard precautions of infection prevention and control that should be applied in all situations of providing care for patients regardless of whether they have an infectious disease or not. In addition to the transmission-based precautions that should be implemented in certain cases when treating patients that are confirmed to have a certain type of infection. Many studies have identified barriers to compliance with infection prevention and control precautions. The most crucial barrier to understand the practices aimed at preventing Healthcare-Associated Infections is the low knowledge of infection prevention and control standard precautions concepts among healthcare providers (Adegboye et al., 2018; Akagbo et al., 2017).

Another barrier concluded in several studies to compliance with standard precautions of infections is the lack or inadequacy of personal protective equipment (PPE) which is an essential element in prevention and control of infections (Adly et al., 2014; Naing et al., 2001; Ogoina et al., 2015).

Other studies have shown that the heavy workload of healthcare providers make compliance with standard precautions of infections is burdensome (Aluko et al., 2016; Hu et al., 2012).

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An effective communication between nurses and doctors has a significant impact on ensuring the quality of patient care and on promoting patient safety (Amudha et al., 2018). And as they are on the front line of patient care, nursing staff will have to collaborate with the physicians concerning their patients’ treatment and follow up.

Daily assessment of patients on invasive devices for early signs and symptoms of infections and the evaluation of the need to proceed with these devices is a critical task of nursing staff and the findings of their assessment must be reported to the attending physicians in order to facilitate decision-making in the patients care plan.

The prevention of HAIs requires significant training for healthcare workers, particularly nurses (Brusaferro et al., 2015; Pegram and Bloomfield, 2015). Even with good knowledge about infection control, but nurses still have a well-noted gap with the practical aspect (Menegueti et al., 2015).

This study focuses on increasing knowledge and practice awareness among critical care nurses in the prevention and control of infections to help reduce the prevalence of HAIs by developing and implementing a multi-modality module that promote evidence-based knowledge and knowledge-based practice. The core idea of the module based on promoting high exposure to infection prevention and control information through the use of multi-modality, including education sessions (power points slides), practical sessions (simulation), sharing information via e-mails, visual alerts (posters), quick-access and briefing materials (brochures), nursing guide to infection prevention and control book, infection control digital surveillance forms, electronic statistical tools, and facilitating communication channels with the hospital infection control unit and different healthcare workers.

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7 1.3 Problem Statement

Healthcare-Associated Infections are a major concern of the healthcare sector as they have a detrimental effect on the quality of patient care and increase the economic burden due to prolonged hospital stay and excessive use of antibiotics in the treatment of infections. in Southeast Asia, the pooled incidence density of HAIs was 20 cases per 1000 ICU days, and the HAIs mortality rate ranged from 7% to 46%, while the excess length of stay of infected patients ranged from 5 to 21 days (Ling et al., 2015), and the HAIs caused by multidrug-resistant gram-negative bacteria are prevalent among ICU patients and higher than reported in other regions (Teerawattanapong et al., 2018). The critically ill patients who are treated in an Intensive Care Unit (ICU) have a high risk of having at least one of HAIs (Edwardson and Cairns, 2019) and in low and middle-income countries, device- associated infections in ICU are 13 times higher than in high-income countries (Allegranzi et al., 2017).

Studies have shown that the implementation of proper preventive interventions can reduce HAIs. One of the effective preventive interventions that researchers mostly use is the implementation of an educational program related to one or more infection prevention and control competencies (e.g., hand hygiene) aimed at increasing knowledge and practice awareness among nursing staff (Chandak et al., 2016; Haque et al., 2018; Khan et al., 2017a). Reviewing related literature revealed the need to extend their content to cover more topics needed to enhance the self- confidence and improve awareness and compliance with IPC guidelines among critical care nurses. To the best knowledge of the researcher, Microbiology, body defence mechanisms and immunity, and administration of hospital infection control are not commonly addressed along with IPC standard precautions and HAIs bundles

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of care in a comprehensive education program, although they have a major effect on awareness and compliance with IPC precautions (Collins, 2008; Cox and Simpson, 2018; Durrant et al., 2017; Vayalumkal and Martin, 2014). Another interventions also have been used to prevent HAIs such as antibiotic stewardship program (Murni et al., 2020), developing organizational structures of responsibility (Brewster et al., 2016), waste management and environment cleaning (Stout et al., 2020). According to literature review, very limited studies focused on enhancing the role of critical care nurses in the daily assessment of patients with invasive devices or who underwent surgery, HAIs diagnosing, ensuring the appropriateness of antibiotics according to culture and sensitivity test results, and to participate in performing HAI- related statistics. The involvement of critical care nurses in such practices has a significant impact on their compliance with IPC precautions, increasing their self- confidence as a core member of patient care, improving the quality of care, and reducing HAIs.

Many studies illustrated the role of healthcare setting environment in HAIs, but few studies have introduced an intervention program to ensure a supportive environment for better IPC practices. Visual reminders (posters), availability of quick access guides (brochures), availability of hand hygiene and Personal Protective Equipment (PPE) supplements at the point of care, availability of different types of waste bags and sharp containers at the point of care, and clean environment are all infrastructure for better IPC practice and to encourage critical care nurses to comply with IPC precautions.

The multi-modality program might have a strong impact on the increase knowledge-based practice awareness that would boost the prevention of Healthcare- Associated Infections. The multi-modality program based on three major

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interventions, includes infection control education program, infection control monitoring system, and infection control supporting environment, which will be implemented through multimodality, including education sessions, training sessions (simulation), sharing information via e-mail, visual reminders (posters), quick-access and briefed information sources (brochures), using digital follow-up and monitoring forms, and administration support. In Southeast Asia, studies that adopted multi- modality programs aimed at adult critical care nurses to improve their awareness and practice toward IPC to reduce HAIs are very limited. And to the best knowledge of the researcher, a multi-modality IPC program that integrates a comprehensive IPC education program, an IPC monitoring system, and an IPC supportive environment has not yet been implemented

So, the question arises, what is the impact of the multi-modality intervention infection control module in improving the practice level toward Healthcare- Associated Infections prevention and control among critical care nursing staff?

1.4 Study Area

The study was carried out in HUSM, a teaching hospital affiliated with Universiti Sains Malaysia, as well as a referral centre for Kelantan and nearby states.

HUSM has an infection control surveillance system, which was established in 2000 and promotes kinds of studies that related to the infection prevention and control by providing a pool of needed data. In addition to diagnosing of HAIs using the criteria specified by the CDC guidelines. HUSM has a well-staffed infection control department that collects infection control-related data using standardized protocols (Al-Talib et al., 2010).

In HUSM, studies on the prevalence of HAIs, as well as knowledge and practice awareness among adult critical care nurses, are very limited, but some studies that

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conducted in HUSM have highlighted the need for programs to prevent and control infections. One study that has been conducted in HUSM concluded the need to comply with proper hand hygiene techniques in which it was found that the microorganisms on the hands were more than 50 colony-forming units (CFU) in the 74% of ICU health care workers (Wong et al., 2014). And in an observational prospective study, HUSM recorded 12.8% of patients who underwent general surgery developed an infection with the surgical site (Khan et al., 2016). Another study revealed that the infection prevention and control protocols needed to be updated to prevent SSI in patients undergoing open heart surgery, in addition to the need for a post-operative monitoring system, especially for patients with diabetes (Leong et al., 2017). Illustrating the challenging problem of Healthcare-Associated Infections in the development of Multidrug Resistance Organisms (MDROs) in the intensive care unit, a study conducted in HUSM reported the mortality rate caused by Carbapenem Resistant Acinetobacter (CRA) represent 13.6% of the overall mortality rate for ICU (Hassan et al., 2020b).

1.5 The Rationale of the Study

In addition to the previously stated reasons for the need for such study in HUSM, Umscheid et al. found that evidence-based strategies can prevent 65%-70%

of CLABSI and CAUTI cases, as well as 55% of VAP and SSI cases, and that this would have a positive impact on the cost of healthcare (Umscheid et al., 2011). The burden of Healthcare-Associated Infections in developing countries is high and illustrates the need for infection prevention strategies to overcome this critical problem (Allegranzi et al., 2011). Prevention of HAIs through infection control programs has very positive cost-benefit ratios (Arefian et al., 2016). Health professionals play an important role in the prevention and control of HAIs through

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the knowledge and practice of new infection control techniques (Sun, 2016). For example; knowledge and practice of hand hygiene techniques have a significant role in reducing HAIs (Hongsuwan, 2018).

The effect of high prevalence of HAIs can be explained by increase in mortality rate (Khan et al., 2017b), increase in economic burden of healthcare due to prolong hospitalization (Lv et al., 2019), and the treatment of HAIs with antibiotics, in addition to the high cost added to the patient care, will increase the risk of developing MDROs (Giraldi et al., 2019; Teerawattanapong et al., 2018).

High prevalence of HAIs are correlated with several factors: the availability of resources, knowledge of nursing staff and evidence-based practice of infection prevention and control precautions, monitoring and follow-up systems, and environment. And the most effective way to control HAIs and to reduce their prevalence is by an effective training and practices of infection prevention and control precautions (Singh et al., 2012), improving the knowledge regarding infection prevention and control has significantly affected by effective education programs (Chandak et al., 2018; Gaikwad et al., 2018; McGaw et al., 2012).

Nursing care is the majority of patients’ care in ICUs and promoting their knowledge regarding infection prevention and control and reflecting this knowledge on their daily healthcare activities in the ICUs would come back with benefits on reducing the prevalence of HAIs.

To the best knowledge of the researcher, multi-modality are not commonly used in infection prevention and control programs aimed at nursing staff in ICUs that enhance high information exposure to alert them to infection prevention and control precautions and to easy their work by implementing an efficient follow-up system. In

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addition, to date, no similar study has been reported in Malaysia. Hence the researcher would like to develop a multi-modality module taking in consideration three key factors; the knowledge and practice, follow-up system, and environmental factors to promote infection prevention and control practice among nursing staff in ICUs.

In conclusion, there is a need to develop an infection prevention and control program that would not only focus on educating critical care nurses’ staff but also maintaining an appropriate and safe environment for practicing infection prevention and control strategies, in addition to setting up a clear and specific follow-up system for central lines catheters, surgical sites, indwelling urine catheters, and for patients on mechanical ventilators. There is a lack of such studies that consider many factors of HAIs, especially in Southeast Asia.

1.6 Significance of the Study

The research focused on developing an integrated, affordable, and non- pharmaceutical IPC module to enhance the knowledge and practice of critical care nurses to reduce HAIs. The significance of this study represented by:

1.6.1 Infection Control Education Program (ICEP)

A comprehensive IPC education program that provides the critical care nurse with the requisite evidence-based knowledge and encourages knowledge-based practice. The education program covers three clusters of IPC; (1) fundamentals to understand IPC which includes: microbiology of infection, body defence mechanisms, and administration of hospital infection control, (2) principles of IPC which includes: IPC standard precautions and IPC transmission-based precautions, and (3) specific IPC which includes Healthcare-Associated Infections (HAIs) with

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four subtopics, including: CAUTI, CLABSI, VAP, and SSI. The Educational content was designed in an attractive style, enriched with practical reference illustrations, and published as the “Nursing Guide to Infection Prevention and Control” to be utilized as a reference for critical care nurses.

1.6.2 Infection Control Monitoring System (ICMS)

A follow-up system that promotes regular assessment practices in vulnerable patients, assesses the need for mechanical ventilators, central venous catheters, and urinary catheters to minimize the risk of HAIs arising from extended use, and regular assessment of the surgical site for early signs and symptoms of SSIs. ICMS introduces digital forms to decrease the workload of critical care nurses and to promote assessment and follow-up procedures, in addition to digital statistical tool that simplifies the performance of HAI-related statistics and summarizes the findings in infographics.

The ICMS instruction manual was designed in an attractive format and enriched with illustrations that clarify the steps of how to use and to fill out the digital forms and published to be used by critical care nurses.

1.6.3 Infection Control Supportive Environment (ICSE)

The third intervention that based on fostering a supportive environment that encourages critical care nurses to take IPC measures in the care of their patients. The ICSE concerned to develop visual reminders for IPC standard precautions that distributed in prominent places and quick-accessed informative brochures. In addition to assuring availability of hand hygiene supplements waste management equipment (e.g., bags and sharps containers) at the points of care.

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The ICSE manual was developed and enriched with illustrations and released to be used by critical care nurses as a reference for their practice.

The ICEP, ICMS, and ICSE are combined into a single module named “Multi- modality Multimodality Infection Control” and abbreviated as MIMIC.

1.6.4 Evidence-based and Theory-based MIMIC module

The application of IM protocol facilitated the development of a module that addressed the needs of critical care nurses and helped to improve the HAI-related forms used in ICUs. IM protocol has also enhanced the adoption and implementation of the MIMIC module by the Hospital Management, Hospital Infections and Epidemiology Control Unit, Nursing Department, and critical care nurses. In support of the IM protocol, the adoption of SCT facilitated the development and implementation of MIMIC module and contributed to improving critical care nurses’

self-confidence through applying theory-based teaching methods. The IM protocol supported by SCT reinforces the uniqueness of the developed MIMIC module as an integrated IPC program that tailored to the Adult ICUs’ nurses.

1.7 Objectives

1.7.1 The General Objective

“To determine the Healthcare-Associated Infections prevalence and impact of

“Multi-Modality Intervention Infection Control” module on knowledge and practice among critical care nursing staff in Hospital USM.”

1.7.2 The Specific Objectives

The specific objectives of this study according to the study phases are as follows:

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15 1.7.2(a) Phase I- Retrospective Study

i. To determine the prevalence of HAIs in the adult ICUs in HUSM.

ii. To determine the infection control system in the adult ICUs in HUSM.

1.7.2(b) Phase II- MIMIC Module

iii. To develop and validate the multi-modality intervention infection control module to improve knowledge and practice of HAIs prevention and control.

1.7.2(c) Phase III – Interventional Study

iv. To determine the knowledge scores and levels toward HAIs prevention and control among adult critical care nurses in HUSM.

v. To determine the practice scores and levels toward HAIs prevention and control among adult critical care nurses in HUSM.

vi. To determine the impact of MIMIC module on the knowledge scores toward HAIs prevention and control among adult critical care nurses in HUSM.

vii. To determine the impact of MIMIC module on the practice scores toward HAIs prevention and control among adult critical care nurses in HUSM.

1.8 Research Questions

The research questions of this study are as follows:

1.8.1 Phase I- Retrospective Study

i. What are the prevalence of HAIs in the adult ICUs?

ii. What are the improvements areas of the adult ICUs infection control system?

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16 1.8.2 Phase II- MIMIC Module

i. Is the MIMIC a focused and valid module to improve the knowledge and practice toward Healthcare-Associated Infections prevention and control among critical care nursing staff?

1.8.3 Phase III – Interventional Study

i. What are the scores and levels of knowledge and practice towards Healthcare- Associated Infections prevention and control among critical care nursing staff?

ii. What is the impact of the “MIMIC” on improving the knowledge and practice scores toward Healthcare-Associated Infections prevention and control among critical care nursing staff?

1.9 Research Hypotheses

The research hypothesis for the study are as follows:

i. H1: The MIMIC is a valid module for improving the knowledge and practice toward Healthcare-Associated Infections prevention and control among critical care nursing staff.

ii. H1: There is a significant different score of knowledge towards Healthcare- Associated Infections prevention and control among critical nursing staff pre- and post-intervention.

iii. H1: There is a significant different score of practice towards Healthcare- Associated Infections prevention and control among adult critical nursing staff pre- and post-intervention.

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17 1.10 Operational Definitions

1.10.1 Intensive Care Unit

The intensive care unit (ICU), also known as critical care unit, is an advanced care facility that provides specialized medical and nursing care for critically ill patients who require close monitoring, support from high-tech medical equipment and devices, and specialized life-sustaining treatment (Marshall et al., 2017).

1.10.2 Critical Care Nursing

Critical care nursing is a speciality in nursing focuses on the care of critically ill patients following life-threatening illness, injury, or surgery. The critical care nurse should have advanced skills through special training courses in relating to using of invasive devices such as mechanical ventilators (MV), central venous catheters (CVC) and urinary catheters (UC), monitoring, antibiotic treatment, ICU-related IPC measures, and special intensive care (Adam et al., 2017; HealthWorkforce Australia, 2014; World Health Organization, 2003).

1.10.3 Healthcare-Associated Infections

An infection that develops in a patient in a hospital or other health care facility during the care process that was not present or incubating at the time of admission (World Health Organizatio, 2011).

1.10.4 Prevalence of HAI

The proportion of patients who have specific type of HAI at given point of time (point prevalence) or over a specified period of time (period prevalence) (CDC, 2012).

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18 CHAPTER 2

LITERATURE REVIEW 2.1 Introduction

This chapter provides an overview of related literature on Healthcare-Associated Infections (HAIs). The literature review relied on four main aspects. The first aspect is to illustrate the characteristics of the ICU and the critical care nurses. The second aspect is to identify the core components of infection prevention and control programs and the barriers toward compliance with IPC practices. The third aspect is to understand the HAI by its definition, types, impacts, epidemiology, risk factors, and the need for preventive interventions with more focus on the interventions that applied worldwide to tackle this critical health problem. And the fourth aspect is the review of the Intervention Mapping (IM) protocol in the light of published literatures to assure its feasibility and suitability to develop the IPC interventions that fulfill the study objectives, and to review the implementation of the Social Cognitive Theory (SCT) in IPC education to improve the critical care nurse’s awareness and practices.

Literature review was conducted to justify the need to develop affordable IPC interventions and to confirm the significance of the study in developing innovative IPC interventions tailored to adult critical care nurses and aimed at increasing their awareness and practice of the IPC guidelines and precautions to reduce HAIs.

2.2 Intensive Care Unit

The intensive care unit (ICU), also known as critical care unit, is an advanced care facility that provides specialized medical and nursing care for critically ill patients who require close monitoring, support from high-tech medical equipment and devices, and specialized life-sustaining treatment (Marshall et al., 2017).

Critically ill patients can be defined as patients with life-threatening illnesses that are

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likely to result in morbidity and mortality in the absence of advanced medical interventions (Robertson and Al-Haddad, 2013) that are primarily based on the use of various invasive devices such as mechanical ventilators (MV), urinary catheters (UC), and central venous catheters (CVC) for monitoring, providing treatment, or assistance of body’s organs function (Bennett et al., 2018; Marshall et al., 2017). The physical space of ICU is one of the main factors that support appropriate accommodation for patients’ beds to allow access from all sides to provide patient care and effective implementation of IPC precautions in addition to medical devices and equipment placing (Marshall et al., 2017).

2.2.1 Critical Care Nurse

Critical care nursing is a nursing specialty that focuses on the care of critically ill patients following life-threatening illness, injury, or surgery (HealthWorkforce Australia, 2014). Nurses are health care practitioners who have graduated from a certified nursing program that qualify them to practice patient care (CNANursing, 2019). With reference to the Nursing Program in School of Health Sciences at Universiti of Sains Malaysia (USM) as an example on Nursing Programs, a variety of courses are included in the nursing curriculum, which provide graduates with the knowledge and skills required to practice nursing care for patients and in accordance with IPC measures (School of Health Sciences, 2018). Along with the role of nursing programs in the graduation of qualified nurses at Diploma, Bachelor or Postgraduate level, critical care nurses should learn advanced skills through special training courses to provide care for critically ill patients who require invasive devices such as mechanical ventilators (MV), central venous catheters (CVC) and urinary catheters (UC), monitoring, long term antibiotic treatment, ICU-related IPC measures, and special intensive care (Adam et al., 2017; World Health Organization, 2003).

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