knowledge, attitude and practice regarding universal precautions

115Nursing and Midwifery Research Journal, Vol-4, No. 4, October 2008

Knowledge, Attitude and Practice Regarding UniversalPrecautions among Nursing Students

Rajinder Kaur, Baljit Kaur, Indarjit Walia

Abstract : The study was conducted in the months of September and October 2007 atGovernment Multi Specialty Hospital, Chandigarh. The study aimed at evaluating the knowledge,attitude and practice of nursing students regarding universal precautions. Students of parent instituteand of institutes which make their students visit the GMSH for clinical experience were taken assubjects. These respondents were 144 in number. The study revealed that mean age of the studentswas 20.3 Years, almost all the students were females and about 80% of the students had seniorsecondary certificate while remaining were graduates. About 72% of the students were in the thirdyear of their professional training. The mean knowledge score regarding universal precautions wascalculated to be 60.40 and that of practice score was 83.01. These scores were almost directlyproportionate to year of the training of students.

Key words :

Universal Precautions, Knowledge, Practice,Students.

Correspondence at :

Rajinder KaurNursing Tutor, School of Nursing,Government Multispecialty Hospital,Sector 16, Chandigarh.

Introduction

Universal precautions are the infectioncontrol techniques that were recommendedfollowing the AIDS outbreak in the 1980s.Essentially it means that every patient istreated as if they are infected and thereforeprecautions are taken to minimize risk. Nodoubt, universal precautions are goodhygiene habits, such as hand washing andthe use of gloves and other barriers, correctsharps handling, and aseptic techniques.


Additional precautions are used in addition touniversal precautions for patients who areknown or suspected to have an infectiouscondition, and vary depending on theinfection control needs of that patient.Additional precautions are not needed forblood-borne infections, unless there arecomplicating factors. Universal precautionsare recommended not only for doctors, nursesand patients, but for health care suppor tworkers. Some suppor t workers, mostnotably laundry and housekeeping staff, maybe required to come into contact with patientsor body fluids.1

All health care workers should routinelyuse appropriate barrier precautions to preventskin and mucous membrane exposure duringcontact with any patient's blood or body fluidsthat require universal precautions. Glovesshould be worn: for touching blood and bodyfluids requiring universal precautions, mucousmembranes, or non intact skin of all patients,and for handling items or surfaces soiled withblood or body fluids to which universalprecautions apply Gloves should be changedafter contact with each patient. Hands andother skin sur faces should be washedimmediately or as soon as patient safetypermits if contaminated with blood or bodyfluids requiring universal precautions. Handsshould be washed immediately after glovesare removed. Gloves reduce the incidence ofblood contamination of hands duringphlebotomy, but they cannot preventpenetrating injuries caused by needles orother sharp instruments. In addition, thefollowing general guidelines apply:

• Use gloves for performing phlebotomywhen the health care worker has cuts,scratches, or other breaks in his/herskin.

• Use gloves in situations where thehealth care worker judges that handcontamination with blood may occur.

• Use gloves for performing finger and/or heel sticks on infants and children.

• Use gloves when persons are receivingtraining in phlebotomy.2

All sharps should be handled withextreme care. They should never be passeddirectly from one person to another, and theiruse should be kept to a minimum. Do not recapused needles by hand; do not remove usedneedles from disposable syringes by hand;and do not bend, break, or otherwisemanipulate used needles by hand. Place useddisposable syringes and needles, scalpelblades and other sharp items in puncture-resistant containers for disposal. Puncture-resistant containers must be readily available,close at hand, and out of reach of children.Sharp objects should never be thrown intoordinary waste bins or bags, or to rubbishheaps or into waste pits or latrines.3

Cover any existing cuts or lesions witha waterproof dressing, paying par ticularattention to hands and forearms. Any staffwith chronic skin lesions to hands or forearmsor persistent skin problems should avoidinvasive procedures and seek advice from theOccupational Health Depar tment.4 Handwashing is one of the most impor tantdefenses against the spread of infectious


disease. Hands should always be washed withsoap and running water following contactwith blood or other potentially infectious bodysecretions, even if gloves have been used forthe task. Do remember that hand washing isthe most effective way to reduce the spreadof disease. Here is a brief review of the methodof hand washing:

• Use of liquid soap is best with warmrunning water.

• Rub hands together vigorously for atleast 30 seconds.

• Remember all sur faces includingthumbs, wrists, back of hands, betweenfingers and around and under nails.

• Rinse hands well, letting water drainfrom wrists to fingers - don't turn offfaucet.

• Dry hands with paper towel, then usesame towel to turn off faucet.

• Discard towel.5

Masks in combination with eyeprotection devices, such as goggles orglasses with solid side shields, or chin-lengthface shields, shall be worn wheneversplashes, spray, spatter, or droplets of bloodor other potentially infectious materials maybe generated and eye, nose, or mouthcontamination can be reasonably anticipated.Appropriate protective clothing such as, butnot limited to, gowns, aprons, lab coats, clinicjackets, or similar outer garments shall beworn in occupational exposure situations. Thetype and characteristics will depend upon thetask and degree of exposure anticipated.

Surgical caps or hoods and/or shoe coversor boots shall be worn in instances whengross contamination can reasonably beanticipated (e.g., autopsies, or thopaedicsurgery).6

One study done by Snowden L inCanterbury Christ Church College, Englandwas aimed to examine whether a 3-yearprogramme of nursing studies enablednursing students to graduate from the coursewith greater knowledge and more positiveattitudes towards HIV infection and AIDS thanwhen they began the course. Students on amaths and information technology coursewere used as controls. The study involved theuse of a questionnaire which gatheredinformation about students' experience,knowledge, attitudes and moral judgmentregarding HIV infection and AIDS. Theexperimental hypothesis stated that nursingstudents would show a greater increase inknowledge and positive attitude changetowards HIV infection and AIDS than mathsstudents. The results showed significantdifferences between third year nursingstudents' knowledge about HIV and AIDSwhen compared with other groups but it wasnoted that knowledge levels for all groups wasquite low. There was no difference betweenfirst and third year nursing students' attitudesand moral judgment about HIV and AIDS butthere was a significant difference betweennursing students and students ofmathematics. It was suggested that there is aneed to modify nurse education programmesin order to have greater impact on this topicarea.7


Another research on needle stickinjuries (NSI) done in Taiwan by Judith Shu-Chu Shiao, et al concluded that the majority(70.1%) of NSI occurred in the patient's room.Hollow-bored needles contributed to half(219/438) of the NSIs of which 86.8% weresyringe needles. Just over half (53.2%) ofthose items involved in NSIs had been usedon patients. Of the hollow-bored needlesinvolved in NSIs, 21.5% had been used on apatient with an infectious disease.8

One study done on the student nursesat the University of Ibadan, Nigeria, examinedthe impact of systematized education's impacton their knowledge, attitudes and compliancewith universal precautions. This paper reportsthe findings of a study which examineschanges in a group of B.Sc. Nursing students'perceptions, knowledge of and attitudestowards human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), occurring from attempts at asystematized education for the cohort. Basedupon a 3-month study of 141 registerednurses enrolled in the programme, itinvestigates alterations in knowledge andattitudes resulting from intense instruction onHIV/AIDS, AIDS patient care, and compliancewith universal precautions. With regard toknowledge enhancement and attitudinaltransformation, the research reveals that anumber of positive changes occurred over theperiod of the study. Not only were the nursesbetter informed about AIDS than previously,but their attitudes towards the disease andpatient care had become considerably moreliberal, as well as their disposition to comply

with universal precautions. The conclusionemphasizes that it is very impor tant foreducation about HIV/AIDS to be incorporatedwithin current undergraduate and in-servicetraining programmes for nurses.9

A study, on the universal precautions'training of preclinical students showed thatUniversal precautions' knowledge scoresincreased significantly af ter training(P < 0.0001). Personal assessments of therisk of developing HIV due to patient caresignificantly decreased (P < 0.0001) andwillingness to provide care for AIDS patientsincreased (P = 0.004). Importantly, studentsreported that high expected rates of contactwith HIV-positive and other patient groupswould not significantly affect their specialtychoice. Observed compliance with universalprecautions procedures during practicaltraining ranged from 95 - 99% for glove use,76 - 77% for direct sharps disposal withoutneedle recapping, and 56 - 78% for handwashing af ter glove removal duringphlebotomy and intravenous catheterinser tion. The study concluded that suchprograms were effective in increasingstudents' knowledge of universal precautions.Training favorably affects students' willingnessto care for HIV-positive patients and theirassessed risk of developing occupationalblood borne infection.10

Another study titled, "Compliance withuniversal precautions: knowledge andbehavior of residents and students in adepar tment of obstetrics and gynecology"done at USA showed that thir ty residents(100%) knew the appropriate barrier


equipment required for each type ofprocedure performed. One student (< 1%)did not know that booties were appropriatefor the surgical procedures. Rationale for lackof compliance with universal precautionselicited by the questionnaire included timeconstraints (64%), inconvenience (52%), andpresumption that patient was not infected(34%). The observed rate of compliance withuniversal precautions by par ticipantsindicates that individual compliance wasinversely related to the years of experience(overall compliance rate of students was 96%;for first-year residents, 92%, second-yearresidents, 89%, third-year residents, 84%,four th-year residents, 78%; r = -0.9918,P = 0.0009). The study concluded that theknowledge regarding universal precautionswas nearly 100%, while overall observedcompliance was only 89%. Compliance withuniversal precautions was better amongstudents (96%) than among residents (88%).Compliance with universal precautions wasinversely related to years of experience.11

An impor tant study conducted onsenior medical students' knowledge ofuniversal precautions by Koenig S, Chu J, atUniversity of Washington School of Medicine,Seattle US, studied that the questionnaireswere completed by 137 (91%) of thestudents. The mean percentage of correctanswers by the responding students was67%. For five of the ten procedures, from 104to 123 (76-90%) of the students reported theproper levels of protection. For the remainingfive procedures, from 58 to 75 (42-55%) ofthe students knew the proper levels of

protection. The study concluded that theresults of the survey were worrisome,because many students--immediately beforethey graduated--lacked adequate knowledgeof universal precautions regarding the tencommon clinical procedures. This studyadvocated more emphasis on universalprecautions during undergraduate medicaleducation.12

Though many studies could be quotedfrom developed nations but there is paucityof data related to nursing students'knowledge, attitude and practices regardingUniversal Precautions especially in Indianscenario. Thus the present study wasundertaken with the main objective to assessthe knowledge and practice of nursingstudents regarding universal precautions andthereby planning to develop requiredinterventional strategies.

Materials and Methods

The study was conducted in theGovernment Multi-Specialty Hospital, Sector16, Chandigarh which has the strength of 500beds. It has an emergency unit which iscombined with Critical Care Unit, AIDS Cell,20 indoor wards/ departments and 10 out-patient depar tments. The hospital has onedialysis unit and four major operation theatersand there are three minor operation theaters.The students from various nursing schoolsand colleges including the school of nursingof parent institute come for clinical practice inthe hospital especially in the obstetrics,gynecology and neonatology wards. Thepurposive sampling technique was followed


and all the Nursing students were taken forthe purpose. The tools used for datacollection were Interview schedule for dataidentification which included 9 questions,Structured Questionnaire for assessing theknowledge regarding universal precautionswhich included 15 questions and StructuredQuestionnaire for assessing the practice andattitude regarding universal precautions thatcontained 25 questions. The tools werevalidated by the experts. Data was collectedduring the months of September and October2007.

Results

Table 1 shows the socio demographiccharacteristics of the students whoparticipated in the research study. As the tableshows, a total of 144 students were the

respondents for this study. Age of thestudents varied from 18 - 23 years. Thestandard deviation of the students wascalculated to be ± 1.020. It is evident thatabout more than 60% were in the age groupof 20 -21 years. The mean calculated for theage is 20.03 years. The next most accountedcategory for age group was 18-19 which had30% respondents. All the respondents werefemales with the exception of one male. Thereason being that male students are juststar ting getting attracted towards thisinternational job oriented course. Theacademic qualification of students is such that79.20% of them had senior secondarycer tificate while 20.80% of them weregraduates. The graduates included those whoafter completing their general graduationstar ted the job oriented courses of nursing.

Table 1: Socio demographic characteristics of the respondents N = 144

Characteristics f (%)

Age of Respondent (in Years)

18 - 19 43 ( 29.9)

20 - 21 90 (62.5)

22 - 23 11 ( 7.6)

Sex

Females 143 (99.3)

Males 1 ( 0.6)

Academic Qualification

Senior Secondary 114 (79.2)

Graduation 30 (20.8)

Mean = 20.03

S.D. ± 1.020

Range = 18-23


Table 2 shows the distribution ofstudents according to their professionalqualification. It shows the course and thecourse year in which students are presentlyenrolled in. The students taken for the presentstudy were B.Sc. (total 85) and GNM (total59) courses. While only third year students

were taken from B.Sc. whereas for GNM allthree years students participated. The reasonfor this is that the students of the parentinstitute gain clinical experience right from thefirst year itself, whereas the students fromother nursing institutes come only formidwifery experience in the third year.

Table 2: Distribution of the respondents according to professional qualification N=144

Year of Training f (%)

First Year 18 ( 12.5)Second Year 23 ( 16.0)Third Year 103 ( 71.5)

Type of Professional Course

B. Sc. 85 ( 59.0)

G. N. M. 59 ( 40.9)

Figure 1 shows the classification ofstudents according to their scores of theknowledge of universal precautions. Neitherof the students was below 20 marks nor above80 marks. The mean marks were calculated

to be 60.4. Those who scored in the categoryof 40-60 marks were 52.10% of the totalstudents, while 40.30% of the students scoredin the category of 60-80 marks.

Stu

den

ts (

in p

erce

nta

ge)

60

50

40

30

20

10

0

Marks Obtained

<20 20-40 40-60 60-80 >80

0

7.64

52.08

40.28

0

Figure 1: Classification according to knowledge score N = 144

Mean Score = 60.40


Figure 2 describes the scores of thestudents for their practice of universalprecautions. Only 1 student was below thescore of 60%, while 60-70% score wasobtained by 4.16% of them. Thus, 96% of thestudents scored more than 70%. Here thesefigures may be misleading if not seen from

the perspective of the seriousness ofconforming to guidelines of universalprecautions. Each and every student mustreach near per fect 100 score because ifstudents are not trained of this grade they willmalpractice in their profession which dealswith lives of people.

Figure 2: Classification according to practice score N = 144

<90

80-90

70-80

60-70

50-60

< 50

Mar

ks O

bta

ined

10 20 30 40 50 600

17.36

52.78

25

4.16

0

0.7

Students (in Percentage)

Mean Score = 83.01

Figure 3 shows the occurrence offrequency of injury among the respondentsduring last six months. When surveyed, therespondents were asked about any needleprick injury caused to them during last six

months during practical hours. It wassurprising to know that 54% subjects out ofthe total of 144 reported injury due to needleprick. Out of the total injured respondents,those got injured once were 25.6% and thosewho got injured twice were 32%. Students


with needle prick injury frequency of three andfour times were 15.4 and 14.1% respectively.The needle prick caused injury to 6.4%students 5 times. There were 2 students whoinjured themselves 6 times with needle prickand another 2 students who got this injury10 times during last six months of theirpractical classes. One students reported to

Figure 3: Distribution of the Respondents According to Frequency of Needle Prick Injury

N = 144

have been injured 15 times with needle prick.The frequency of injury was higher in thestudents who in the first year of their training.It is fur ther surprising to know that 61.2% ofthe B.Sc. 3rd year students got needle prickinjury whereas 11% of the GNM students wereinjured with needle prick.

35

30

25

20

15

10

5

0

Res

po

nd

ents

( in

Per

cen

tag

e)

Non Injured = 66Injured = 78

Frequency of Needle Prick injury

Once Twice Thrice 4 Time 5 Time 6 Time 10 Time 15 Time

32

15.4

14.16.4

2.6 2.6

25.6


Table 3 shows the comparison ofknowledge and practice scores of studentsof different institutes. The students who getmore practice hours do better in practicescore. This is irrespective of the course ofwhat they are enrolled in. The mean of GMSHstudents was 56.23 for knowledge and 85.68for practice. GN College of Nursing students

Table 3: Comparison of knowledge and practice scores of different institutions

N = 144

Institution Knowledge Score Practice Score

(Mean) (Mean)

GMSH (GNM) 56.23 85.68

GN CON (B.Sc.) 64.13 81.78

Silver Oaks CON (B.Sc.) 62.40 77.19

GMSH (GNM) = Government Multi Specialty Hospital, Sector 16, Chandigarh.

GN CON (B. Sc.) = Guru Nanak College of Nursing, Dhahan Kaleran, Jalandhar.

Silver Oaks CON (B. Sc.) = Silver Oaks College of Nursing, Mohali,

Table 4 shows change in knowledgeand practice quotient of GNM students ofdifferent years in the GMSH School ofNursing. When compared, the mean score ofknowledge of first and second year students

were almost the same (52) but it increased inthird year students to 66.26. Where as thepractice score variation in different years wasmore conspicuous as the practice scoreincreased with an average of about 5%.

got 64.13 mean knowledge score and 81.78as mean practice score. Mean values forknowledge and practice scores of Silver OaksCollege of Nursing were 62.40 and 77.19respectively. This table shows theoutperformance of GNM students in practicewhen compared to their B.Sc. counterpar tsin the study in terms of years of training.

Table 4: Comparison of knowledge and practice scores of GNM students of different

years of training N = 59

Year of Training Knowledge Score Practice Score

(Mean) (Mean)

First Year 52.22 79.33

Second Year 51.59 86.65

Third Year 66.29 90.78


Discussion

Universal precautions are infectioncontrol guidelines designed to protect peoplefrom diseases spread by blood and cer tainbody fluids. Always assume that all "bloodand body fluids" are infectious for blood-bornediseases such as HBV (Hepatitis B Virus), HCV(Hepatitis C Virus) and HIV (Human Immuno-deficiency Virus). 13

A total of 144 students were therespondents for this study. Age of thestudents varied from 18 - 23 years. Thestandard deviation of the students wascalculated to be ± 1.020. It is evident thatabout more than 60% were in the age groupof 20 -21 years. The mean calculated for theage is 20.03 years. The next most accountedcategory for age group was 18-19 which had30% respondents. The academic qualificationof 79.20% students was senior secondarycer tif icate while 20.80% of them weregraduates. The students taken for the presentstudy were of B.Sc. (total 85) and GNM (total59) courses. While only third year studentswere taken from B.Sc. whereas for GNM allthree years students par ticipated. Thereforea total of 71.5% students were in the thirdyear of their professional training. Only 16%and 12.5% were in second year and first yearof the professional GNM training respectively.

Neither of the students was below 20marks nor above 80 marks in the knowledgescore. The mean marks were calculated to be60.4. Half of the Students 52.10% scored inthe category of 40-60 marks while 40.30% ofthe students scored in the category of 60-80

marks. The results were directly proportionateto the year of training of the students. Still,the performance of students in knowledgescore was quite low as no student could getmarks more than 80. A study conductedamong senior medical students' knowledgeof universal precautions concluded that mostof the students lacked adequate knowledgeof universal precautions. This studyadvocated more emphasis on universalprecautions during undergraduate medicaleducation.

Practice of universal precautions showsthat only 1 student obtained below 60% marks.Only 4.17% students obtained 60-70% marks,about 96% of the students obtained more than70% marks. Here these figures may bemisleading if not seen from the perspectiveof the seriousness of conforming to guidelinesof universal precautions. Each and everystudent must reach near perfect 100 scorebecause if students are not trained of thisgrade they will malpractice in their professionwhich deals with lives of people. A researchconducted on needle stick injuries (NSI) donein Taiwan revealed the worrisome results asabout 22% of the respondents were injuredwith needles which had been used on patientwith an infectious disease.

Comparison of knowledge and practicescores of students of different institutionsshows that students who get more practicehours do better in practice score. This isirrespective of the course they are enrolledin. The mean of GMSH students was 56.23for knowledge and 85.68 for practice. GNCON


students got 64.13 mean knowledge scoreand 81.78 as mean practice score. Meanvalues for knowledge and practice scores ofSilver Oaks CON were 62.40 and 77.19respectively. This shows the outperformanceof GNM students in practice when comparedto their B.Sc. Nursing Students counterpar tsin the study in terms of years of training. Onestudy done by Snowden l in Canterbury ChristChurch College, England aimed to examinewhether a 3-year programme of nursingstudies enabled nursing students to graduatefrom the course with greater knowledge andmore positive attitude revealed that theknowledge level for all groups was quit low.The study suggested a need to modify nurseeducation programmes in order to increasethe understanding of universal precautionsamongst students.

Present study shows change inknowledge and practice quotient of GNMstudents of different years in the GMSH Schoolof Nursing over 3 years of course. Whencompared, the mean score of knowledge offirst and second year students was almost thesame (52) but it increased in third yearstudents to 66.26. Where as the practice scorevariation in different years was moreconspicuous as the practice score increasedwith an average of about 5% and the thirdyear students got 91 as mean marks inpractice of universal precautions. Theknowledge score creates concerns over theunderstanding of universal precautionsamongst students and therefore there is aneed to organize different educationalprogrammes with greater student involvement

and at the same time curriculum should alsobe more student engaging.

Recommendations:

1. Administration should initiate inincreasing the knowledge andunderstanding of students regardinguniversal precautions.

2. Educational programmes regardinguniversal precautions should beorganized for students at the time ofcommencement of their training andbefore they graduate the course.

3. The involvement of students in differentactivities regarding universalprecautions should be encouraged andevents such as exhibitions, postermaking, quizzes, debates and othercompetitions regarding universalprecautions should be organizedconsistently.

4. There should be qualifying exams forstudents before sending them topractise in clinical duties.

References

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URL : http://www.cdphe.state.co.us/ps/hcc/univprecautions.pdf

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10. Diekema DJ, Schuldt SS, Albanese MA,Doebbeling BN. Universal precautions trainingof preclinical students: impact on knowledge,attitudes, and compliance. Journal of Preventivemedicine 1995 Nov;24(6):580-5. Available fromURL :-http://www.ncbi.nlm.nih.gov/pubmed/8610081 ? ordinalpos=4 & itool = Entrez System2 . PEntrez. Pubmed. Pubmed_Results Panel.Pubmed_RVDocSum

11. Helfgott AW, Taylor-Burton J, Garcini FJ,Eriksen NL, Grimes R. Compliance withuniversal precautions: knowledge and behaviorof residents and students in a department ofobstetrics and gynecology. Available from URL:- http://www.ncbi.nlm.nih.gov/pubmed/9785108? ordinalpos = 10 & itool = EntrezSystem2. PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

12. Koenig S, Chu J. Senior medical students'knowledge of universal precautions. Journal ofthe Association of American Colleges. May1993;68(5):372-4. Available from URL: - http://www.ncbi.nlm.nih.gov/pubmed/8484851?ordinalpos = 3 &i tool= Entrez System2. PEntrez.Pubmed.Pubmed_Results Panel. Pubmed _RVDocSum

13. Universal Precautions Guidelines.University of Waterloo. Available from URL:- http:// w ww. he a l th s er v i c es . u wa t e r loo . c a /occupationalhealth/universalprecautions.html

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