Information, Motivation And Behavioural Skills As Predictors Of Utilization Of Universal Precautions Among Nurses In Sagamu, Ogun State, Nigeria
- Background. Health-care providers are at major high-risk for contracting blood-borne infections during the discharge of their duties in health-care facilities now than ever before. This study aimed to assess how these three factors (information, motivation and behavioural skills) can serve as predictors of the utilization of universal precautions among nurses in health facilities in Sagamu, Ogun state, Nigeria.
- Methods. A cross-sectional study was conducted among 330 nurses in both public and private health facilities. Data acquisition was performed using an inquiry-questionnaire. Data were analyzed using Statistical Package for Social Science (SPSS) version 21.0. Correlation, linear regression, T-test and ANOVA were evaluated to test the research hypotheses.
- Results. The adherence practice of universal cautions among the nurses was not optimal (9.86 (0.18) 2.62) which is 65.73%. Nurses with the least occupational level scored the lowest across all the variables and the adherence practices were not optimum.
- Conclusion. Non-compliance of the precautionary measure poses a threat to their health and the services provided.
1.1 Background to the Study
Health-care providers are at major high-risk for contracting blood-borne infections during the discharge of their duties in health-care facilities now than ever before. Despite the introduction of these preventive procedures in the training of healthcare workers such as nurses, doctors, medical laboratory scientist among others, the possibility of an occupational injury is high due to risk practices among these individuals. Various studies have revealed that blood-borne infections constitute a sizeable number of serious risk exposures for health-care providers from patients diagnosed with Hepatitis virus (HBV) and Human immunodeficiency virus (HIV) in the course of providing care for these patients (Anozie, Anozie, Lawani, Mamah, Ajah & Nwali, 2016; Sheth, Leuva & Mannari, 2016) .
Health-care providers carry out a number of tasks which are not limited to administration of drugs by injection procedures, taking birth deliveries, wound dressing, handling blood samples and other body fluids which may result in exposure through percutaneous and needle-stick or other sharps injuries including accidental splashes (Elseviers, Arias-Guillén, Gorke & Arens, 2014).Evidence from a number of studies have reported risk exposures that have resulted to about two to four needle-stick injuries annually among o health-care providers during the process of discharging their duties particularly in Africa (Mbaisi, Ng’ang’a, Wanzala & Omolo, 2013). Among health-care providers in Nigeria who are exposed to these risks, the nurses are most affected and do not give incident report at each occurrence (Diwe & Chineke, 2013).
Health-care providers can also transmit infective agents associated with blood-borne pathogens from one person to another. Transmission occurs as a result of direct contact with infected blood or blood products, and other body fluids between health-care providers and infected patient. Also,infected body fluids such as blood, sputum and urine can penetrate mucus membranes or enter through open wounds, cuts, abrasions and damaged skin. Blood-borne pathogens may also be transmitted through mucous membrane of the eyes, mouth and nose occasional by splashes. The Needle-stick and sharp object injuries symbolize a major occupational challenge to health-care workers (Memish, Assiri, Eldatlaony, Hathouth, Alzoman & Undaya, 2013).
In 1995, Hospital Infection Control Practices Advisory Committee (HICPAC) in the United States introduced the concept of standard precautions which combines the major features of universal precautions and body substance isolation into a distinct set of precautions to be adopted by health-care workers for the care of all patients in hospitals regardless of their presumed infection status. These precautions are to help prevent the transmission of blood-borne infections. Should these standard precautions be framed into daily operational procedures at health-care facilities and enforced, probably the percentage of compliance would have been more adequate which will transit to minimal occurrence of infection(s).
Health-care workers (especially nurses) are at high risk of becoming exposed to blood-borne infections through needle stick and sharp object injuries (Zehnder, 2010). Various studies had posited a number of factors that affect the utilization of universal precautions by nurses.Three major areas that should not be overlooked include engineering factors such as the form of sharp devices and unavailability of devices (Wilburn & Eijkemans, 2004), organizational factors such as the existence of supplies and policies for reporting, and behavioral factors which are disposal-related issues (Hossein, Hosein, Eesa & Ali, 2016).
These three areas (engineering factors, organizational factors and behavioral factors) are in coherence with the information, motivation measures and behavioural skills the nurses may possess for the application of standard equipment and object-handling precautions. The use of available sharp devices should come with information guiding their usage for all professions, particularly nursing because of the sensitivity of their profession (Hughes, 2008; Rutala & Weber, 2008). Existing policies guiding the procedures for use and monitoring would serve as factors that motivate nurses to apply the precautionary measures (Houser & Oman, 2011). The behavioural factors revolved around their ability to carry out what they have received information about and their willingness to practice these precautions (Ryan, 2009). Majority of the health-care workers are still at high risk of contracting blood-borne infections due to the lack of application of the universal precautions.
1.2 Statement of the Problem
Over the years, the effects of occupational accidents have generated a lot of concerns for health care managers and workers. The occasional contact with blood and body fluids from infected patients by healthcare workers during treatment without precautionary measures has become a growing concern and as such elicit probe to stem down the tide of occurrence. The World Health Organization (2006) in a program with the theme “Working Together for Health” posited that unsafe working conditions has eroded the confidence of health-care workers in many countries due to work-related illnesses and injuries which has resulted to fear of health workers on occupational infections.
Some studies have linked poor information to the risk of contracting blood-borne diseases among nurses (Abdela, Woldu, Haile, Mathewos & Daressa, 2016) while some others have associated the risk of getting blood-borne infections to low level of professional competence among healthcare providers (Aluko, Adebayo, Adebisi, Ewegbemi, Abidoye & Popoola, 2016). None of these studies have however linked the risk of contracting blood-borne infections to level of information, motivation and behavioral skills. Regular information about the contents of the universal precautions would improve their knowledge and enable them apply the precautions (Quan, Wang, Wu, Yuan, Lei, Jiang, & Li, 2015). Motivation on the other hand is the constant supply of necessary kits and drive that makes applications of the preventive measure optimal (Amoran, & Onwube, 2013). Behavioural skills are the competent skills that are required to maximize the full benefit of utilizing universal precautions (Yousafzai, Janjua, Siddiqui & Rozi, 2015).
Based on this premise, this study would seek to investigate how these three factors (information, motivation and behavioral skills) can serve as predictors of usage of universal precautions in the prevention of blood-borne infections among nurses. The factors are developed from the IMB (Information Motivation Behavioral skill) Model (Fisher & Fisher, 1992) and used to derive relevant information on this salient issue of concern. The study aimed to assess information, motivation and behavioural skills as predictors of the utilization of universal precautions among nurses in health facilities in Sagamu, Ogun state.
1.3 Objective of the Study
The main objective of this study was to assess the factors associated with the utilization of universal precautions among nurses in health facilities in Sagamu, Ogun state, Nigeria. The specific objectives are to:
- Determine the level of information of respondents through assessment of their knowledge about universal precautions;
- Determine the level of motivation to utilize universal precautions among the respondents;
- Measure the level of Behavioral skills of respondents by assessing perceived self-efficacy and perceived benefit to utilize universal precautions;
- Assess the level of utilization of universal precautions among the respondents;
- Determine if information is associated with the utilization of universal precautions among the respondents;
- Determine if motivation is associated with the utilization of universal precautions among the respondents;
- Determine if behavioural skills is associated with the utilization of universal precautions among the respondents and
- Identify which of these variables information, motivation and behavioural skills will predict the utilization of universal precautions most significantly among the respondents.
1.4 Research Questions
- What is the level of information of the respondents in this study?
- What is the level of Motivation of the respondents in this study?
- What is the level of Behavioral skills of the respondents in this study?
- What is the level of utilization of universal precautions among the respondents in this study?
- What is the association between information and the utilization of universal precautions among the respondents in this study?
- What is the association between motivation and the utilization of universal precautions among the respondents in this study?
- What is the association between behavioural skill and the utilization of universal precautions among the respondents in this study?
1.5 Justification for the Study
The prevalence of blood-borne infections among health-care workers has become a case of serious concern in the field of public health (WHO 2016). The Center for Disease Control and Prevention (CDC) pointed out that the incidence of blood-borne related infections from needle-stick injury results from improper needle-sticks disposal-related activities, activities after use and prior to disposal such as item disassembly and recapping a used needle. The situation of needle-stick injury poses a threat for further transmission of blood-borne infections and this has aroused researcher interest in health-care workers as they are the most at risk.
Studies have pointed out that non-utilization of the universal precautions are due to poor knowledge of the nurses about blood-borne diseases (Gupta, Bajapai, Sharma, Shah & Sarin, 2013) and lack of materials for carrying out the precautionary measures (Frickman, Schmeja, Reisinger, Mittlmeier, Mitzner, Schwarz et al, 2016). However, of the many studies that have been conducted on occupational-risk exposure and risk preventive practices, only a few were theoretical and conceptually grounded (Atulomah & Oladepo, 2002; Efstathiou, Papastavrou, Raftopoulos, & Merkouris, 2011; Alemie, 2012). Most of the studies were carried out on general health care workers with only a few laying emphasis on the nursing profession (Hassanpour, Mohammadi & Nikbakht-Nasrebadi, 2015; Sin, Lin, Chan & Wong, 2016).
Therefore,this study would fill the gap identified in these studies by assessing how a behaviour theory, the information, motivation and behavioural skills model can effectively predict utilization of universal precautions to prevent blood-borne infections among nurses. The study wouldattempt to find suitable explanations for continued exposure of occupational risk of blood-borne infections despite the well-established introduction of the preventive measures. At the end of this study, issues regarding information-received by nurses and their reasons for non-utilization of universal precautions would be revealed. The findings might provide guidance and standards for complying with these precautions. This would improve the health care facilities and services provided. Therefore making Sagamu nurses healthy people and by extension nurses in Nigeria.
This study hypothesized the following:
- H1: There will be a significant relationship between information and the utilization of universal precautions among the respondents.
- H2: There will be a significant relationship between motivation and the utilization of universal precautions among the respondents.
- H3: There will be a significant relationship between behavioural skills and the utilization of universal precautions among the respondents.
- H4: One of these variables information, motivation and behavioural skill will predict the utilization of universal precautions most significantly among the respondents.
1.7 Operational Definition of Terms
These are set of procedures and guidelines to prevent parenteral, mucous membrane and non-intact skin exposures of health-care workers to blood-borne pathogens, which was publish by centers for disease control and prevention (CDC) as recommendation for prevention of blood-borne infections among health-care providers. Universal precautions require the use of protective equipment such as gloves, apron, mask, goggle and safe disposal of sharp devises to minimize percutaneous injuries.
Information in this study connotes knowledge. Information can be converted into actionable knowledge in support of decision making process. Effect of information is mainly expressed as a result of the development and deployment of prevention behavioural-skills that are directly applied to the initiation and maintenance of preventive behaviour
Motivation in this study explains the reason for constant repetition of behaviour. Motivation is internal and external factors that arouse desire and drive for a continually role by building ones interest. The direct effect of motivation on preventive behaviour is prominent when complicated or unusual behavioural-skills are not required to perform a preventive behaviour.
Behavioural-skills in this study are supplementary requirement to perform preventive behaviour. It also determines whether even knowledgeable individual and highly motivated individual will be capable of practicing the necessary prevention. It composes of a person objective ability and perceived self-efficacy concerning performance of the sequence preventive behaviour.
Summary, Conclusion and Recommendations
Universal precautions to prevent the contraction of blood-borne among healthcare workers has not strictly been adhere to. Hence, this has expose healthcare workers especially the nurses to blood borne infectionsin the course of discharging their duties.
This study was conducted among nurses in both public and private health facilities in Sagamu, an urban community to assesshow information, motivation and behavioural skills to utilize universal precautions can predict the adherence practice of universal precautions. From this study it was deduced that the adherence practice of universal precautions among the nurses was not optimal (9.86 (0.18) ±2.62) which is 65.73%. The study showed thatparticipants scored 79.31% in information, 70.96% in motivation and 82.93% in behavioural skills.
Majority of the participants understood that universal precautions are means of protection against blood borne diseases and that utilization of universal precautions cannot result in transmission of infections during procedure. The participants were aware that protective barrier are needed to carry out universal precautions and that hand washing decreases the incidence of transmitting infections. However, only below average of the participants could identify the protective barriers necessary to carry out universal precautions and might be due to the fact that not a good number of them were informed regularly about the universal precautions.
This is consistent with findings from studies that stated that healthcare workers are knowledgeable about the hazards in healthcare facilities and the application of universal precautions, however were at variance with practice (Olufemi, Ayobami, Titilayo, Mathew, Abiodun & Bukola, 2016 and Watson, Williams-Johnson, Watson, Walters, Williams & Eldemire-Shearer, 2014).
Participants in this study received less motivation (70.96%) when compared to their information. Only 33% participant used the protective barrier even when it’s not convenient and 51.7% believed hand washing should be done after each procedure even when the glove is intact. Also, only 69.9% of the participant could recognize the danger in recapping,disassembling used need and then take necessary measures when disposing it, and only 56% believeit’s of great benefit toreport every injury sustain. These are due to the fact that only 44.9% are supervised to strictly comply with universal precautions, while 52.2 % have access to puncture resistance container and policy for reporting needle-stick injury, post exposure prophylaxis program and awareness of reporting procedure are made available to 49.8%, 43.5% and 43.5% respectively.
However there is significant relationship between motivation to utilize universal precautionsand adherence practice of universal precautions (B=0.141; β=0.274; R2=0.075; P=0.000) has also been traced to relevant literature.Akinboro, Adejumo, Onibokun and Olowokere, (2012) indicated that lack of organizational sustenance; inadequate provision of necessary consumables and less supervision are responsible for the unsafe working environment for the health-care providers. Also, Sin, Lin, Chan and Wong, (2016) reported that percutaneous injury is very common but there was no regularity in the post-exposure prophylaxis. Also a study carried out by Isara, Oguzie and Okpogoro, (2016) reveals that most of these injuries are not reported and there was no post exposure prophylaxis.
Majority of the participant recognize that strict compliance of universal precaution is beneficial (82%) and washing of hands before and after procedure would reduce the risk of transmission. While only 45% are sure not to sterilize glove for reuse and only 70.8% admit that safe handling and disposal of used sharp objects is part of their job. Only 39.7% would report injury incidence sustained irrespective of the outcome it would generate. The relationship between behavioural skills to utilize universal precautions and the adherence practice of universal precautions (B=0.481; β=0.466; R2=0.217; P=0.000) can be linked to the level of motivation they have and the level of information they receive and their ability to comprehend the information.This finding is consistent with a study conducted by Yousafzai, Janjua, Siddiqui and Rozi, (2015) reveals that the compliance with universal precautions as a preventive measure among health-care providers is very low and it’s associated with self-efficacy in performing universal precautions, benefit of utilizing universal precaution and perceived susceptibility.
Result from this study showed that NNPC medical center scored highest in adherence practice of universal precautions, these might be due to the fact that they had the highest score in motivation to utilize universal precautions, behavioural skills to utilize universal precautions and second highest information. This discovery is similar to many findings that showed that an adequate skill was applicable to practice universal precautions (Bolaji-Osagie, Adeyemo, & Onasoga, 2015).
This finding also showed that nurses below the mean age scored the lowest across all variables while nurses above the mean age (38.76) scored highest across the entire variable and the adherence practice of universal precautions. However, this is consistent with findings froma descriptive study design carried out by Bolaji-Osagie, Adeyemo, and Onasoga (2015) revealed that the midwives had sufficient knowledge about universal precautions based on their age, and years of working experiences as contributing factor which enable them to practice universal precaution optimally.
Finding from this studies showed that majority of the respondent are females and the male in the nursing professions are few. The male nurses in this study had the highest score across the entire variable including the adherence practice but this was not significant.However, this study revealed that nurses that are separated in marital status scored the highest across the entire variable and their adherence practice was optimum.
Result from this study revealed that nurses with the least qualifications scored the lowest across all the variables including the adherence practice of universal precautions, this finding is similar to the study carried out by Piai-Morais, Orlandi, and Figueiredo, (2015), which revealed that nursing professionals have high adherence to preventive measures, while the nursing assistant have lower adherence to preventive measures when compared,because of their low level of training and perceived availability of personal protective equipment.
This study discovered that nurses with the least occupational level scored the lowest across all the variables and the adherence practices of universal precautions was not optimum. This finding was in disagreement with the findings from a study by Malaguti-Toffano, Santos, Canini, Galvão, Brevidelli, and Gir, (2012), which stated that there was no statistical difference in adherence to preventive measures among occupational categories of the of nursing professionals.
This finding also showed that nurses with less than five years of experience on the job scored the least across all the variables including the adherence practice of universal precautions. This finding is consistent with a study carried out by Aluko, Adebayo, Adebisi, Ewegbemi, Abidoye and Popoola, (2016) high level of knowledge and practice were demonstrated by certified female nurses with more than 5years experience at work even though their practice was at variance with the knowledge. Also healthcare worker with more years of working experience have higher tendency of adhering to universal precautions in the cause of discharging their duties (Fayaz, Higuchi, Hirosawa, Sarker, Djabbarova, & Hamajima, 2014).
The deficiencies identify in this study has revealed that nurses are prone to contacting blood-borne infections at work, which in turn have consequences on their health and the services provided. It is proven from this study that to address the issue of non-compliance to universal precautions among nurses; activities should begeared towards improving the behavioural skills of the nurses. This require improving the nurses’ knowledge through adequate information on safe handling of all equipment, and practical display on how best to utilize the necessary kits for universal precautions. If possible complex equipment used by the nurses should come withinstruction manual on how to be handled to avoid injuries.
Also, necessary provision of kits to utilize universal precautions should be made available. Emphasis should be laid on supervision and disciplinary measures to ensure the optimum use of the universal precautions. However, there should be policy for reporting injuries sustained during procedure and provision for post exposure prophylaxis program. These serve as motivation for the nurses to utilize universal precautions.
The effectiveness of any planed intervention would be realistic with more emphasis been laid on nurses that are upcoming in the profession and the older one should not be left out. Nurses holding higher post should compel the junior staff nurse to strict compliance to universal precautions and at the same time serve as role model to them. These can be achieved with necessary measure such as incentives,
Conscious effort should be made by the government, policy maker and stake holders of health facilities to ensure a safe working environment for the nurses. Provision of safer devices that minimize injuries among the nurses should be made, more awareness on the danger of been exposed to blood-borne diseases and benefit of strict compliance with the universal precautions should be emphasized on. There should be provision for regular screening for blood-borne infections for nurses, more training section on regular basis and adequate supplies of the necessary kits. There should be full immunization program for nurses against vaccine preventable diseases, with strict compliance and monitoring. The information given to the nurses should be screen to ensure the content of the messages are relevant.
5.4 Implication of the Study to Health Promotion
Nurses are at risk of contracting blood-borne infections and non-compliance of the precautionary measure poses a threat to their health. Provision of facilities and improved knowledge of the nurses will ensure the maximum utilization of universal precaution. Policies can be implemented to ensure the compliance of the nurses to universal precautions. This would minimize occupational injuries and halt the spread of blood-borne infections among the nurses. It will also improve workplace health promotion.
5.5 Limitations of the Study
This study is not without limitation, firstly, this study did not encompass all categorizes of nurses. Only qualified nurses are considered which meant that auxiliary nurses and student nurses were not included, therefore result may not be generalized for all nurses in Sagamu. Secondly, respondents may have been bias in giving response to some items in the instrument since the data retrieved were based on self-reported information from them.
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