Knowledge, attitudes, and practices of ICU head nurses regarding infection control and antimicrobial resistance in Iran: a cross-sectional study

Hospital-acquired infections, also known as healthcare-associated infections (HAIs), are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 h or more after hospital admission, or within 30 days after having received health care. HAIs not only endanger patients but also impose significant financial burdens on healthcare systems. HAI infections include catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), surgical site infections (SSI), Hospital-acquired Pneumonia (HAP) and Ventilator-associated Pneumonia (VAP) [1, 2]. HAIs are not only dangerous for patients but also have financial burden for health care system and cause bacteria to become resistant to antibiotics. According to the World Health Organization (WHO), the estimated prevalence of HAIs ranges from 3.6 to 12% in high-income countries and from 5.4 to 19.1% in low- and middle-income countries [3]. Antimicrobial resistance (AMR) threatens the treatment of HAIs, and has been identified as a global health threat by the WHO. Hence, prevention and control of HAIs appear as an important public health problem.

It has been estimated that rising rates of multidrug-resistant bacteria (MDR) infections could lead to the death of some 10 million people and cost the world’s economy USD 100 trillion by 2050 [4]. Infections by MDR isolates occur frequently in patients admitted to intensive care unit (ICU) and are associated with increased mortality, prolonged duration of ICU stay and healthcare costs [5]. In recent years, studies in Iran have shown that the prevalence of MDR specially carbapenem-resistant gram-negative bacteria in ICUs has increased significantly, and some studies have shown that some outbreaks has occurred in ICUs. Healthcare workers (HCW), especially the nurses play a unique role in spreading the infection caused by these organisms and they are considered as key members of managing and controlling the HAIs [6]. Infection prevention and control (IPC) measures are critical in preventing the risk of acquiring and transmitting HAIs. The lack of IPC practices in ICUs is a contributing factor to spread of MDR pathogens and AMR [7].

According to WHO, poor knowledge, attitude, and practice (KAP) among the HCWs are among the key predictors of HAIs [8]. Globally, a number of studies have investigated the involvement of nurses in AMR and infection prevention and control, focusing on their KAP. Individual studies among nurses have suggested that suitable knowledge and attitude can be very important factors in good infection control and prevention measures [1, 9]. Some studies have also showed that low and moderate levels of knowledge among nurses regarding AMR and of infection prevention [9, 10]. However, no study has thus far been conducted towards these issues among ICU head nurses in different hospitals.

On the one hand, the highest rate of MDR infections occurs in the ICUs of Iranian hospitals, and on the other hand, ICU supervisors are one of the most key employees of the healthcare system that play an important role in the control of HAIs due to MDR pathogens and they can also apply the rules and regulations of their department within the framework of the general policies of the hospital in any committee, this study has been conducted to examine the ICU head nurses’ KAP towards AMR and infection control and prevention standards.

The participants were invited to the study from 40 eligible hospitals (with at least one ICU). Overall, there were 64 ICU head nurses across 40 hospitals in Isfahan province. Of these, 61 head nurses (95.3% response rate) from 36 hospitals participated in the study. The participant’s ages ranged from 27 to 56 years old with a mean age of 39.3 ± 5.6 years. As for the professional qualification of the participants, 75.4% of them had a bachelor’s degree and 24.6% had a master’s degree. Among them, (91.8%) were female, the mean work experience in the ICU and duration of experience in the hospital was 8.1 and 16.2 years, respectively (Table 1).

Table 2 shows the number of the participants with the correct answers in each knowledge statement. The mean (± SD) score for knowledge was 3.84 ± 1.86, with a range of 0–9. We found that 80.3% of the participants had good knowledge (≥ 80%correct response) about the possibility of contamination of blood sampling with Staphylococcus epidermidis. We found that almost half of the participants correctly responded to the knowledge statements related to classification of drug resistant bacteria (50.8%), the last line treatment for Gram-negative bacterial infection in Iran (57.4%) and the median cost of a single CRO infection in hospitals (50.8%). While fewer participants (less than 35%) correctly responded to the statements related to questions number 2, 3, 5, 6, and 7.

In relation to the attitude of nurses (Table 3), the mean score was 35.84 ± 4.19, with a range of 24–48. When asked about compliance with standard precautions, 27.9% of participants answered that it is not easy to follow (strongly agree or agree). 41% of head nurses disagreed or strongly disagreed that healthcare workers are occupationally exposed to infectious diseases. Around 80.3% strongly agreed or agreed that they feel frustrated when others neglect hand hygiene while 95.1% strongly agreed or agreed that hand hygiene could reduce the spread of infections.

In relation to the practice of nurses (Table 4), the overall mean practice score was 21.27 ± 3.13, with a range of 17–29. The majority (70.5%; 43/61) of participants stated that when a patient acquired an MDR infection, they use a warning sign above the patient’s head or room to prevent its spread. Around 50% of them stated that chlorhexidine bathing in their ICUs is done every five days. A total of 17/61 (27.9%) head nurses responded that they isolated infected patient with MDR bacteria in a single room. More than half (52.5%; 32/61) of the participants responded that nurses use one glove for each patient care and one gown for each work shift. Almost 68.9% stated that HCWs in their ICU wash their uniforms or scrubs weekly. Almost most of the participants (63.9%; 39/61) stated that the monitoring of patients infected with XDR bacteria is done to prevent and control the spread of drug-resistant bacteria in their ICUs.

Data analysis showed a significant relationship between the mean of head nurses’ knowledge score and their total years of experience mean (r = 0.256, P < 0.048) (Fig. 1). As can be seen in Table 5, no statistically significant association was observed between demographic and other occupational characteristics with knowledge, attitude and practice scores.

HAIs and antibiotic resistance are one of the main problems in health care system worldwide and it helps a lot handling the problem if HCWs have adequate knowledge, attitude and practice toward this [11, 12]. The present study is the first study conducted with the aim of investigating head nurses’ knowledge and practice of and attitude toward AMR and infection control and prevention standards.

In the present study only 19.7% of participants had suitable practice. In a similar study in Zabul, Iran, 2014, about nurses KAP toward standard precautions for hospital-acquired infection on 145 nurses only 22% had good knowledge about HAIs [13]. Therefore, it seems that KAP in the field of HAIs among nurses and ICU head nurses is low in Iran, and in fact, this could be one of the important factors in the high rate of hospital infections with MDR pathogens in ICU wards in Iranian medical centers. That could be explained by a lack of regular training on IPC measures and AMR. The paucity of training in the areas of IPC programs and AMR in nursing faculties contributes to the spread of MDR strains, irrational antibiotic prescribing and increased AMR.

In contrast, the findings of our result were higher than that reported in Saudi Arabia among 341 nurses, where their knowledge score about antibiotic use and prevention of AMR was 13.1% and this wasn’t related to gender or any other demographic characteristics [14]. This finding stresses the need of regular AMR training of health workers. In another study conducted in Ethiopia in 2021 among nurses about Knowledge and practice toward HAIs prevention and associated factors, their knowledge was categorized into two groups: adequate and inadequate; 45.5% had adequate knowledge and this score was 53.3% among males and 38.16% among females and gender (specifically here, being male) had relationship with knowledge score [6]. In contrast, a study by Gruda et al. in Kosovo reported that 90% of the nurses exhibited an excellent knowledge toward management of HAIs which is relatively high compared to other studies, including this study [15], therefore, this could indicate the importance of training courses for nurses during education, which has increased knowledge in the field of HAIs.

In our study total years of experience had a significant relationship with mean knowledge score (r = 0.256, P < 0.048), and this indicate that with the growth of work experience, the ICU head nurses’knowledge increases. In this study 24.6% had master’s degree while 75.4% had bachelor’s degree and 17.39% of nurses with bachelor degree and 26.7% of nurses with master degree had good knowledge, the impact of level of education on knowledge was not significant. In Zabul work experience and level of education did not have significant effect on Knowledge [13]. This could be because the present study was conducted among ICU head nurses who usually have more work experience than regular nurses. In Saudi Arabia there was no significant association between work experience and knowledge about antibiotic use and AMR prevention but it has a strong correlation (p < 0.001) with working unit which was higher in specialized/critical units than ambulatory units [14]. In India 2012 a study conducted on nurses about their knowledge toward infection control practices and it shows 70% of nurses who had more than 5 years of work experience had good knowledge (80-90%) comparing to junior nurses (< 5 years of work experience) that 30% of them had good knowledge [16].

In the present study, attitude score didn’t have significant correlation with any of the demographic’s characteristics. This findings reported in this study were consistent with a study conducted in Zabul that revealed 37% of participants had average attitude and this score didn’t have any significant relationship with any of the demographic’s characteristics [13]. As expected, some ICU head nurses had not a good attitude concerning about HAIs and antibiotic resistance. One way to combat this negative attitude is to hold ongoing training classes on AMR and HAIs and also improve their knowledge in these areas. Another study in Saudi Arabia reported that 76.6% had good attitude toward AMR and prevention of it [14].

Unfortunately, most ICU head nurses in this study had weak practices toward HAIs and antibiotic resistance. The weak practices concerning HAIs and antibiotic resistance among participants could be due to their lack of training and experiences to adhere to the IPC measures. However, depending on the hospital, other important factors such as shortage of personnel, lack of equipment, lack of support from the management team, and inappropriate ICU structure can contribute to poor nurse practices. In the present study, only 19.7% of participants had suitable practice. These results were contrasted with the results of another study carried out in Ethiopia, which showed 64.8% (60.1-69.5%) of nurses had good practice toward HAI prevention [6] and this score was 76.2% in Kosovo [15]. In Ethiopia and Kosovo nurses who had BSc degree and above had better practice and the impact of level of education on nurses practice was significant, while in Zabul, Iran level of education didn’t have a significant impact on practice [13].

In this study, most of the participants stated that they use warning signs to identify patients with MDR infection. The MDR patient’s bed or room is often labeled with a sign signaling including MRSA, VRE, ESBL, CRKP and CRAB the contagious status. In fact, labeling the patient’s room or bed shows the risk of hand and glove contamination after contact with a MDR (+) patient environment [17]. These symptoms indicate a visible reservoir of MDROs, which can ultimately help reduce the spread of these bacteria.

In 2021, a recent systematic review by Lena et al. [18] indicated that different types of HCW uniforms were found to be contaminated with MRSA and other MDR bacteria, which could potentially play a role in the spread of nosocomial infections. Therefore, work clothes should be washed to prevent the spread of infection and to reduce bacterial load on the hands. In the present study, most participants (68.9%) stated that nurses’ uniforms are washed once a week, which can increase the chance of infection transmission in the ICU. This delay in washing nurses’ uniforms can be due to reasons such as the lack of changing facilities and lack of washing facilities, the lack of awareness of ICU head nurses about the importance of washing uniforms in controlling the spread of MDR strains, and the failure of the hospital management team to provide enough clothes for personnel. This contradicts the finding of Riley et al. [19], who have recommended washing uniforms separately after every shift and within 24 h of the shift starting.

Based on previous studies [20, 21], daily bathing with 2% chlorhexidine is now one of the most investigated infection control strategies. Because it can significantly reduce HAI incidence and the risks of acquisition of MDROs in intensive care settings. Almost half of the participants (50.8%) said that bathing with chlorhexidine is done once a week for each patient, and 16.4% also declared that it is not done due to the lack of staff.

WHO recommended some IPC measures to prevent the spread of MDR bacteria [11]. Single room isolation policy as an infection control strategy has contributed significantly to the reduction of cross-transmission of resistant pathogens in ICUs. In this study, only 27.9% of the participants said that they always use the single isolation room for infectious patients, while 18% stated that their ICU does not have an isolation room at all. It seems that in several Iranian hospitals, the ICUs are not structurally designed properly, and in some cases, the insurance does not cover the cost of the isolation room for the patient, on the other hand, 26% announced that only according to the order. Doctors transfer infected patients to the isolation room.

Respiratory tract suctioning is an important factor in caring for patients with respiratory obstruction. According to nursing references, suctioning in the upper and lower respiratory tract should be done in a clean and sterile process, respectively. Though suctioning is a normal process, it is critical to prevent HAIs. Therefore, suctioning of the patient’s nose or mouth should be done cleanly with a pair of clean protective gloves and a sterile suction catheter to prevent bacterial colonization and secondary infection. While in most ICUs of Iranian hospitals which are endemic MDR bacteria, clean suction technique is not observed and suction is performed with contaminated gloves, which increases the risk of colonization in the patient’s mouth or lower and upper airways. Therefore, it is suggested to follow a clean technique or use gauze or sterile gloves. In the present study, almost 50% of the participants stated that gauze or sterile gloves are used during oral suction in their ICUs.

The main limitation of our study was the relatively small sample size selected from one province of central Iran which may limit the generalizability of our findings to the national level, but we are confident that our findings are useful in strengthening the current IPC and AMR measures and developing new ones. Another limitation was that, like most surveys, the use of self-report questionnaires might lead to false information because some participants may have answered some questions by chance.

Having good KAP of healthcare workers especially nurses regarding infection control programs and AMR is vital to prevent the spread of HAIs among inpatients. The findings of our study indicate that most ICU head nurses had weak knowledge, attitudes and practices toward infection control and AMR. Therefore, arranging training courses for ICU head nurses might be useful in refreshing and improving their knowledge of IPC and AMR. Improving KAP among ICU head nurses is important because they can reduce antibiotic consumption, length of stay, costs, and mortality by properly planning and implementing infection control protocols to prevent the spread of resistant strains among patients admitted to the ICU. Finally, it is recommended that Iran’s Ministry of Health and Medical Education and the subsidiary universities make changes in educational curricula, especially in nursing schools to improve awareness and create a favorable attitude among nurses towards the infection control programs and AMR.