The quantitative data revealed no significant differences in the knowledge, attitudes, and practices related to infection control among nurses, residents, and senior practitioners and between the gender. However, the participants from the intensive care units had a better score in the knowledge of HAI and the practice of infection control measures. Our finding is contrary to results from other studies that demonstrated poor knowledge of HAI and non-compliance in infection control measures among intensive care unit HCWs [29, 30].
Another KAP study on hand hygiene among HCWs from Al Qassim, Saudi Arabia, reported excellent knowledge but rather poor compliance with the practice of infection control measures and standard precautions [31].
The U.S. Centers for Disease Control and Prevention (CDC) emphasizes the need for HCWs to have sound Knowledge of HAIs and their different types to ensure adequate prevention and control [32]. The qualitative data also made it clear that participants had a sound understanding of the definition of HAIs, the various types, and which types are most common in their hospital, as well as the overall importance of adequate infection control measures.
However, several junior residents in the study demonstrated a lack of knowledge of the different types of HAIs. One recent study revealed the insufficiency of infection control training in medical schools [33]. Another KAP survey from Riyadh on hand hygiene done on three groups of students (medical/nursing/respiratory therapy students) concluded that knowledge of hand hygiene was excellent among all the groups with highest among the nursing and lowest among respiratory therapy students. It was also concluded that good knowledge was associated with good compliance with hand hygiene [34]. A KAP survey from neighboring Namibia reported better KAP scores for medical students as compared to the nursing students. The study emphasized the need to impart knowledge on infection and infection control measures earlier in the curriculum of the students, as we have done in our study [35].
Medical and nursing students in Saudi Arabia are introduced to HAIs and infection control through short lectures in the third year of medical school and the first year of nursing school, respectively. However, they have little access to hospitals during this phase of their studies. We suggest that a practical orientation on infection control measures, along with lectures in teaching hospitals, would benefit students. The training might include weekly practical demonstrations (at least one hour), practice sessions (one hour), presentations (one hour), and a journal club (one hour) for four weeks in the third year of medical school and the first year of nursing school, as a complement to regular lectures. These sessions should focus on the demonstration of hand hygiene techniques, correct usage of PPE, sterilization/disinfection measures, and waste and sharps disposal measures.
Furthermore, short multiple-choice question exams or objective structured practical examinations at the end of these training sessions could also be useful assessments. Intervention at this point is necessary because, during their clinical rotations, students are more focused on clinical cases than on learning infection control measures. Training students at this early stage may help produce medical personnel who are knowledgeable in HAIs and infection control measures.
Well-devised infection control programmes are necessary for preventing HAIs [36]. In our study, participants were aware of the existence of an infection control department in their hospital that functioned in line with CDC guidelines. Studies have demonstrated that many HCWs have inadequate motivation for practicing handwashing techniques and that there is a lack of regular monitoring of compliance with handwashing practices. The lack of motivation may arise from a lack of positive feedback for proper handwashing practices [37]. In our study, regular monitoring of handwashing compliance was conducted, and most HCWs stated that they performed adequate handwashing procedures; this was especially true of nurses, who also actively monitored handwashing practices of other HCWs. The motivation was further boosted via an annual ‘hand hygiene week,’ where the most active participants were rewarded. However, the VRE results demonstrated an apparent lapse in handwashing techniques among residents as compared to nurses. This behaviour has also been reported by many international studies, where compliance with handwashing techniques and recommendations were lower among doctors as compared to other HCWs [38].
The CDC has stressed the need for the availability of different combinations of PPE in ICUs, isolation wards, and other areas in the hospital [39]. All the participants were aware of the importance of PPE but felt usage was only necessary for isolation wards or the ICU. We believe that these problems can be dealt with via education and training regarding the proper use of PPE, as part of an update on infection control practices. The participants also claimed that although gloves and masks were available, there was usually a shortage of gowns, as reported by similar studies where the nonavailability of PPE is a concern [40,41,42]. The lack of availability of PPE has been brought to the notice of the infection control unit. They, in turn, have alerted the hospital authorities who have promised to address these lacunae.
According to the National Institute for Occupational Safety and Health, workplace needlestick injuries can occur through improper sharps disposal [43]. In our study, nurses were aware of and practiced safe disposal of sharps. Nurses also tended to make sure it was practiced by all HCWs, including doctors, which helped in achieving overall compliance.
HCWs should be mindful of the management of waste, which includes generation, segregation, storage, transport, and disposal [44]. While all participants were aware of the separation of hospital-generated waste and the system of color-coding, very few were aware of the waste management process. We believe that the infection control department should develop training programmes on waste management. Action in this regard should be swift, as ineffective hospital waste management can lead to outbreaks of resistant organisms in the community and, thereby, a serious public health issue. A cross-sectional survey conducted in Saudi Arabia also concludes the fact that extensive training programmes should be in place for the HCWs, especially sanitary workers in hospital settings [45].
Relatedly, hospital policy should ensure that general cleaning, sterilization, and disinfection techniques are strictly followed [46]. HCWs should be aware of how to clean blood spills and blood-contaminated fluids with gloves and the use of internationally approved disinfectants [47]. In the present study, both doctors and nurses were aware of the importance of sterilization and disinfection measures. Nurses were also aware of how to manage chemical/blood spills and followed strict protocols for disinfection. However, several of the junior residents were ignorant of the procedures for chemical/blood spill management as they believed it was not their responsibility. Junior residents should take on the responsibility of educating themselves in the management of blood spills. We, as authors, believe that HCWs, in general, should be trained in blood spill management through seminars and workshops. In our study, as part of the orientation programme, seminars, and presentations on HAIs and infection control were conducted annually by the hospital’s infection control board. However, many of the participants felt that workshops and hands-on training programmes every three months would help update their knowledge. We, the authors believe that intensive training sessions, seminars, journal clubs, and competency assessment tests for all HCWs, including paramedical staff, every three months would ensure that they are equipped with the latest information on HAIs and infection control.
The quantitative and qualitative analysis demonstrated excellent knowledge, practices, and attitudes of HCWs towards HAI and infection control. However, the VRE noted that several residents and nurses did not have complete working knowledge of HAIs nor used the PPE appropriately.
Following the feedback and reflective session, a participant (nurse) acknowledged her lapse in protocol and said that she would wear a surgical mask over her face cover in the future. Similarly, the residents were contrite and promised to follow better infection control measures. The focus group strongly emphasized to the nurse that the face-covering veil is a part of the daily dress code and not a piece of PPE like a surgical mask or surgical gown. As per the guidelines of the Ministry of Health, the surgical mask or N95 respirator should be worn behind the veil or face cover, and then a face shield can be worn over the veil [14, 48]. However, it is evident in our study that nurses and female residents in MERS-CoV endemic areas do not follow these guidelines thoroughly.
Published studies have affirmed that hand hygiene and PPE are essential aspects of infection control in the containment of MERS-CoV outbreaks [49, 50]. In our research, PPE, which plays a significant role in the control of airborne diseases, was not being used appropriately, nor were the five moments of hand hygiene implemented adequately, as demonstrated by the VRE findings. This finding is contrary to the qualitative results, which claimed that sterilization and disinfection measures were followed impeccably.
The crossover of unsterile materials into sterile areas was another problem identified in the video sessions. A similar study conducted in Australia using VRE also reported this problem. It concluded that HCWs should better understand boundary and buffer zones (clean areas) to prevent contamination and the unnecessary crossover of non-sterile items into the sterile zone. They should also prepare well ahead of the procedure to ensure smooth movement across boundaries and fair usage of PPE, and practice effective hand hygiene [51]. Following the reflective sessions, the participants acknowledged their lapses concerning crossover and were open to following strict protocols and changing their working methods.
The solutions to the problems suggested by the focus group, and the details of the reflective sessions in our study, will be presented to the infection control unit and the respective administrative departments to allow for further scrutiny of infection control protocols and practices currently in place. One recent study noted that video-assisted monitoring of clinicians and HCWs could ensure that the HCWs can visualize their flaws and better appreciate current infection control protocols. Regarding the present study, the VRE results can enable the hospital’s infection control unit and administrative board to reflect on the limitations of infection control protocols and the feasibility of implementing more effective infection control practices [52]. An effective way to overcome the lapses is through constant monitoring of HCWs through video footage of sterile procedures.
A cause for concern is the recent reporting of MERS-CoV in parts of Saudi Arabia (Abha and Riyadh) and the new COVID-19 outbreak [53]. As already mentioned, one of the ways to contain the infection is through the effective use of PPE. As per a study conducted in Abha, Saudi Arabia, the Physicians felt that surgical masks were more effective in the prevention of the spread of MERS-CoV as compared to other forms of PPE [50]. Our study implies a lapse in the use of PPE, especially the surgical face masks. It can be argued that if this lapse is not handled appropriately, it can help in the fast spread of airborne diseases like MERS-CoV and COVID-19 in the region as well as the country. Similar reports in the failure of the usage of PPE from different centers can make our argument and findings stronger to gain the attention of the concerned medical authorities and imply strict repercussions to curb this substandard practice.
