Impact of Training Education Program on Improving of Nurses Performance Regarding Infection Control in Endoscopy Unit

Background and study aim:Endoscopes are complex and reusable devices. Understanding infection control in the context of endoscopy is important in reducing the transmission of infection. This study aims to evaluate the effect of an educational program on improving nurse's knowledge and practice regarding infection control in endoscopy unit at Zagzig  University Hospital. Subjects and methods: A quasi experimental research design was used.  The study was conducted in the Endoscopy Unit at Zagazig University Hospitals. The study samples were all available endoscopy nursing staff . First tool was Questionnaire sheet, to assess nurses' knowledge. The second tool was observational checklist to assess nurses' practice. Results:this study revealed that two third of nurses were in the age group of more than 40 years with mean age 42.2 ± 8.4 years and the majority of the sample had more than 10 years experience. There was improvement in total level of nurses'knowledge and practice regarding infection control with highly statistically significant difference between pre- post and pre-follow up program phase as regarding to infection control. Conclusion:The implementation of health educational program had improved nurse's knowledge and practice regarding endoscopy infection. Recommendations: Continuous educational and infection control training programs are recommended in endoscopy units. So incorporation of such interventions apply in all endoscope unite all over Egypt.


INTRODUCTION
The endoscopy itself is not dangerous, but the current cleaning process used between procedures leaves patients susceptible to infection and troubles many healthcare practitioners [1].The Emergency Care Research Institute, listed that, inadequate reprocessing of endoscopes as one of its "Top 10 Technology Health Hazards," asserted that reprocessing guidelines should be continuously reviewed and technicians should be better trained [2].Bommarito reported that about 15% of endoscopes in Untied States (US) hospitals failed to achieve an accepted standard of cleanliness after liquid reprocessing (the prevailing disinfection process used between patient procedures in his study, duodenoscopes were the dirtiest at a 30% contamination rate, and colonoscopes were the cleanest at a 3% contamination rate [3].Peery et al. stated that more than 18.6 million gastrointestinal endoscopies were performed at least every year in the US alone [4].While The Gastrointestinal Endoscopy Center at Zagazig University Hospital offers a highly specialized medical service for many clients suffering from different GIT problems.The monthly reports of that center indicated that, during the first four months of 2013, more than 500 GIT endoscopy were performed each month [5].Approximately 3 million health care workers (HCWs) experience percutaneous exposure to blood borne viruses (BBVs) each year.This results an estimated 16,000 hepatitis C, 66,000 hepatitis B, and 200 to 5000 human immunodeficiency virus (HIV) infections annually.
More than 90% of these infections are occurring in low-income countries and most of are preventable.Several studies report the risks of occupational BBV infection for HCWs in highincome countries where a range of preventive interventions have been implemented.In contrast, the situation for HCWs in low-income countries is not well documented, and their health and safety remains a neglected issue [6].
Nurses have a professional and legal responsibility in preventing cross-infection from reaching to the patient [7].Teaching and training are essential for the nursing staff members to improve the quality of health care and to acquire new knowledge and skills.Educational programs are considered as means for providing nurses with theoretical and technical information needed to acquire new skills and to continually improve nursing practice.Also help nurses to accept responsibilities for their professional development.The knowledge and practices of nurses in relation to infection control were deficient.The implementation of a specially developed program has led to statistically significant improvements in nurses' knowledge and practices [8].The well-trained nurse is the backbone of a well-organized department.Today's technical and scientific advances in nursing and increasing consumer demand for high quality health care urged the nurse to keep current in a field that is exploding with new information and increases the need for developing nursing staff education [9].

Significance of the study
Infection control has recently received a considerable amount of attention.Each year, there are more than 2 million healthcare-associated infections causing 90,000 deaths in the United States.Gastrointestinal (GI) endoscopes are used in more than 10 million procedures annually [10], and contaminated endoscopes have been linked to more outbreaks of healthcare-associated infections than any other medical device [11].All staff in any setting where gastrointestinal endoscopy is performed must adhere to infection control principles that will maintain a safe environment, free from the possibility of spreading disease to patients and co-workers.This is true regardless of the setting (hospital, clinic, ambulatory care center, and office), relative to any and all types of gastrointestinal (GI) procedures performed.Each individual who reprocesses instruments should complete the initial infection control orientation and reprocessing competency.Competency review and infection control updates should be validated and documented annually [12].

Aim of study:
This study aimed to evaluate the effect of an educational program on improving nurse's knowledge and practice regarding infection control in endoscopy unit at Zagazig University Hospital.

Research design:
A quasi experimental design was utilized in this study.

Research Setting:
The study was conducted in endoscopy units in Zagazig University Hospitals.

Subjects:
The subjects of the study compromised of all available endoscopy nursing staff.

Tools for Data Collection:
Two tools were used for data collection from endoscopy nurse which include: 1-Questionnaire sheet to assess the endoscopy nurses knowledge regarding infection control (Pre, during, and Post) procedure.

3-Implementation phase: Included;
The implementation of this program was covered over small sessions, including theoretical and practical content developed and selected to meet the participants' needs and correspond to their interaction and level of understanding as stated by the pilot study.Teaching was done through classical lectures and group discussion which were strengthened by demonstrating the role played by using suitable teaching aids prepared specially for the program such as lecture, handout, posters, colored pictures and simulators.

Practical part included:
Practical part: 10 sessions for practical, it composed of the application of patient preparation before procedure, care during procedure, and care after procedure, endoscopy reprocessing as (pre-cleaning, cleaning, rinsing, disinfection, drying, and storage.Demonstration and re-demonstration several time until correct done of the pre-duringand post endoscopy use.

4-Evaluation phase:
Evaluation was done immediately post program implementation and after six months of the follow up phase.The follow up was done to assess the nurses knowledge and practice of infection control and prevention in endoscopy unit through comparing the results of the pre, post and follow up phases to assess the continuous effect of educational program and the sheets were answered within 30-45 minutes, then collected.

III-Administrative design:
An official permission was obtained from Medical director and nursing director of the study setting.After clear explanation about the study title, aim of the study and setting where the study would be conduct and its benefits.

Ethical consideration:
The purpose of the study was explained to the nurses and oral consent was obtained from them to participate in this study.They were given an opportunity to withdraw from the study without given a reason and they were assured that anonymity and confidentiality of information was protected.Ethics, values, culture, and beliefs were respected.

VI -Statistical Analysis
All collected data were organized, categorized, tabulated, entered, and analyzed by using SPSS (Statistical Package for Social Sciences); a software program version 15, which was applied to frequency tables and statistical significance.The statistical significance and associations were assessed using, the arithmetic mean, the standard deviation (SD), Wilcoxon Signed Ranks test (Z test), Pearson chi-square test (X 2 ) and Pearson Correlation (r) to detect the relation between the variables.Graphs were done for data visualization and using Microsoft Excel.

RESULTS
Table 1: It was found that two third 66.7% of nurses were in the age group of more than 40 years with mean age 42.2 ± 8.4 years.In relation to the training 63.3% of them were not receive any training.Meanwhile ninety percent of the sample had completed their Secondary nursing school education while 10% had Bachelor in Nursing.As regards to occupation most of studied nurses 80% were staff nurse.As well as majority 93.3% of the sample had more than 10 years of experience with mean 23.8 ± 8.6 years.
Table (1) shows also 60% of nurses had medical examination pre working, while only 10% of them had medical examination during working.Figure 1: shows that regarding to Hepatitis B Vaccination; 76.7% of study sample were received the vaccine.
Table (2) and Figure (2) show that there was highly statistically improvement in of total nurses knowledge including :infection in general, nosocomial infection, principle of disinfection, infection control precaution, and endoscopy reprocessing when comparing with pre and post, pre and follow up implementation of educational program, at P≤0.01**.Also represented that total nurses knowledge in per program was 3.3% only satisfactory increased to 80% in post phase and 70% in follow up phase of educational program.
Table (3) shows that there were highly statistically improvement of Practice Level regarding standard precaution as hand washing-wear protective cloth (Wear overshoes, wear mask and goggles, wear sterile gown, wear sterile gown, and wear sterile gloves), when comparing with pre and post, pre and follow up of implementation of educational program, at (p≤ 0.01**).
Figure (3) shows that there were highly statistically improvement of practice level regarding adherence to infection control principles restrictedly during procedure as satisfactory level increase from 10% in pre phase to 83.3% inpost, pre and follow up of implementation of educational program.
Table (4) Shows that regarding to Nurses' Practices of Infection Control Precautions post endoscopy procedures there were highly statistically improvement of practice level regarding of infection control in all table items namely pre-cleaning,leakage testing, manual cleaning, high level disinfected, manual disinfecting, endoscopy storage, and nurses total post procedure when comparing with pre and post, pre and follow up of implementation of educational program, at (P≤0.01**).
Table (5) and figure (4): Illustrated that there were a highly significant statistical improvement of total nurses practice level regarding infection control in endoscopy unit (P≤0.01**).As satisfactory level was 0% in pre-program increased to 80% post, and 76.7% follow up of implementation of educational program.Also, Hosoglu et al. mentioned that more than two-thirds of the participants, in their study, had not been trained on the prevention of bloodborne diseases and the risks of occupational injuries [19].The finding of the current study can be explained in the light of the belief that training within the unit is enough , also it may be due to lack of nurses' interest about the infection control training that done by the infection control team in the hospital.This justify is appreciated by Kandeel et al. who stated that the experience of developing and implementing an infection control (IC) program in Egypt has highlighted many constraints that are common in developing countries, including the lack of trained health care professionals and IC specialists who can implement IC programs [20].
In relation to pre-employment screening and periodic examination during the work, three fifth of nurses had medical examination before working, while only ten percent of them had medical examination during working, thus there is increased risk of spread of infection, absenteeism and disability.This finding goes in the same line with Ghonaiem, and Mohammed who found that the majority of nurses had no pre employment screening and periodic examination during the work [21,22].
Regarding to Hepatitis B Vaccination the current study revealed that, three fourths of study sample were received the vaccine.This is may be due to the increased awarenessof the hospital administration about the importance of the vaccine.Also Ghonaiem, and Mohammed revealed that the majority of nurse had not immunized against viral hepatitis [21,22].This result is in agreement with EL-Badawy who found that, in the Liver Institute and in Shebin EL Kome Teaching Hospitals, Menofuya, Egypt, about 8% of nurses had positive hepatitis B surface antigen, 28% of them had positive anti-hepatitis B surfaces, and 24% had positive anti-hepatitis C [23].This finding also consistent with Daniels who mentioned that the nurses should be vaccinated to prevent the potential risk of HBV The current study also showed that regarding automated disinfected and rinse the study represented that minority of nurses in preprogram increased to one third in post program, while endoscopy handling were most of nurses increased to majority post program, and endoscopy storage more than one third increased to 100% post program.Regarding their total practice, none of the nurses had satisfactory level which improved to half and two fifth in post and follow up respectively.This finding supported by the study carried by Ali and Taha who reported that, in relation to applying reprocessing steps correctly which include rinsing, storage, documentation and decreasing microbial contamination the results of our study indicated effectiveness of the provided program toward this issues [37].
The current study illustrated that there were a highly significant statistical improvement of total nurses practice level regarding infection control in endoscopy unit, (p≤0.01**).As satisfactory level was 0% in pre -program increased to most of study subject in post program, and more than three fourth in follow up of implementation of educational program.This result was congruent with El ghatey et al. who reported that there were highly statistical significant differences between nurses practice pre and posts program implementation [6].This result consistent with Ali and Taha who stated that the improvement in nurses' practices after the intervention was also noticeable since their practices before the guidelines were even worse compared with knowledge.In fact none of them had adequate practice at the pre-program phase.Like knowledge, the adequate practice continued throughout the follow-up, and the attendance of the program were the only independent predictors that positively influenced the practice score [37].

CONCLUSION:
There is improvement in total level of nurses' knowledge, and practice regarding infection control when comparing with pre-post, post/ follow up implementation of educational program.

RECOMMENDATIONS:
Continuous educational infection control training programs are recommended in endoscopy units.
So incorporation of such interventions apply in all endoscope units all over Egypt.

Theoretical part included: Theoretical part: it
The program was implemented through the theoretical and practical sessions.Informed participant with time tables as follow: 1. Maintaining of administration acceptance.2. Timing of the program implementation, which used to be in the morning and the follow up used to be conducted in endoscopy (9 AM o'clock until 1 PM o'clock).3. Informing the nurses with time table chart.4. Conducting the program.covered by two sessions about definition of endoscope, uses, importance, indication, patient preparation, and complication, and two session covered definition of infection, nosocomial infection, chain of infection, disease transmitted through endoscope, tow session about standers universal precautions, and aseptic techniques.

Satisfactory at 75% Unsatisfactory at < 75% Figure
(3):Adherence to infection control principles restrictedly during procedure Table (3): Frequency Distribution regarding Nurses' Practices of Infection Control Precautions Prior to Endoscopy Procedures Throughout The Study Phases (n=30)

Table ( 4
): Frequency Distribution of Nurses' Practices regarding Infection Control Precautions Post Endoscopy Procedures

Table ( 5
): Total Nurses' Practices of Infection Control in Endoscopy Unit Throughout the Study Phases (n=30) Figure (4): Total Nurses' Practices of Infection Control in Endoscopy Unit [36] this is supported by El Ghatey et al. who stated that, as regard to sterile glove technique, minority of nurses showed unsatisfactory level of practice with the same score in the pretests.This could be attributed to the lack of information regarding the importance of using sterile gloves in aseptic technique and lack of motivation[6].Burdick, andHambrick added that the disinfection process requires immersion of the endoscope in the high-level disinfectant and ensuring all channels are perfused for the approved contact time[36].