Greek Nurses’ Knowledge and Attitudes Concerning Prevention and Treatment of Infections in the ICUs

Introduction: An Intensive Care Unit (ICU) is an autonomous department, which requires the cooperation of specialized health care professionals and the use of advanced technology in order to provide intensive patient care. The most common infections occurring in the ICU are urinary tract infections, Ventilator Associated Pneumonia, intravascular catheter infections and infectious diarrhoea. Purpose: To investigate the knowledge and attitudes of ICU nursing staff concerning the prevention and treatment of infection. Methodology: Experimental design was used. Only the experimental group attended an interactive lecture based on the newly constructed protocol by actively participating in the program. The information was collected using a questionnaire. Result: Upon completion of the lecture regarding necessary infection control interventions, the percentage of the experimental group’s (Group A) knowledge increased significantly (78.3% rated excellent). Although nurses agree that nursing protocols help nurses to provide a high level of nursing care, ICU nursing staff agree that the implementation of nursing protocols reduces the rate of infections. Conclusion: Establishing new and contemporary nursing protocols and updating guidelines regarding infection control in the ICU, continuous education and webinar courses can prevent nosocomial infection and improve the quality of nursing care provided.


Introduction
In recent years there is an increase in nosocomial infections worldwide. Bacteria spread mainly through the air, direct or indirect contact with contaminated objects and surfaces as well as among patients and health care professionals. The main factor associated with nosocomial infections is prolonged hospitalization, especially for critically ill patients in Intensive Care Units (ICUs) [1]. In addition, there is a direct link between nosocomial infections and medical or nursing interventions such as urinary catheter placement, endovascular catheters, tracheal or tracheostomy care, and ventilator use [2]. The incidence of nosocomial infections in the ICU has been reported to be approximately 2 to 5 times higher than in other hospital departments [3]. The increased morbidity and mortality associated with nosocomial infections in the ICU is a matter of serious concern. More than one hundred thousand cases of nosocomial infections are recorded each year in the U.K., causing five thousand deaths at a cost of more than 1.6 billion euros [4].
According to the Centre for Disease Control and Prevention (CDC), nosocomial infections are one of the leading causes of death in the United States [5].

Causes of Infection
The majority of nosocomial infections (90%) are mainly caused by bacteria [6], while immunosuppressed patients with malignant disease or HIV are considered to be high risk. Gramnegative bacteria, such as coliforms, Enterobacteriaceae, clepsiella, and pseudomonas, are most common in patients with nosocomial infections [7]. In recent years, acinetobacter seems to be appearing more often in the ICU. Gram-positive bacteria, Staphylococcus aureus (cutaneous and epidermidis) and enterococcus are becoming more common due to the extensive use of catheters [8].

Risk Factors
They are classified into two main categories. The first category includes factors that allow pathogenic microorganisms to invade areas of the patient's body that are more easily infected, due to surgery, catheter insertion, intravenous delivery, tracheal intubation, or use of technical equipment such as respirators [9]. The second category includes factors that reduce the patient's immune resistance due to a disorder of chemical or cellular immunity, such as the nature and severity of the patient's underlying disease, the type of medication provided and radiotherapy [10].

Intensive Care Unit (ICU)
Approximately 12% of the total number of hospital beds (within a hospital), are allocated to intensive care services within the ICU [11]. Intensive care includes, 24-hour continuous monitoring, 1:1 nurse -patient ratio, interdisciplinary care, patient support regarding organ and system deficiencies as well as continuous training and education of medical and nursing staff [12]. The role of the nurse in the ICU is not limited to the performance of simple nursing duties such as measuring and recording but provides a holistic approach to the disease manifestation and to the patient.
Nursing education should focus on the development of knowledge and skills as well as promote continuing education and research thus, providing quality nursing care [13]. Highly trained nursing staff maintains and improves the quality of care provided. According to the literature quality indicators such as errors in medication due to staff stress as well as nosocomial infections are significantly reduced through continuing education (CE) and increasing the number of competent staff members [14].
Simultaneously, nursing science can evolve through continuing education and the nurses themselves can gain autonomy, confidence and satisfaction from their work. Providing continuing education for nurses is very important to patients' positive outcome, creating a reliable professional identity as well enhancing cooperation between nurses [15].
A study by Nia et al. [16] included 10 general hospitals in China involving 2,727 nurses, found that 97.3% had participated in a continuing education program in the last 12 months and 92.2% claimed they were familiar with the value of continuing education.
Also, Wolff-Skaalvik, Gaski and Norbye [17], while conducting a study in Norway, found that 56% of nurses employed in a position with a corresponding specialization had voluntarily participated in a continuing education program, while 31% had completed more than one educational program. However, in Greece, the shortage of nursing staff does not facilitate their availability to participate in continuing education programs and in addition and the lack of funds are some obstacles regarding the implementation of such programs [18]. Furthermore, even though progress has been made in recent years, it is necessary to increase the number of ICU beds.
After a relevant study, Zakynthinos and Vrettou [19] estimated that the real needs for ICU beds in the hospitals are 4% of the total beds for local hospitals and over 10% of those for regional or university hospitals. After the covid-19 pandemic, the situation has improved considerably since according to the Ministry of Health the available beds in ICUs in the regional hospitals have increased by 30%.

Infections in the ICU
The most common infections in the ICU are the following: a) Urinary tract infections: Although urinary tract infections (UTIs) are considered to have a good prognosis, the mortality of microbial urinary tract infections is close to 30% [20].
Risk factors for the development of microbial UTI are gender (women outnumber men), diabetes, old age and microbial colonization of the urinary tract [21]. b) Intravascular catheter infections are one of the three leading causes of nosocomial sepsis, often including up to 20% of all ICU infections [22]. Despite the development of antibiotics and the better understanding of the mechanism of this type of infection, the mortality from bacteremia associated with catheters remains high (10-20%) [23]. A review by Shah et al. [24] concluded that the incidence of Catheter-related bloodstream infection (CRBSI) is between 0.1% and 22.5% and between 0.1 and 2.7 per 1000 days, respectively.

c)
Hospital-acquired pneumonia (HAP) and ventilatorassociated pneumonia (VAP) are the leading causes of morbidity and mortality, despite improved antimicrobial therapy, hospital care and prevention measures [25]. VAP usually affects critically ill patients admitted to the ICU, while resulting in an increase in hospitalization days and a mortality rate of up to 20-30% [26].

d) Infections that develop in immunosuppressed patients
such as, infectious diarrhoea. Diarrhoea that occurs in the ICU is a very common problem. Its cause is often based on many factors, can lead to a high number of adverse clinical symptoms, and is associated with extended hospitalization and mortality in ICU patients [27].

Effects of Nosocomial Infections
Nosocomial infections are responsible for increasing mortality, morbidity, rising costs and extended hospitalization (Shepherd & Pottinger, 2013 [36]. Most research is descriptive, focusing on hand hygiene protocol guidelines [37], knowledge related to preventing and treating bed sores, safety tactics for the prevention of surgical infections [38] and methods of preventing respiratory-related pneumonia [39], as well as the effect of the nursing workload on the incidence of infections and mortality of ICU patients. It seems that there is a lack of research studies in Greece on the attitudes and knowledge of nursing staff working in the ICU concerning the prevention and treatment of infections, while examining the four main infections that occur in the ICU.

Materials & Methods
Experimental

Data Collection Method
Data were collected using a questionnaire with a total of 34 questions constructed by the researchers. The questionnaire consisted of three parts, in which the content, structure and wording were the same in both groups. In the first part of the questionnaire, Due to the morning shift increased workload, the lectures were held in the afternoons in consultation with the nurse managers.
It was difficult for the members of the staff to participate due to rotation schedules. As a result, the lectures were presented to groups of 5-6 nurses. Finally, measurements were repeated after the administration of the experimental intervention.

Sample
In the present study, convenience sampling was used due to financial resources. The study included ICU nurses from two public hospitals within the region of Western Greece. A total of 53 nurses were approached while, 45 participated in the survey (84.9%).
Group A (experimental group) was divided into 2 sub-groups of 15 nurses each: before and after the effect and group B (control group) included 15 nurses.

Statistical Analysis
The collected data were analysed using the statistical program SPSS 24. Statistical significance level was set at p <0.05.

Correlation Per Group
The study showed statistically significant results in the following correlations:

Discussion
Infections in ICU patients are accompanied by high mortality, increased length of hospital stay [41] thus affecting patient recovery and increasing costs for the hospital as well as the patient. The role of the nurse in the ICU is multidimensional, knowledge, skills and abilities to carry out appropriate nursing interventions and provide a high level of nursing care are needed. Nursing education should be continuously updated focusing on knowledge as well as skills, continuing education and nursing research [42].
The present study demonstrated that the knowledge of nurses regarding the most common infections in the ICU (respiratoryrelated pneumonia (VAP) and intravascular catheter) is inadequate. This is probably due to the fact that the protocols for nursing interventions to prevent and treat these infections are either outdated or non-existent. Most developed countries have up-todate protocols, thus educating staff on the latest infection data.
However, the nurses' knowledge increased significantly (78.3% excellent level of knowledge) after the lecture on infection control was completed.
Additionally, nurses in both groups agreed that aseptic technique should be applied when treating intravascular catheters.
Most infections can be prevented by using aseptic technique when inserting, treating and changing catheters [43]. Still, hand hygiene is the most important and effective skill for preventing and controlling the spread of hospital-related infections. Fligou et al. [44] in a prospective study, found that the implementation of intensive hand hygiene protocols by ICU staff in conjunction with total indoor reconstruction projects can lead to a statistically significant reduction in the frequency of VAP. A study by Juneja et al. [45] showed that 94.4% and 97.6% of health care professionals working in the ICU mentioned premature ventilator weaning and hand washing as key preventative measures, respectively.
It is also important to note that in the present study, the majority of nurses in all groups agree that nursing protocols help provide a high level of nursing care thus decreasing the number of infections.
Nursing protocols are comprehensive structured plans describing the procedure a nurse should follow during an intervention. The widespread interest in clinical protocols stems from issues most healthcare systems are dealing with such as, the rising cost of healthcare and the growing demand for quality care [46].
The importance of nursing protocols was shown in the present research as the intervention team significantly increased their knowledge after the lectures. One of the most important advantages of nursing protocols is the quality they have as "evidence", which are the basic rules of quality. The application of the most up-todate knowledge in daily clinical practice aims mainly at reducing ineffective and costly practices [47]. In addition, with the existence shown that the greater the experience in the department the better the scores of the nursing staff in the knowledge test. Similar results were found in the study of Blot et al. [49] which showed that experienced nurses have a higher level of knowledge compared to nurses with less than 5 years of experience [50].

Study Limitations
A limitation of this research study is the small sample from one Region. Although the research provided important data on the knowledge and attitudes of ICU nursing staff concerning prevention and treatment of infections, it is considered necessary in the future to conduct a study with a larger sample working in hospitals in various Greek cities.