https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article Nurses’ Self-report on the Infection Control Unit Activities and their Experience in the Hospital toward Nosocomial Infections in the Sulaimani Hospitals ABSTRACT INTRODUCTION Nosocomial infections (NIs) are present in both developed and developing countries, but 75% of this burden occurs in develop- ing countries [1]. The number of NIs in low- income countries is three times higher than in high-income countries and the neonatal incidence is 3-20 times higher [2]. Background and objectives: Nurses can prevent the occurrence and transmission of noso- comial infections by following infection control measures such as wearing gloves and masks, using appropriate disinfection of skin and preventing accidental needle-stick inju- ries. This research aimed to evaluate the availability of hospital uniforms, personal protec- tive equipment, and infection control activities at hospitals in Sulaimani in the Kurdistan Region of Iraq, and to examine nurses’ experience of nosocomial infections. Methods and materials: A cross-sectional study was performed at 10 governmental hospi- tals during the period from 20th February to 28th September 2018. 525 nurses were se- lected as participants by a convenience sampling method. A self-administrated question- naire was used to collect data, which were analysed using SPSS software. Results: The results showed that 268 nurses (51%) reported that their hospitals provided sufficient uniforms to all the medical staff and the majority of nurses, 444 respondents (84.6%) stated that they were responsible for cleaning their working uniforms. 441 nurses reported that they did not acquire a nosocomial infection, and 479 (91.2%) did not have an accident during their work in the hospital. 79.9% of the nurses (404) reported recapping syringe needles after the usage, and 98 (18.7%) gave a low rating to the infection control unit activity in their hospitals. Finally, more than half of nurses (330) representing 62.9% of the sample were vaccinated against nosocomial infections. Conclusions: Most of Sulaimani governmental hospitals are providing sufficient uniforms for the health staff, the majority of nurses were vaccinated against one or more nosocomi- al infections, and the majority of nurses do needle syringe recapping. Keywords: Nosocomial infection, Infection control unit, Nurse’s accident. Ramand Muhammad Haji; Department of Community Health, Technical College of Health, Sulaimani Polytechnic Uni- versity, Sulaimani, Iraq. (Correspondence: ramandranya@yahoo.com ) Dana Abdilmagid Abdilkarim; Department of Medical Laboratory, Technical College of Health, Sulaimani Polytechnic University, Sulaimani, Iraq. Salar Ibrahim Ali; Department of Community Health, Technical College of Health, Sulaimani Polytechnic University, Sulaimani, Iraq. Srwa Salih Mohammad; Department of Community Health, Technical College of Health, Sulaimani Polytechnic University, Sulaimani, Iraq. 166 Erbil Journal of Nursing & Midwifery Received: 17/03/2020 Accepted: 27/7/2020 Published: 30/11/2020 According to Samuel and Alp, this differ- ence in developing countries is related to the ineffective infection control programmes resulting from lack of prob- lem awareness, understaffing, heavy work- load, overcrowding, erratic electricity sup- ply, poor water supply, ineffective https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article antibiotic policies with the emergence of multiple antibiotic-resistant microbes, poor laboratory backup, poor funding, lack of personal protective equipment, and unsafe working practices [3, 4]. NIs have serious negative consequences such as increased costs of healthcare, prolonged hospital stay, economic hardship to patients and their families, long-term disability, increase mortality rate and increase of antimicrobial resistance [5-8]. NIs are caused by ever- present pathogens that are present in the air, on surfaces and equipment such as bacteria, viruses and fungi [9]. Further- more, nosocomial cases do not include on- ly patients but also healthcare workers, visitors and suppliers who got the infection during work in a hospital environment [10, 11].Nurses are vital healthcare workers who are in more continuous and direct contact with patients than other health staff. They are therefore at higher risk of NIs and also play a vital role in their trans- mission [12]. Research studies show that nurses have a big effect on transfer of NIs [9, 13, 14]. Furthermore, NIs are an occu- pational hazard for nurses [15] and includ- ing this topic in a nursing curriculum has a significant role in their prevention [16]. In- fection prevention and control measures aim to protect patients and hospital staff from acquiring an infection while they are inside the hospital [17]. Infection control should be one of the main responsibilities of all hospital workers and they should have appropriate knowledge and essential related skills [18]. Nurses can prevent the occurrence of NIs by following control measures such as putting on gloves and masks, using appropriate disinfection of skin, changing the infusion sets, avoiding contact with secretions, applying standard precaution principles, appropriate isolation of patients and preventing accidental nee- dling [19]. This study aimed to evaluate the availability of hospital uniforms, personal protective equipment and infection control activities in Sulaimani hospitals and to in- vestigate the nurses’ experiences of noso- comial infections A cross-sectional study was carried at gov- ernmental hospitals in Sulaimani in the Kurdistan Region of Iraq (Table 1). The study included 887 nurses and excluded nurses who were on vacation during the period of study and who worked in posi- tions without direct contact with patients. Data were collected from 20th February to 28th September 2018. To determine the study sample size, Daniel’s method with the formula (N = (Z)2 *P*( 100 – P ) / D2) was used [20]. The prevalence rate (P) as- sumed was 45% depending on Kaushal’s study in 2015 [21], confidence level Z- alpha (Z) 1,96, confidence interval differ- ence (D) 4.5 at 10% of the prevalence and power of prevalence was 45% decreased to 39% to cover the missing data. After ap- plying this formula, the sample size of the study was approximately 525 nurses. A convenience sampling method was used to select the participating nurses. The sample size was divided for each of the 10 hospi- tals by a proportion formula, which is as follows: (number of nurses in a group / to- tal number of nurses *sample size). The sample size number for each hospital is shown in Table 1.A self-administrated questionnaire was utilised to collect data and the firs section included questions about demographical information and workplace characteristics such as age, gen- der, professional education, work experi- ence, hospital, department etc. (Table 1). The second section contained multiple- choice questions about Personal Protective Equipment (PPE) provided by hospitals. The third section included questions about nosocomial infections-related subjects studied at the university, NIs training in 167 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article 168 Erbil Journal of Nursing & Midwifery This study was approved by the Sulaimani Directorate of Health and the administra- tions of the involved hospitals. Further- more, the researchers obtained the verbal informed consent from nurses after ex- plaining the details and importance of the study. This study included 525 nurses at 10 gen- eral hospitals in Sulaimani (Table 1). The mean ± standard deviation (SD) of nurses’ age were 33.28±8.42 with a range of 19-62 years old. Most of the nurses were in the 26-36 years old group (41.5%), followed by the 37-47 years old group (27.3%) and the 25 or less years old group (19.8%) . Figure 2 and 3). In terms of place of work, 192 nurses (36.6%) worked on hospital adult wards, 99 (18.9%) practised in an emergency room, 78 (14.8%) in the oper- ating theatre, 67 (12.8%) in the ICU, 28 (5.3%) on the paediatric ward, 11 (2.1%) in the premature babies unit, and 50 (9.5%) of nurses did not disclose their workplace. RESULTS Figure 1. Nurses’ age groups Figure 2. Nurses’ gender the hospital, nurses’awareness of infection control unit, their estimate of the safety of their hospital, experiences of accidents and acquired NIs, and recommendation to their hospital regarding NI control. The validity of the questionnaire was con- firmed through review by infection control experts at the Sulaimani hospitals and Sulaimni Polytechnic University. After the collection, the data were analysed using SPSS (Statistical Package for the Social Sci- ences) version 22.To obtain descriptive statistics, the mean, standard deviation, frequency and percentage were calculat- ed. In addition, the Endnote software ver- sion 7.5 was used for management of the references. as demonstrated in Figure 1. The majority of respondents were females (67%) in comparison to males (33%). Most of the nurses held institute diploma certificate (66.1%), followed by a bachelor degree (16.4%), and a high school diploma degree (14.5%). Table 1: Representative number of nurses and selected nurses in each governmental hospitals in Sulaimani Hospital Number of nurses Selected nurses Shar General Hospital 262 155 Maternity Teaching Hospital 105 62 Internal Teaching Hospital 88 52 Paediatric Teaching Hospital (Dr.jamal) 87 52 Cardiac Specialists Hospital 72 43 Emergency Surgery Hospital 70 41 Burn and Plastic Emergency Hospital 69 41 Surgery Teaching Hospital 58 34 Internal Emergency Hospital (Hemn) 40 24 Hiwa Hospital for Cancer 36 21 Total 887 525 https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article (Table 2).The majority of nurses (295) had 8 or fewer years of experience (56.2%), 116 nurses worked for 9-17 years (22.1%), while there was 1 nurse who had 36 years of experience (0.2%). 14 nurses (2.7%) did not provide this information. Furthermore, near half of the participated nurses (227/ 43.3%) had every workday contact with patients, followed by 3-4 days of contact per week (177/33.6%). 111 (21.2%) of nurs- es had less than 3 days of patient contact per week and 10 nurses (1.9%) did not an- swer the question (Table 2).The results in Table 3 show that 268 nurses (51%) report- ed that hospitals provided sufficient uni- forms for staff. However, one-third (194) of the participated nurses (37%) indicated that the hospitals did not provide uniforms and 58 (11%) of respondents did not have information about whether hospitals pro- vided uniforms and gloves. The inquiry into the experiences of participated nurses with the cleaning of their working uniforms at hospitals revealed that 444 nurses (84.6%) stated that they were responsible for washing their working uniforms and 41 (7.8%) stated that their working uniforms were cleaned by the hospital cleaning staff (Table 3).Furthermore, a large number of nurses stated that their hospitals did not have a dedicated team for checking and cleaning medical staff uniforms; whereas, 144 (27.4%) of the participating nurses said that the hospitals had such a team. 86 (16.4%) of participants did not have information to answer this question. 139 (26.5%) of participating nurses gave low and 139 (26.5%) allocated a very good satisfaction rating for their hospital uni- forms followed by a good satisfaction rating by 118 nurses (22.4%). 169 Erbil Journal of Nursing & Midwifery Figure 3. Nurses’ professional education Table 2: Distribution of nurses' workplace characteristics Variables groups Frequency Percentage Hospital working units Emergency room 99 (18.9) Intensive care unit (ICU) 67 (12.8) Paediatric wards 28 (5.3) Premature unit 11 (2.1) Surgery room 78 (14.8) Adult wards 192 (36.6) Total 475 (90.5) Missing 50 (9.5) Experi- ence (year) ≤ 8 295 (56.2) 9-17 116 (22.1) 18-26 79 (15) 27-35 20 (3.8) ≥ 36 1 (0.2) Total 511 (97.3) Missing 14 (2.7) Period in con- tact with the patients per week Always (every workday per week ) 227 (43.3) Sometimes (3-4 days per week) 177 (33.6) Few-times (less than 3 days per week ) 111 (21.2) Total 515 (98.1) Missing 10 (1.9) https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article 170 Erbil Journal of Nursing & Midwifery Table 3 :Distribution of personal protective equipment availability Variable groups Frequency Percentage Does the hospital provide sufficient uniforms for health staff? Yes 268 (51) No 194 (37) Do not know 58 (11) Total 520 (99) Missing 5 (1) Who has the responsibility of cleaning your work uniforms in the hospital? Hospital cleaning staff 41 (7.8) Myself 444 (84.6) Others 29 (5.5) Total 514 (97.9) Missing 11 (2.1) Does the hospital have a special team for checking and cleaning health staff uniforms? Yes 144 (27.4) No 292 (55.6) Do not know 86 (16.4) Total 522 (99.4) Missing 3 (0.6) If yes, how often are the uniforms washed? Monthly 8 (6.4) Weekly 11 (8.8) Daily 52 (41.6) Not in regular times 54 (43.2) Total 125 (100) Missing 19 If you rate your working uniform, what rate do you give it out of 100%? Very low (≤ 25%) 63 (12) Low (26%-50%) 139 (26.5) Good (51%-75%) 118 (22.4) Very good (76%-100%) 139 (26.5) Total 459 (87.4) Missing 66 (12.6) https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article Table 4 reveals that 441 nurses (84%) re- ported that they did not acquire any NIs, and 80 nurses (15.2%) claimed that they acquired infection from working in the hos- pital. Furthermore, the infection was the most repeated (21 nurses, 34.4%) occupa- tional health problem compared with aller- gy and influenza at 20 nurses (32.8%) for each. The majority of nurses (479) did not have an accident during their duty at the hospital (91.2%), while 41 respondents (7.8%) experienced an accident at work. A needle-stick injury was the most common accident suffered by 18 nurses (51.4%), 16 respondents (45.7%) accidentally cut them- selves with a sharp object, while a spillage of blood was the least common accident (1 case, 2.9%). The majority of nurses (404) reported recapping syringe needles after using it on the patients (76.9%), and 119 (22.7%) of nurses denied recapping. The results related to nurses’ knowledge about an infection control unit in their hospitals showed that 320 nurses (61%) were aware that their hospital had an infection control unit, 109 (20.7%) of nurses reported that there was no such a unit in their work- place, and 89 nurses (17%) did not know. In addition, most (98) of participating nurs- es (18.7%) gave a low rating to an infection control unit activity in their hospitals and followed by 80 good ratings (15.2%), and 68 very good ratings (13%). The very low rating of the activity of the infection con- trol unit was given by 29 nurses (5.5%).Nurses’ reports on their safety and vaccinations for nosocomial infections. The results in Table 5 indicate that most of the nurses 330 (62.9%) were vaccinated against NI and 185 nurses (35.2%) of nurs- es did not receive vaccinations. 198 nurses (76.7%) were vaccinated against the Hepa- titis B virus (HBV), followed by 33 nurses who received an Influenza vaccine (12.8%), Tetanus (TT) 24 nurses (9.3%) and Tubercu- losis (TB) 3 nurses (1.2%). Nurses’ reports on their safety and vac- cinations for nosocomial infections. The results in Table 5 indicate that most of the nurses 330 (62.9%) were vaccinated against NI and 185 nurses (35.2%) of nurs- es did not receive vaccinations. 198 nurses (76.7%) were vaccinated against the Hepa- titis B virus (HBV), followed by 33 nurses who received an Influenza vaccine (12.8%), Tetanus (TT) 24 nurses (9.3%) and Tuber- culosis (TB) 3 nurses (1.2%).Concerning the safety of their working place, the majority (145) of nurses (27.6%) gave a low rating to their working place safety, followed by a very good rating by 127 nurses (24.2%), and 110 good ratings (21%). 64 nurses (12.2%) evaluated safety in their hospital as very low. Furthermore, the study inves- tigated the nurses’ fear of acquiring occu- pational NIs during work in the hospital. The majority of nurses (427/81.3%) stated that they were afraid of getting NIs, while 85 nurses (16.2%) of respondents were not afraid. Moreover, this study explored, how nurses maintained hygiene during nursing procedures. Most of the nurses (347), which represents 66.1% self-reported that their compliance was very good, followed by a good rating by 87 nurses (16.5%), and low rating by 34 respondents (6.5%), while 4 nurses rated their compliance to hygiene as very low (0.8%).Finally, the majority (397) of nurses (75.6%) who participated in this study reported that they consider NIs very seriously during their work in the hos- pital environment and 45 of them (8.6%) stated that they do not consider NI seri- ously. According to the results, 10 nurses (1.9%) did not care about NIs and 57 re- spondents (10.9%) were not sure how to deal with NI in their working environment. 171 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article 172 Erbil Journal of Nursing & Midwifery Table 4: Distribution of nurses' accidents and nosocomial infections Variable groups Frequency Percentage Have you acquired any infection related to your work in the hospital? Yes 80 (15.2) No 441 (84) Total 521 (99.2) Missing 4 (0.8) If yes, what was the type of infection? Allergy 20 ((32.8 Infection 21 ( 33.3( Influenza 20 (32.8) Not mentioned 19 Did you have an accident in the hospital that may cause nosocomial infection? Yes 41 (7.8) No 479 (91.2) Total 520 (99) Missing 5 (1) If yes, what was the type of accident? Spill blood 1 (2.9) Cut 16 (35.7) Needle-stick injury 18 (51.4) Not mentioned 6 Do you recap needle syringes after been used on the patients? Yes 404 (76.9) No 119 (22.7) Total 523 (99.6) Missing 2 (0.4) Does your hospital have an infection control unit? Yes 320 (61) No 109 (20.7) Do not know 89 (17) Total 518 (98.7) Missing 7 (1.3) If yes, out of 100% how do you rate their activity? Very low (≤ 25%) 29 (5.5) Low (26%-50%) 98 (18.7) Good (51%-75%) 80 (15.2) Very good (76%-100%) 68 (13) Total 275 (52.4) Missing 250 (47.6) https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article 173 Erbil Journal of Nursing & Midwifery Table 5 :Distribution of nurses' perception of safety and vaccinations to nosocomial in- fections Variable groups Frequency Percentage Have you taken any vaccine to protect you against nosocomial infections in the hospital? Yes 330 (62.9) No 185 (35.2) Total 515 (98.1) Missing 10 (1.9) If yes, for what disease or infection? Tetanus (TT) 24 (9.3) Tuberculosis (TB) 3 (1.2) Influenza 33 (12.8 Hepatitis B virus (HBV) 198 (76.7) Not mentioned 72 How do you rate the safety of your workplace for nosocomial infections out of 100%? Very low (≥25%) 64 (12.2) Low (26%-50%) 145 (27.6) Good (51%-75%) 110 (21) Very good (76%-100%) 127 (24.2) Total 446 (85) Missing 79 (15) Are you afraid to get an infection in the hospital? Yes 427 (81.3) No 85 (16.2) Total 512 (97.5) Missing 13 (2.5) How do you rate your compliance with hygiene rules during your procedures on patients? Very low (≥25%) 4 (0.8) Low (26%-50%) 34 (6.5) Good (51%-75%) 87 (16.5) Very good (76%-100%) 347 (66.1) Total 472 (89.9) Missing 53 (10.1) How seriously do you take nosocomial infections? Very serious 397 (75.6) Not seriously 45 (8.6) Not care 10 (1.9) Not sure 57 (10.9) Total 509 (97) Missing 16 (3) https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article vides sufficient uniforms for all nurses. Oliveira’s review on nine articles from 2000 to 2010 shows that medical staff uni- forms and gloves are among the main sources of microorganisms, including the resistant microorganisms [22]. The white coat used by some medical staff and stu- dents for hospital work practices is known as a source of potential microorganisms [23, 24]. Hospital staff clothes acquire NIs during different procedures and through various contacts in the hospital environ- ment and can transmit the infection from one patient to another. Wiener recom- mends that health staff should wear daily washed uniforms, cleaned through ade- quate laundry by a specialist hospital team under the supervision of the infection con- trol unit [25]. The infection control unit is responsible for the application and moni- toring of all infection control guidelines to prevent NIs [26]. Unorganized and ineffec- tive infection control unit is one of the main causes of NIs in developing countries compared to developed countries [3]. In the current study, 84.6% of nurses report- ed that they wash their uniform them- selves, and 55.6% of nurses reported there is no special team at the hospital to check and monitor uniform hygiene. The majority of nurses in this study reported that they did not experience an accident in the hos- pital that may cause them NIs, the needle- stick injury was the highest accident among those nurses who experienced acci- dents, followed by cutting by sharp objec- tives. Alazawy’s study on the prevalence of needle-stick accidents and knowledge on standard precaution and blood-borne dis- eases among medical staff reported that 53% of nurses in his study experienced a needle-stick injury [27], and Honda report- ed that 55.5% of nurses experienced sharp injuries accident, 91.1% of accidents in- volved blood, and the most common inju- ries were a needle-stick injury (52.8%) Nurses’ suggestions to the hospitals re- garding the control of nosocomial infec- tions. Most nurses (110) suggested estab- lishing a more effective infection control unit as the best way for their hospital to be more effective against NIs (48.2%), fol- lowed by continuing training to staff sug- gested by 54 nurses (23.7%), care more about hospital hygiene by 24 nurses (10.5%), better hospital building by 17 nurses (7.5%), better administration to hospital by 13 nurses (5.7%) and provide more PPEs by 10 nurses (4.4%) (Figure 4). This cross-sectional study evaluated nurs- es’ self-report on the infection control unit activities and their experiences toward nosocomial infections in 10 Sulaimani gov- ernmental hospitals from 20 February to 28 September 2018 with the convenience sampling of 525 nurses using a question- naire for data collection. In developing countries, the main obstacle to infection control units is the lack of or insufficient basic personal protective equipment for all staff [4]. In this study, the majority of nurs- es reported that the hospital provides 174 Erbil Journal of Nursing & Midwifery Figure 4 Nurses’ suggestions to the hospital re- garding control of nosocomial infections DISCUSSION https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article and working in the hospital environment. The majority of nurses reported that their hospital provided uniforms, which they washed themselves, and there was no ded- icated team for checking and cleaning health staff uniforms. Most of the partici- pating nurses were vaccinated against one or more nosocomial diseases, mostly against Hepatitis B. In addition, the major- ity of nurses did not feel safe in hospitals and were afraid to acquire nosocomial in- fections. Most nurses recommended the establishment of more effective infection control units that can be more active against nosocomial infections. [1] Obiero CW, Seale AC, Berkley JA. Empiric treatment of neonatal sepsis in developing countries. The Pediatric infectious disease journal. 2015;34(6):659-61. DOI:10.1097/ INF.0000000000000692. [2] Nejad SB, Allegranzi B, Syed SB, Ellis B, Pittet D. Health-care-associated infection in Africa: a systematic review. Bulletin of the World Health Organization. 2011;89:757-65. DOI:10.2471/BLT.11.088179. [3] Samuel S, Kayode O, Musa O, Nwigwe G, Aboderin A, Salami T, et al. Nosocomial in- fections and the challenges of control in de- veloping countries. African journal of clinical and experimental microbiology. 2010;11(2). DOI:10.4314/ajcem.v11i2.53916. [4] Alp E, Leblebicioglu H, Doganay M, Voss A. Infection control practice in countries with limited resources. Annals of Clinical Microbi- ology and Antimicrobials. 2011;10(1):36. DOI:https://doi.org/10.1186/1476-0711-10- 36. [5] Engemann JJ, Friedman JY, Reed SD, Griffiths RI, Szczech LA, Kaye KS, et al. Clinical out- comes and costs due to Staphylococcus au- reus bacteremia among patients receiving long-term hemodialysis. Infection Control and Hospital Epidemiology. 2005;26(6):534- 9. DOI:https://doi.org/10.1086/502580. followed by cutting by ampule (26.2%). The majority of nurses in the current study were aware of the fact that their hospital has an infection control unit and the major- ity of them gave a low rating to the unit’s role in the hospital. All the hospitals includ- ed in the current study have an infection control unit with low activity as nurses re- ported. Non-organized or non-active infec- tion control units remain one of the main obstacles in developing countries against good control and prevention of NIs. The infection control unit is responsible for all applications and monitoring of standard and special precautions in each hospital including improving nurses’ knowledge by training. Infection control units should be working more actively, to be provided with more guidelines and to be stricter in imple- menting the guidelines. More than half of the nurses who participated in this study were vaccinated against NIs, and HBV was the most common diseases nurses were vaccinated against. These results are in agreement with Eskander’s study that showed that 80% of nurses received a vac- cine against NIs, 74% of those vaccines were for HBV and 11% for the influenza virus. Fashafsheh reported that more than 80% of nurses who participated in their study were vaccinated against HBV [28].The majority of nurses in the current study gave a low rating to the safety in their hospital. Low perception of safety during their work in hospital decreases nurses performance and can cause injuries to themselves and the patients [29]. Also, the majority of nurses in this study were afraid of occupational NIs during their work in the hospital, they took NIs very serious- ly, and gave a high rating to their compli- ance to hygiene during procedures on pa- tients. Nurses’ fear of occupational NIs might make nurses more compliant and more careful about infection control pre- cautions when dealing with patients 175 Erbil Journal of Nursing & Midwifery CONCLUSION REFERENCES https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article [15] Joshi R, Reingold AL, Menzies D, Pai M. Tu- berculosis among health-care workers in low -and middle-income countries: a systematic review. PLOS Medicine. 2006;3(12):e494. DOI:10.1371/journal.pmed.0030494. [16] Kelcíkova S, Skodova Z, Straka S. Effective- ness of hand hygiene education in a basic nursing school curricula. Public Health Nurs- ing. 2012;29(2):152-9. DOI:https:// doi.org/10.1111/j.1525-1446.2011.00985.x [17] Damani N. Manual of infection prevention and control: OUP Oxford; 2011. [18] Saleh Moghadam R, Mir Salari N. Knowledge and practice of nurses in relation to operating room pollution. Journal of knowledge management. 2005;39:21-8. [19] Stone PW, Hasan S, Quiros D, Larson EL. Effect of guideline implementation on costs of hand hygiene. Nursing economic. 2007;25 (5):279. [20] Daniel W. Biostatistics: A Foundation for Analysis in the Health Sciences, 7th ed R Wiley. New York. 1999. [21] Kaushal G, Doke P, Shah A, Verma V. An analysis of knowledge, attitude and practices regarding standard precautions of infection control and impact of knowledge and atti- tude of ICU nurses on self-reported practices of infection control. International Journal of Hospital and Health care Administration. 2015;2:79-85. [22] Oliveira ACD, Silva MDM, Garbaccio JL. Clothing of health care professional as po- tential reservoirs of micro-organisms: an integrative review. Texto & Contexto- Enfermagem.2012;21(3):684-91. DOI:https://doi.org/10.1590/S0104- 07072012000300025 [23] Robati R, Farokhi MM, Jaberi FM, Hashemi SA. Effect of white coats on spread of noso- comial infection. European Journal of Experi- mental Biology. 2013;3(3):156-9. [24] Banu A, Anand M, Nagi N. White coats as a vehicle for bacterial dissemination. Journal of clinical and diagnostic research: JCDR. 2012;6(8):1381.DOI:10.7860/ JCDR/2012/4286.2364 [25] Wiener-Well Y, Galuty M, Rudensky B, Schle- singer Y, Attias D, Yinnon AM. Nursing and physician attire as possible source of noso- comial infections. American Journal of Infec- tion Control. 2011;39(7):555-9. [6] Kaye KS, Anderson DJ, Sloane R, Chen LF, Choi Y, Link K, et al. The effect of surgical site infection on older operative patients. Journal of the American Geriatrics Society. 2009;57 (1):46-54. DOI:https://doi.org/10.1111/ j.1532-5415.2008.02053.x [7] Scott RD. The direct medical costs of healthcare-associated infections in US hospi- tals and the benefits of prevention. 2009. [8] Glance LG, Stone PW, Mukamel DB, Dick AW. Increases in mortality, length of stay, and cost associated with hospital-acquired infec- tions in trauma patients. Archives of Surgery. 2011;146(7):794-801.DOI:10.1001/ archsurg.2011.41. [9] Lepelletier D, Perron S, Bizouarn P, Caillon J, Drugeon H, Michaud J-L, et al. Surgical-site infection after cardiac surgery: incidence, microbiology, and risk factors. Infection Con- trol and Hospital Epidemiology. 2005;26 (5):466-72.DOI:https:// doi.org/10.1086/502569. [10] WHO. The burden of healthcare-associated infection worldwide 2016 [Available at: http://www.who.int/gpsc/country_work/ burden_hcai/en/. [11] McBryde E, Bradley L, Whitby M, McElwain D. An investigation of contact transmission of methicillin-resistant Staphylococcus aure- us. Journal of Hospital Infection. 2004;58 (2):104-8.DOI:https://doi.org/10.1016/ j.jhin.2004.06.010. [12] Shinde MB, Mohite VR. A study to assess knowledge, attitude and practices of five moments of hand hygiene among nursing staff and students at a tertiary care hospital at Karad. International Journal of Science and Research (IJSR). 2014;3(2):311-21. [13] de Oliveira AM, White KL, Leschinsky DP, Beecham BD, Vogt TM, Moolenaar RL, et al. An outbreak of hepatitis C virus infections among outpatients at a hematology/ oncology clinic. Annals of Internal Medicine. 2005;142(11):898-902. [14] Pessoa-Silva CL, Hugonnet S, Pfister R, Tou- veneau S, Dharan S, Posfay-Barbe K, et al. Reduction of healthcare-associated infection risk in neonates by successful hand hygiene promotion. Pediatrics. 2007;120(2):e382- e90. DOI:https://doi.org/10.1542/peds.2006- 3712. 176 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2020.19 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov 2020 Original Article [26] Storr J, Twyman A, Zingg W, Damani N, Kil- patrick C, Reilly J, et al. Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations. Antimicrobial Resistance & Infection Control. 2017;6(1):6. DOI:https:// doi.org/10.1186/s13756-016-0149-9 [27] Alazawy SA. The Prevalence of Needle Stick Injuries among Health Care Workers in Baqu- ba Teaching Hospital. Diyala Journal For Pure Science. 2010;6(3):260-71. [28] Fashafsheh I, Ayed A, Eqtait F, Harazneh L. Knowledge and Practice of Nursing Staff to- wards Infection Control Measures in the Pal- estinian Hospitals. Journal of Education and Practice. 2015;6(4):79-90. [29] Barton A. Patient safety and quality: An evi- dence-based handbook for nurses. AORN Journal. 2009;90(4):601-2. DOI:https:// doi.org/10.1016/j.aorn.2009.09.014 177 Erbil Journal of Nursing & Midwifery