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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 1-9

The effect of nursing educational program on knowledge and practice of nurses regarding infection control measures for children under hemodialysis


1 Department of Pediatric Nursing, Faculty of Nursing, Sohag University, Sohag, Egypt
2 Department of Pediatrics, Faculty of Medicine, Assiut University, Assuit, Egypt
3 Department of Public Health, Faculty of Nursing, Assiut University, Assuit, Egypt

Date of Submission07-Aug-2016
Date of Acceptance18-Aug-2016
Date of Web Publication10-May-2019

Correspondence Address:
Youssria E Yousef
71515
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-6021.257964

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  Abstract 


Background/aim The aim of the present study was to assess the knowledge and practice of nurses regarding the prevention of infection for children under hemodialysis, and to evaluate the effect of an educational nursing program on nurses’ knowledge and practice regarding the prevention of infection among children undergoing hemodialysis.
Patients and methods We chose a quasi-experimental research design for the present study. The study was conducted in the renal dialysis unit at Assiut Children University Hospital. A convenience sample of 32 nurses working in the pediatric renal dialysis unit, who accepted to participate in this study, were enrolled. Following tools were used in the study. Tool 1, which was a structured questionnaire sheet about nurses’ knowledge including sociodemographic data; and nurses’ knowledge about renal failure, renal dialysis, and general precautions during nursing care for children under hemodialysis. Tool 2, which was an observational checklist sheet developed by the researcher to assess nurses’ practice for children under hemodialysis. It was applied before and after 2 months of the implementation of the educational program. It consisted of general and specific precautions to be taken during care of children under hemodialysis and application of infection control measures.
Results The levels of knowledge scores were satisfactory among 90.6% of the nurses. There was a highly significant improvement in the nurses’ practice scores regarding general precautions, hand-washing, wearing gloves, wearing mask, catheter insertion, skin preparation technique, taking care of patients’ equipment, dealing with sharp objects, dealing with blood, body secretions, and fluids, and maintaining clean environment and safe injection practices in addition to the total practice score. There were significant improvements in items of the nurses’ practice such as laboratory-style covering coats, full isolation, and catheter care. The practice score level was adequate among 68.7%, whereas inadequate among 31.3% of the nurses. There were significantly higher nurses’ knowledge score and levels of improvement of their knowledge score after the education program among older nurses and those with Bachelor of Nursing.
Conclusion Nurses’ knowledge and practice regarding hemodialysis and infection control guidelines are inadequate. Carrying out nursing education programs about infection control measures when dealing with children under hemodialysis resulted in a significant improvement in nurse’s knowledge and practice.
Recommendations Nurses should be encouraged to attend specific meetings such as workshops and seminars held for infectious diseases and infection control to be acquainted with the recent advances and skills in the hemodialysis unit.

Keywords: children, educational program, hemodialysis, infection control measures, knowledge, nurses, practice


How to cite this article:
Yousef YE, Elashir UM, Mahmoud SR, Maghraby N. The effect of nursing educational program on knowledge and practice of nurses regarding infection control measures for children under hemodialysis. Egypt Nurs J 2019;16:1-9

How to cite this URL:
Yousef YE, Elashir UM, Mahmoud SR, Maghraby N. The effect of nursing educational program on knowledge and practice of nurses regarding infection control measures for children under hemodialysis. Egypt Nurs J [serial online] 2019 [cited 2019 Aug 25];16:1-9. Available from: http://www.enj.eg.net/text.asp?2019/16/1/1/257964




  Introduction Top


Chronic kidney disease (CKD) is characterized by an irreversible deterioration of renal function that gradually progresses to end-stage renal disease (ESRD). CKD has emerged as a serious public health problem. Data from the US Renal Data System (2010) show that the incidence of kidney failure is rising among adults and is commonly associated with poor outcomes and high cost. Moreover, in the past two decades, the incidence of the CKD in children has steadily increased, with poor children and those from ethnic minorities disproportionately affected (US Renal Data System, 2010).

Globally, the prevalence of CKD stage II or lower in children is reported to be ∼18.5–58.3 per million children. Disease prevalence is much lower than that in adults. Data from the ItalKid study reported a mean incidence of 12.1 cases per year per million in the age-related population (age range: 8.8–13.9 years) and a prevalence of 74.7 per million in this population (Ardissino et al., 2003). However, underreporting because of a lack of recognition may suggest an even higher prevalence in children (Choi et al., 2009).

About 70% of children with chronic kidney disease develop ESRD by age 20. Children with ESRD have a 10-year survival rate of about 80% and an age-specific mortality rate of about 30 times of that seen in children without ESRD. The most common cause of death in these children is cardiovascular disease, followed by infection (Craven et al., 2007). Staphylococcus aureus is the most common pathogen associated with these infections (Vandecasteele et al., 2009).

In medicine, hemodialysis (HD) is a method that is used to achieve the extracorporeal removal of waste products such as creatinine and urea and free water from the blood when the kidneys are in a state of renal failure. HD is one of three renal replacement therapies (the other two being renal transplant and peritoneal dialysis). An alternative method for extracorporeal separation of blood components such as plasma or cells is apheresis (Kolff and Berk, 2013).

HD patients are uniquely vulnerable to the development of healthcare-associated infections (HAIs) because of multiple factors including exposure to invasive devices, immunosuppression, the lack of physical barriers between patients in the outpatient HD environment, and frequent contact with healthcare workers during procedures and care (Siegel et al., 2007).

In an environment where multiple patients receive dialysis at the same time, there are opportunities for person-to-person transmission of infectious agents that can lead to a HAI. This can occur directly or indirectly through contaminated devices, equipment, and supplies, environmental surfaces, or the hands of healthcare personnel. In addition, HD patients have weakened immune systems and require frequent hospitalizations and surgery, which increases their opportunities for exposure to HAIs such as central-line bloodstream infection (Center for Disease Control and Prevention, 2011a, 2011b).

Nurses traditionally provide front-line care and have daily contact with patients, fulfilling vital services such as inserting and changing i.v.’s, administering medications, interacting with the patients and their families, and monitoring and maintaining patient hygiene, to name a few responsibilities (The Joint Commission, 2010).

Standard precautions (formerly universal precautions) refers to the practices that are designed to prevent transmission of infection by contact with bodily fluids. In HD settings, in addition to standard precautions, more stringent measures are recommended because of the increased potential for contact with blood and blood-borne pathogens including HIV, hepatitis B virus, and hepatitis C virus. The risk for exposure is increased because accessing the bloodstream is required during the dialysis sessions (Association for Professionals in Infection Control and Epidemiology, 2010).

The role of the nurse is very important in breaking the chain of infection. She can do this by applying proper infection control practices to interrupt transmission of microorganisms and by breaking or blocking the transmission of infection from one link in the chain to the next (Royal College of Nursing, 2012).

Magnitude of problem

Patients undergoing HD are at an increased risk for contracting viral infection due to the underlying impaired cellular immunity, which increases their susceptibility to infection. HD patients require blood transfusion, and frequent hospitalization and surgery, which increases opportunities for nosocomial infection exposure. The most frequent viral infections encountered in HD units are hepatitis B virus, hepatitis C virus, and, to a lesser extent, HIV infection (Karkar et al., 2006). The reported prevalence of HCV infection among dialysis patients in developed countries ranges from 3.6 to 20%, with higher rates in developing countries (Khodir et al., 2012). It was estimated to be 52.1 in Egypt (Afifi, 2008). Establishing an infection prevention and control program that includes a bundle of strategies and interventions that are consistently performed will reduce the infection risk for both employees and patients (Vandecasteele et al., 2009 and Friedman and Sexton, 2015).


  Aim of the study Top


  1. To assess the knowledge and practice of nurses regarding the prevention of infection in children under HD.
  2. To evaluate the effect of educational nursing program on nurses’ knowledge and practice regarding the prevention of infection among children undergoing HD.


Research hypotheses

  1. The postprogram mean knowledge scores of nurses who will be exposed to educational nursing program will be higher than their preprogram mean knowledge scores.
  2. The postprogram mean practice scores of nurses who will be exposed to educational nursing program will be higher than their preprogram mean practice scores.



  Patients and methods Top


Research design

We chose a quasi-experimental research design for this study.

Setting of the study

The study was conducted in the renal dialysis unit at Assiut Children University Hospital.

Patients

A convenience sample of all available nurses (32 nurses) working in the pediatric renal dialysis unit who accepted to participate in this study.

Study tools

The data of this study were collected by using the following three tools.

Tool 1: Structured questionnaire sheet

It was constructed by the researcher on the basis of current national and international literature to assess nurses’ knowledge about HD before and after the implementation of educational nursing program.

It consisted of the following: sociodemographic data including age, sex, marital status, qualifications, and years of experience; nurses’ knowledge about renal failure (nine questions); nurses’ knowledge about renal dialysis (10 questions); nurse’s knowledge about general precautions (eight questions); and nurses knowledge about general precautions during nursing care for children under HD (60 questions). The questionnaire sheet was distributed by the researcher to the nurses for answering, and then collected back.

Scoring system: Each right answer was given a score of 1 and a wrong answer was given a score of 0. Those obtaining less than 70% were considered as having unsatisfactory level of knowledge, those obtaining from 70 to 90% were considered as having satisfactory level, and those obtaining above 90% were considered as having a good level of knowledge.

Tool 2: An observational checklist sheet for the nurses

It was developed by the researcher to assess nurses’ practice for children under HD. It was applied before and 2 months after the implementation of the educational nursing program. It consisted of the following items.
  1. General precautions during care of children under HD, which included six items (hand-washing, wearing gloves, removal of gloves promptly, wearing gowns, wearing mask, and eye protection).
  2. Specific precautions to minimize infection during HD, which included insertion and care of a vascular catheter, initiation of dialysis session, care of exit-site of a vascular catheter, steps of skin cleansing of a vascular catheter, skin preparation technique for subcutaneous arteriovenous accesses, and patient-care equipment.
  3. Application of infection control measures including dealing with sharp objects, dealing with blood, body secretions, and fluids, and maintaining clean environment and safe injection practices.


Scoring system: Each item was observed, categorized, and scored into either ‘done correctly’ (a score of 1) or ‘not done’ (a score of 0). Those who obtained less than 70% were considered as having unsatisfactory level, those who obtained from 70 to 90% were considered as having satisfactory level, and those who obtained above 90% were considered as having good knowledge and practice level.

Tool 3: Educational nursing program

It was developed according to the needed nurse’s knowledge and practice that can help nurses to provide safe care for children under HD.

Procedure: A structured interview was utilized to fill out the questionnaire sheet (tool 1). Observation technique was utilized to fill out the observation checklist for practice of nurses (tool 2).

Methods

This study was carried out in three phases.

Preparatory phase

The researcher designed and tested the proposed educational nursing program after extensive literature review (nursing textbooks, journals, internet resources, etc.) and assessment of nurses’ knowledge and practice in this regard. Then, the final form of the proposed educational nursing program and the study tools were checked by a panel of experts for content validity and applicability.

To facilitate the implementation of the educational nursing program about infection control among children under HD, the researcher prepared the training places, teaching aids, and media (pictures and handouts). This was followed by arranging for the educational nursing program schedule on the basis of the contents of the program, number of staff involved, time availability, shifts, and the resources available.

Implementation phase

The researcher met the enrolled nurses to schedule teaching sessions. The number of sessions varied according to their understanding.
  1. At initial interview, the researcher explained the nature and purpose of the educational nursing program and helped respondents to fill out the questionnaire sheet to assess nurse’s knowledge before the educational nursing program.
  2. The nurses were divided into small groups; each group involved two to four nurses. Each group of nurses was given the freedom to choose their optimal duration of the educational nursing program whenever they had minimal workload. The educational nursing program was conducted for nurses in the form of teaching sessions, with a total of nine sessions.
  3. The duration of each session was 1 h, including 15 min for discussion and feedback. Each session usually started by a summary of what had been learned during the previous sessions and the objectives of the new topics. Feedback and reinforcement of teaching were carried out according to the nurses’ needs to ensure their understanding.
  4. Each nurse obtained a copy of the educational nursing program booklet prepared by the researchers, which included all the training contents.


Evaluation phase

It was the last phase, in which the nurse’s knowledge and practices were evaluated before and immediately after and then after 2 months of protocol implementation. The duration of educational nursing program implementation was 1 year, lasting from July 2014 to August 2015.

Pilot study

It was conducted on five nurses (10%) to ascertain the relevance of the tools, detect any problem peculiar to clarity of the statements that might interfere with the process of data collection, and to estimate the time needed to complete the interview schedule. Analyses of the pilot study revealed that minimal modifications were required. These modifications were made and the participants were excluded from the actual study.

Content validity

The content validity of study tools was checked by five experts in the pediatric field of nursing and medicine, and its result was 96%. Reliability was estimated by using α Cronbach’s test for the tools, and its result was R=0.66.

Ethical considerations

An official permission to conduct the study was obtained from the director of Children Assiut University Hospital and the head of the renal dialysis unit. This study was approved by the ethical committee of the Faculty of Medicine, which controls Children Assiut University Hospital. Each patient and nurse was informed about the purpose of the study. Participation in the study was voluntary and confidentially of data and anonymity of the participants were assured through coding of all data, and protection of the patients from hazards. Verbal consent was obtained from the nurses before their participation in the study.

Statistical analysis

The collected data were tabulated and statistically analyzed using the computer program SPSS (version 17; Inc., Chicago IL, USA). Data were expressed as mean, SD, number, and percentage. Student’s t-test was used to compare between numeric variables and the χ2-test to compare between nonparametric variables. A probability level of 0.05 was adopted as the level of significance.


  Results Top


[Table 1]shows the sociodemographic data of the nurses working in the pediatric hemodialysis unit regarding their age, sex, residence, marital status, level of education, and duration of nursing experience. About two-thirds of the nurses were between 20 and 30 years of age (62.5%), whereas 25% were more than 30 years old, with a mean age of 25.77±6.32 years. More than two-third of the nurses were married (68.75%), whereas 31.25% of them were single. About two-third of the nurses (62.5%) were from rural areas. As regards their qualification, more than two-thirds of the nurses (68.75%) had secondary Diploma in Nursing, 18.75% of the nurses had attended technical institute of nursing, and 12.5% had a Bachelor’s in Nursing. As regards nurses’ years of experience, it was noticed that 43.4% of the nurses had a work experience of less than 5 years, 40% had a work experience of 5–10 years, and 16.7% had a work experience of more than 10 years.
Table 1 Sociodemographic characteristics of nurses of pediatric renal dialysis unit (n=32)

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As [Table 2]shows, there were statistically significant improvements in the nurses’ knowledge regarding renal failure (15.53±5.56 vs. 32.27±3.36), HD (16.23±8.05 vs. 29.20±5.76), and infection control measures (48.93±16.67 vs. 113.37±10.61) and total knowledge (80.70±18.48 vs. 174.83±18.37) after the educational program (P=0.000). The levels of knowledge scores were satisfactory for 90.6% of the nurses.
Table 2 The effect of the educational program on the mean nurses knowledge scores regarding renal failure, hemodialysis and infection control

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[Table 3]shows the effect of the educational program on the mean nurses’ practice scores regarding measures of infection control. There were highly significant improvements in the nurses’ practice scores regarding hand-washing, wearing gloves, wearing mask, catheter insertion, skin preparation technique, taking care of patients’ equipment, dealing with sharp objects, dealing with blood, body secretions, and fluids, and maintaining clean environment and safe injection practices in addition to the mean total practice score (66.17±8.67 vs.78.00±6.82). There were significant improvements in items of the nurses’ practice such as laboratory-style covering coats, full isolation, and catheter care, whereas no significant changes in the nurses’ practice items such as removing gloves and dialysis session initiation. Regarding the practice score level, it was adequate in 68.7% of the nurses and inadequate in 31.3%.
Table 3 The effect of the educational program on the mean nurses practice scores regarding measures of infection control

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[Table 4]shows the percentages of improvement of some items of infection control measures after implementation of the education program. There was a highly significant improvement in the items of hand-washing and changing gloves (P<0.001), and, also, significant improvement in other items such as wearing gloves (P<0.04), wearing face masks (P<0.01), cleaning environment (P<0.04), and taking care of patient equipments (P<0.01). On the other hand, all participant nurses wore full body gowns before and after the implementation of the education program.
Table 4 The comparison between preprogram and postprogram regarding the implementation of some items of infection control measures

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[Table 5]shows the relationship between mean nurses’s knowledge score and sociodemographic characteristics for nurses before and after the educational program. There were significantly higher nurses’s knowledge score and levels of improvement in their knowledge score after the education program among older nurses (85.76±9.54 vs. 176.48±19.45; P=0.03) and those with Bachelor of Nursing (79.34±6.01 vs. 177.65±18.96; P=0.04). On the other hand no significant difference regarding marital status, years of experience and those taking previously training programs about infection control.
Table 5 Relationship between mean nurses’s knowledge score and sociodemographic characteristics for nurses’ pre-educational and posteducational program

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[Table 6]shows the relation between the acquired knowledge and practice of nurses about HD after the educational program, where 91% of the nurses had satisfied knowledge and adequate practice, which indicate the parallel improvement of both knowledge and practice of nurses.
Table 6 Relation between knowledge and practice of nurses about hemodialysis posteducational program

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  Discussion Top


This study aimed to assess the knowledge and practice of nurses regarding the prevention of infection in children under HD and to evaluate the effect of educational nursing program on nurses’ knowledge and practice regarding prevention of infection among children undergoing HD at Assiut Children University Hospital.

Infection control precautions have been strongly recommended by the Center for Disease Control and Prevention for many decades as a means of avoiding the spread of cross-infection and disease outbreaks, and to ensure healthcare workers’ occupational safety. Such precautions have involved a two-tiered approach based on modes of disease transmission and they included both standard and additional precautions (Siegel et al., 2007).

The use of universal infection control precautions reduces the potential transmission of blood-borne pathogens and those from moist to body substances (feces, urine, sputum, saliva, wound drainage, and other body fluids). Healthcare personnel follow universal infection control precautions whenever there is the potential for contact with blood or all other bodily fluids except sweat, regardless of whether or not they contain visible, nonintact skin and mucous membranes (Timby and Smith, 2007).

The Center for Disease Control and Prevention universal precautions intended to prevent parenteral mucous membrane and nonintact skin exposure to blood-borne pathogens. These have been broadened to encompass a set of more extensive standard precautions intended to afford protection against transmission of full range of pathogens implicated in HAIs. These standard precautions, which must be adopted during the care of every patient irrespective of the disease status, define framework protocol for hand-washing (Center for Disease Control and Prevention, 2011a, 2011b).

Applying and practicing all these precautions is strongly recommended in everyday clinical activities to prevent infections and thus to ensure the safe delivery of healthcare (Affonso et al., 2004; Quah and Lee, 2004).

The current study revealed a great lack of knowledge and practice regarding infection control measures related to patients with HD before the application of educational program, as all nurses had an unsatisfactory knowledge score levels. Similarly, Chau et al. (2009) mentioned a study by the Hong Kong government reporting hospital infection control standards to be inadequate, and thus in need of audit, development, and implementation. In this respect, Isara and Ofili (2009), in Nigeria, emphasized the need for intensive enlightenment programs to educate healthcare workers on various aspects of standard precautions and infection control programs and policies.

In the present study, nurses aged 20–30 years had higher total knowledge scores than did those aged less than 20 years. In agreement with these results, Asadollahi et al. (2015) found a statistical positive relation between knowledge of participant nurses about hand hygiene and their age. On the other hand, these findings disagree with those of Kagan et al. (2009), who noted that, nurses’ knowledge scores were higher among younger and newly graduated nurses. Similarly, Fashafsheh et al. (2015) found a negative but significant correlation between the mean knowledge scores of nurses and their ages, and added that older age is an important determinant of lower knowledge levels.

The findings of the present study regarding application of the universal precaution revealed a significant increase in applying hand-washing, wearing gloves, and wearing face mask after the program compared with the application of the universal precautions before the program. In this respect, Heseltine (2001) reported that although healthcare workers have been taught that cross-infections are transmissible but not contagious, and that the most effective way to prevent these cross-infections is to wash their hands before and after every patient contact, they do not do it. The limited compliance to hand-washing in the personal study might be attributed to inconvenient placements of sinks, lack of adequate hand-washing equipment and supplies, insufficient time to accomplish that task, lack of role models, lack of its priority over other procedures, lack of supervision by a senior staff, and lack of monitoring by the members of the infection control committee.

Moreover, Smeltzer and Bare (2009) emphasized that mask and gloves reduce accidental contamination of nurses’ hands and all sterile objects by air-borne droplet nuclei. To impact the previous shortage concert effort is needed to improve health workers’ knowledge of the occupational role in spreading protective measures and practices. In addition, hand hygiene is the single most important infection control measure used in nursing (Cohen et al., 2003). Hand hygiene has been singled out as the most important measure in preventing hospital-acquired infection (Lam et al., 2004).

The present study revealed that, a minority of nurses carried out items of infection control measures before implementation of the education program, as hand-washing (15.6%), changing gloves (15.6%), wearing face masks (6.3%), cleaning environment (31.3%), and taking care of patient equipments (18.7%), whereas half of them were wearing gloves (50.0%). These findings are significant in a setting like children undergoing HD. This could be related to lack of nurses’ knowledge regarding the importance of infection control measures. However, all nurses did not carry out certain procedures such as wearing eye protection and face shield, as they did not find these facilities in the hospital. In their study, Pratt et al. (2007) reported hand contamination to be one of the main contributing factors in the current infection threat; contaminated hands are responsible for transmitting infections. Effective hand-cleaning can significantly reduce infection rates in high risk areas.

Pessoa-silva et al. (2004) found that the use of gloves does not replace hand-washing. Gloves become easily contaminated and hands are then contaminated during the removal of gloves. Pratt et al. (2007) and Bhalla et al. (2004) found that the gloves of healthcare workers can easily be contaminated without direct contact with a colonized patients; they only require contact with the patient’s bed rails.

As mentioned by Wilson (2001), masks, eye protection, plastic aprons and gloves, to be used appropriately, must be readily available in all clinical areas. The critical care nurse manager and the unit director are responsible for assuring that the whole range of personal protective equipment in appropriate size must be available and readily accessible for the work that involves gloves, gowns, and face shields or masks. On the other hand, the gloves should be worn for any activity where body fluids may contaminate the hands, but to prevent transmission of infections, gloves must be discarded after each procedure, even when involving the same person (Center for Disease Control and Prevention, 2011a, 2011b).

The current study revealed a great improvement in the practice score levels obtained by nurses after the educational nursing program. There were significant differences between the results before and after the program. These findings indicated that skills can be easily improved, especially if linked with their relevant scientific base of knowledge. These results were in agreement with those of Willetts and Leff (2003), who documented that, the in-service training program has a beneficial effect on improving the nurses’ knowledge and skills. They also recommended that educational programs should be organized according to the needs of nurses with continuous evaluation.

The present study indicated significant change in the practice of the studied nurses in compliance with most of the items of infection control standards after the education program. This is in agreement with the findings of a study by Zakzouk (2004), who mentioned that, at least one separate room must be maintained for dialysis of patients with hepatitis B. After each patient treatment, it must be cleaned and a low-level disinfection must be carried out for the environmental surfaces of the dialysis station, including that of dialysis bed or chair, countertops, and external surfaces of the dialysis machine.


  Conclusion Top


On the basis of the results of the present study, it can be concluded that nurses’ knowledge and practices regarding HD and infection control are inadequate. Carrying out a nursing educational program about infection control measures when dealing with children under HD resulted in significant improvements in nurses’ knowledge and practice, which favorably improved the outcomes of HD.

Recommendations

The following recommendations are proposed.
  1. Nurses should be encouraged to attend specific meetings such as workshops and seminars held for infectious diseases and infection control so as to acquaint them with the recent advances and skills in the HD unit.
  2. Written standard precautions for infection control should be available in the HD unit.
  3. Adequate supplies and facilities should be available to hospital personnel to maintain good infection control practice and maintain safe environment for patients and staff.
  4. Periodic training programs and refreshing courses should be provided to nurses to improve their knowledge, which will reflect into their performance and minimize the risk for transmission of infection.
  5. Periodic revision of the practice of infection control guidelines.
[34]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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  In this article
Abstract
Introduction
Aim of the study
Patients and methods
Results
Discussion
Conclusion
References
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