Effect of Educational Intervention on Nurses Performance to Control Infection in Neonatal Intensive Care Unit Tanta University Hospital

Nursing care of the high risk neonates requires critical care nursing, which has created a need for highly skilled personnel trained in the art of neonatal intensive care. The incidences of infection among high risk neonates are more frequent due to their immature immune system. It’s considered the most serious complications and represents about 60% of neonatal death in Neonatal Intensive Care Unit (NICU), Tanta university hospital. The aim of this study was to evaluate the effectiveness of educational intervention on nurse’s performance to control infection at neonatal intensive care unit, Tanta University Hospital. The sample was consisted of all nurses working in the unit and all high risk neonate who were admitted over a period of 3 months. Two tools were used to collect data. Checklist for nurse’s performance and health assessment sheet for high risk neonate. The result shows that, before intervention 70.49% of nurses had unsatisfactory grade, while after intervention two-thirds of them (63.39%) were good and 21.31% of nurses were satisfactory in their performance. This difference was statistically significant (p< 0.05). According to condition on discharge, it was found that 76% of study group improved, compared to 60% of control group. In Conclusion: Risk of infection can be controlled, if the health team and other workers have understood the principles and methods of controlling infection. Nurses at NICU need pre service as wells inservice educational program to refresh their knowledge and improve their skills. INTRODUCTION: The neonatal period is a highly vulnerable period during which many of the physiologic adjustments required for extra uterine existence are completed. (1) High risk means an infant exposed to any condition that makes their survival in danger. They include infant of diabetic mothers, neonatal jaundice, neonatal 510 Bull High Inst Public Health Vol.38 No.3 [2008] sepsis, respiratory distress syndrome, congenital anomalies, low birth weight, pre term, and post term baby.(2,3) Nursing care of high risk neonate requires critical care nursing which has created a need for highly skilled personnel trained in art of neonatal intensive care.(1,4) The neonatal intensive care unit (NICU) is technology focused and crisis drive. Working there demands technical competence as well as the emotional attitude to ensure that neonates are cared in an environment that value their basic human needs.(5, 6) Modern technology and expert nursing care have made important contributions to improving the health and overall survival of high risk neonates. Nursing care can be made easier by the provision of special equipment.(4) The nursing staff must be trained in the use of such equipment, in order to give a high standard of care that those infants need. So nurses need a continuous health educational intervention to restore their stability and prevent complications.(7, 8) The term infection is generally used to mean the deposition and multiplication of bacteria and other micro-organisms in tissues or on surfaces of the body.(9) The commonest infections transmitted to neonates by hospital staff, a part from upper respiratory viral infection, staphylococcal sepsis, streptococcal, sore throat, and infective diarrhea. The likelihood of transmission clearly depends on the activities of the infected person. Symptomless carriers of virulent pathogenic organisms among members of staff are also a potential hazard of infection to child.(10) Newborns infected (symptomatic or asymptomatic) with any organisms constitute a real danger on other newborns and personnel working in these units.(11) The incidence of infection is more frequent, due to their immature immune system which renders the neonate especially vulnerable one to infectious organisms. It’s considered the most serious

Bull High Inst Public Health Vol.38 No. 3 [2008]   sepsis, respiratory distress syndrome, congenital anomalies, low birth weight, pre term, and post term baby. (2,3)Nursing care of high risk neonate requires critical care nursing which has created a need for highly skilled personnel trained in art of neonatal intensive care. (1,4)The neonatal intensive care unit (NICU) is technology focused and crisis drive.Working there demands technical competence as well as the emotional attitude to ensure that neonates are cared in an environment that value their basic human needs. (5,6) ern technology and expert nursing care have made important contributions to improving the health and overall survival of high risk neonates.Nursing care can be made easier by the provision of special equipment. (4)The nursing staff must be trained in the use of such equipment, in order to give a high standard of care that those infants need.So nurses need a continuous health educational intervention to restore their stability and prevent complications. (7,8)  term infection is generally used to mean the deposition and multiplication of bacteria and other micro-organisms in tissues or on surfaces of the body. (9)The commonest infections transmitted to neonates by hospital staff, a part from Symptomless carriers of virulent pathogenic organisms among members of staff are also a potential hazard of infection to child. (10)Newborns infected (symptomatic or asymptomatic) with any organisms constitute a real danger on other newborns and personnel working in these units. (11)e incidence of infection is more frequent, due to their immature immune system which renders the neonate especially vulnerable one to infectious organisms.It's considered the most serious complications and represents about 60% of neonatal death in NICU unit, at Tanta University hospital. (12)Hospital mission is to promote a healthy and safe environment by preventing transmission of infections agents among children, staff, and visitors. (13)Infection transmission in care settings can happen because of accidents, carelessness, poor practice, poor working conditions, and lack of barrier protection.All of these risks can be controlled if health team and other workers have some knowledge of the facts and problems of cross infection and understand the principles and methods of controlling infection. (14,15)e of the most important component of the infection control programme is education and training of health care workers. (16)They should be equipped with requisite knowledge, skills, and attitudes for good infection control practices. (17,18)Staff training is important to understand the principles and methods of controlling infection. (9)Education is a large part of infection control practice.Careful design, implementation and evaluation of educational program will hopefully be reflected in lowered infection rates in health care facilities. (19)

AIM OF THE STUDY
To evaluate the effect of educational intervention on nurse's performance to control infection in neonatal intensive care unit, at Tanta University Hospital.

Setting:
The study was conducted in neonatal intensive care unit at Tanta University Hospital.The capacity of the unit was 45 incubators.

Samples:
The sample consisted of two groups: 1-Nurses:-

Tools:
Two tools were used to collect data.

1-Checklist for nurses:
To assess the achievement of nursing competencies.
It includes:- -Steps to prevent infection from one neonate to others (8 points).
-Daily care and skin assessment (6 points).
-Mother health teaching and discharge instruction (3 points).
Score for each step performance was distributed as follows: If the activity was correctly done, one point was given.If incorrectly done or not done, zero score was given.These zero score was resulted to because if the activity was not done, it will affect the survival of the neonate.
Since the numbers of activities for each procedure were different, the performance score was calculated for each one independently.Nurse's performance was considered unsatisfactory when their total score is less than 35 points because of the seriousness of high risk neonate condition.

Method:
1-Permissions for data collection were obtained from the responsible director after explanation of the purpose of the study.

2-Personal communication with
attending pediatrician and nurses were carried out to ensure their cooperation.
3-Tools were constructed after review of literature.

Educational intervention construction:
The educational intervention was developed as followed: Objective: To enhance nurses' knowledge about Bull High Inst Public Health Vol.38 No. 3 [2008]   infection control.
To change nursing care activities focusing on infection control.

Content:
Related to the objective and nurses needs as well as available facilities, it contains: -General procedure of infection control.
-Prevent infection of high risk neonate feeding technique.
-Providing hygienic care and skin assessment of high risk neonate.
-Specific therapies of high risk neonate and health instruction.

Strategies:
Different strategies were implemented as short lecture, role play, demonstration, and group discussion.
Educational sessions: The instructional scheme was conducted in 8 sessions for 6 weeks.The time of each session ranged from 25 -30 minutes. Evaluation: Evaluation of nurses' performance: was carried 2 times before and after the educational intervention. Includes: -Nurses performance in different activities according to score given.
-High risk neonate condition as: length of stay, incidence of infection (diarrhea, skin infection as "diaper rashes or bed sores") and condition on discharge.

Statistical Analysis:
Data were collected, coded, tabulated, and analyzed using the Statistical Package for Social Sciences (SPSS).Chi square test was used for statistical correlation.P value was statistically significant at level <0.05%.

RESULTS
Part I: Data related to Nurses:

DISCUSION:
In infection control, nurses need safe knowledge and proper skills about the importance of preventing infection.Nurse is an important member of the health team that should follow and apply aseptic technique in all procedures that are related directly or indirectly to nursing management of high risk neonates. (20,21)Morgan et al.,(2003) (22) mentioned that risk factor related to infection among neonates in providing critical care nursing. (20)ull High Inst Public Health Vol.38 No. 3 [2008]   The present study showed that the most common diagnosis of high risk neonates admitted to NICU unit is RDS which constitute more than quarter in both groups.Followed by neonatal sepsis and neonatal jaundice.Before the educational intervention most nurses' performances were unsatisfactory and had a score less than 70% in infection control procedures as a general such as hand washing and wearing "gown, musk and overshoes".After the intervention, they showed improvement in their performances as well as the progress of neonates.These results were in harmony with other researches, (23) they were found nearly the same finding.
Regarding to nurses performance according to total score in all nursing procedures to prevent infection, it was observed that the total average percentage of nurses' performance after intervention was good by 63.39 % and 21.31% was satisfactory.Same finding was detected in other researches. (23,24) his showed the effect of in-services training program on improving nurse's care provided to high risk neonate.
Preventing infection that are relatively harmless to an adult, may be fatal to the neonates especially for high risk neonates, due to diminished immunity, and low resistance in their tissues. (21)The present study was noticed that the incidence of infection (diarrhea and skin infection) is less frequent among study group, compared to the control ones.This result reflects the effect of the intervention on improving their knowledge and their performance.
If mother can hold her baby, she may be able to breastfeed.Most NICUs have screens to allow mothers to breastfeed their babies at the bedside.He suggested that skin-to-skin contact can improve baby's recovery time. (6)Breast milk is easily digested and provides protection from infection.The main responsibility of the nurse is to instruct mothers about hand washing, scrubbing and nipples care before nursing their baby, wearing gown, mask, over head, and shoes. (25)In the present study the nurses' performance about mother instruction was good by only 3.28% of nurses before intervention and the percentage become more than seventy percent after intervention.This finding goes with Bernath (2001) (26) , who found that the effectiveness' indication of the breast cleaning before breastfeeding decreases the infection in NICU.
Frequently, NICU neonates are unable to get as many calories as they need through regular feeding from a bottle, so the nurses will use a small feeding tube to deliver formula.However, if it is in place for a long time, it can cause erosions or infection, so it must be changed routinely to avoid such condition. (27)Also during bottle and gavage feeding she has to follow aseptic technique to prevent infection. (26)e result of the present study showed that improvement in nurses' performance of artificial feeding "bottle and gavage feeding", 81.97% and 49.18%, respectively were good.These findings are consistent with the study of Bernath ( 2001), (26) who reported that sterilization of shared feeding equipment more effective in preventing cross infection in infants.The Food and Drug Administration said that powdered neonate formulas in NICU are not "commercially sterile products" because, unlike liquid formula products or they are not heated long enough to achieve sterility.
They recommend that powdered neonate formulas not be used in neonatal intensive care settings unless there is no alternative available.The agency suggested that if powdered formula is the only option, some precautions done will reduce the risk of infection. (27)ten, high risk neonate or those who have infections have jaundice, which was 20% in study group, phototherapy is used to help get rid of the bilirubin that causes jaundice.Usually they need routinely skin care to limit the risk of infection. (6)The Bull High Inst Public Health Vol.38 No. 3 [2008]   nurse role and goal during phototherapy are to protect neonate from infection by giving extra fluid, she must be alert to ensure optimal hydration, in addition she monitors neonate temperature and observe loose greenish stool. (22,27) studying effect of the educational intervention on high risk neonate's progress, it was found that 76 % of study group improved on discharge compared to 60 % of the counter one.Centers for Disease Control and Prevention reported that a case in which the death of a neonates in NICU linked with infection. (7)other study showed that the percent of mortality among neonates with infection in NICU was 20.0% and among neonates without infection was 6.54%. ( 8)cidence of infection is considered criteria for evaluating the effect of intervention on neonatal condition.It was observed that infection was less (32%) in study group than the control one (76%).
Diarrhea was only 12% in study group compared to 32% in the control group, while skin infection was twenty percent compared to double percent in control group.The incidence of infection is more frequent in neonates because of immaturity of immune system.The nurse role is to protect him from infection either directly or indirectly by following aseptic technique in all infection control procedures. (23) regards to the relation between neonatal infection and the period of stay of neonates in NICU, Morgan et al., (2003) (22) found that the period of stay in neonates with infection is significantly longer than those without infection.Also, the present study revealed that 48% of study group stay from 5 to 9 days in the unit which is less than control one.It can be explained due to the improvement of nursing care provided to that group.

CONCLUSION:
Nursing care of high risk neonate

6 - 7 -
Data were collected for the control group before giving any instruction to nurses.Available nurses (61 nurses) were observed for half an hour every hour for 3 hours during morning and afternoon shifts.8-Every nurse was observed for two times during different shifts (morning and afternoon shift).
neonatal intensive care unit (NICU) are asymptomatic but later develop handicaps or mainly neurological disturbances.They recommended that workers and employees in the NICU must be informed about the dangers, mode of transmission and preventive measures of infection.Nursing care of the high risk neonates requires critical care nursing, which has created a need for highly skilled personnel trained in the art of neonatal intensive care.They demand team work of highest order, have adequate knowledge, and proper training in

4 -
requires critical care nursing which has created a need for highly skilled personnel, trained in art of neonatal intensive care.Risk of infection can be controlled, if health team and other workers have some knowledge of the facts and problems of cross infection and understand the principles and methods of controlling infection.program that meets the educational needs of all facility, staff, and clients in relation to infection control.2-Neonatal Intensive Care Unit should include Baccalaureate degree nurses to provide competent nursing care especially to high risk neonate.3-Nurses at NICU need pre service as well in-service educational program to refresh their knowledge and improve their skills.All infection control policies to be monitored and reviewed every two years.

Reasons for admission of high risk neonates Study group control group
Figure (I): Reasons for admission of high risk neonates.