CHAPTER I INTRODUCTION

Background of the Study Every nursing book states that handwashing is the best precaution against transfer of microorganisms. When we do handwashing, we loosen superficial microorganisms that could possibly cause infection when it penetrates the skin. This practice is applied in every health care institution worldwide.

Part of daily living of every person is to keep themselves free from any diseases, may it be direct or indirect contact with infectious materials. No matter what profession a person has, it is not a hindrance for them to practice sanitary precaution. For a nurse, it is a fundamental principle to practice handwashing in and out of the hospital.

Handwashing is a fundamental part of standard precaution procedures and disease control for health care personnel, and helps reduce or prevent infection and transmission of microbes among people and objects. For regular procedures, liquid soap and water is sufficient but for surgical procedures, antimicrobial cleansers should be used.

Maintaining intact skin is a must for every person. Any breakage in the skin means a chance for opportunistic pathogens to penetrate our body and cause infectious disease in relation to the nursing profession, this fact is always taken into consideration.

As a student nurse of UERM Hospital, the practice of proper handwashing is being applied to prevent transmission of microorganisms or diseases from patient to nurse or vice versa. And as a part of the health care team that provides wellness, it is a must to comply with the said precautions set by the health institution. The aim of this research is to find the level of extent of every nurse at UERM Hospital complying with handwashing is not just as an institution policy but is also a primary practice to prevent transfer of microorganisms.

Statement of the Problem Starting the researchers Related Learning Experience (RLE) in the clinical areas is part of the Level III Nursing curriculum. As Level III Nursing students, the researchers were assigned to the different hospital areas such as the Ob-Gynecology Ward, Surgery Ward, Pediatric Ward, Medical Ward, Neurology Ward, and pay wards. There, they were exposed to the different situations where they had to utilize the theories and principles they had learned in the classrooms. Furthermore, they were able to employ the basic skills of patient care such as using the standard precautions.

Standard precautions are internationally accepted protocols designed to decrease the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. (Kozier, et. al., 2004). Under standard precaution, handwashing is the main focus of this study.

In the clinical areas they experienced first hand, that handwashing is not strictly performed by nurses. Handwashing must be performed when there is direct contact with blood, body fluids, secretions and excretions or contaminated items, after removing gloves, and between patient contact. However, this principle is seldom practiced by nurses. Due to the existence of this event, the researchers decided to look into the query, What is the most significant factor that affects the level of compliance of 30 nurses on duty in the morning shift at both pay and charity wards in UERM Hospital regarding the proper application of handwashing?

This study is a modest attempt to identify the level of compliance of 30 nurses in applying handwashing in the clinical setting in all wards of UERM Hospital and the factor that most affect the frequency of handwashing in relation to manpower. It also addresses the knowledge gap that certain factors affect the level of conformity to handwashing of the specified population.

This study aims to help these nurses realize the importance of strictly applying the standard precautions, specifically handwashing, and not merely learning its theories and principles. This study also aims to improve the societys awareness to this present situation.

Completion of this study is possible due to the availability of the study participants, their cooperation, adequate time allotment, research materials and the experience of the researchers.

Significance of the Study

This study is to identify the level of compliance of 30 nurses on duty in the morning shift regarding the proper application of handwashing in all wards of UERM Hospital; the factors in relation to manpower affecting their level of compliance, and the most significant among the factors identified.

The result of this study can be of immense importance to nursing students and health care professionals, specifically registered nurses, not only in the researchers institution but also to all concerned individuals. With this study, nurses will be reminded that they have the lives of patients in their hands, hence they should be acquainted, equipped, and guided by Florence Nightingale's observation regarding patient care: "The first responsibility to the patient is to do no harm." (Tasota, N.D.). With this principle in mind, an increase in their awareness may lead to their strict compliance to these precautions and further help in the reduction and elimination of nosocomial infections in their respective wards. It also addresses the knowledge gap that there is a most significant factor that affects the level of compliance of nurses-on-duty in the morning shift to handwashing.

This study aims to help these nurses realize the importance of strictly applying the standard precautions, specifically handwashing and not merely learning its theories and principles. This study also aims to improve the societys awareness to this present situation.

Hypothesis

The most significant factor that affects the level of compliance among 30 nurses-on-duty for the morning shift regarding the proper application of handwashing in all wards of UERM Hospital is the patient-to-nurse ratio.

Statement of the Purpose The purposes of the study are to determine: 1. The level of compliance of 30 nurses-on-duty in the morning shift in all

wards of UERM Hospital regarding the proper application of standard precautions, specifically handwashing.

2.

The most significant factor among the factors identified in relation to

manpower, which affects the level of compliance of 30 nurses-on-duty in the morning shift in all the wards of UERM Hospital regarding to the proper application of standard precautions, specifically handwashing.

Conceptual Framework The conceptual framework of this study was drawn from the Law of Cause and Effect also known as the Law of Causality. Defining the two terms, cause is a reason for an effect or result, while effect is the development, a consequence. (Kimball, J.) Therefore, this law states that, every material effect must have an adequate antecedent cause. Kant, in the first edition of his Critique of Pure Reason, stated that everything that happens (begins to be) presupposes something which it follows according to a rule. In the second edition, he strengthened that

statement by noting that all changes take place according to the law of connection of cause and effect. Schopenhauer stated the proposition as, Nothing happens without a reason why it should happen rather than not happen (Thompson B. 2005).

A specific example on how the law of causality is applied is through this scenario: Good health is affected by a balanced diet. On the other hand, if we do not eat well, this could cause problems and we could become very sick. For instance, if our diet lacks Vitamin A, blindness may result. Many problems affecting the skin and the teeth are due to lack of Vitamin C. When our diet contains recommended amounts of Vitamin A and C, however, our ability to fight diseases like cancer is greatly affected. So it makes sense to eat well because this results in a longer and healthier life. (Kimball, J.)

In relation to this study, the research question is What is the most significant factor that affects the level of compliance of 30 nurses on duty in the morning shift in all wards in UERM Hospital regarding the proper application of handwashing? From this question, the researchers have drawn into conclusion that level of compliance to standard precaution is the effect of certain events, and these events are considered to be unknown. The factors to be determined, on the other hand, are considered to be the cause of the effect which is the level of compliance to standard precautions, specifically, handwashing. These factors are based on our independent variable which is manpower (power available from or supplied by the physical effort of man), specifically; patient-to-nurse ratio, level of knowledge, and years of practice. The most significant factor cannot be determined without identifying the level of compliance, thus, both the factors and the level of compliance need to arrive at the most significant factor.

Conceptual Map Law of Causality

Cause Standard precautions Handwashing

Effect

Adherence/ nonadherence to standard precautions practices

Factors affecting the rate of compliance

Compliance (always, sometimes, never)

Rate of compliance of healthcare providers

Manpower Patient to Nurse Ratio Years of Practice Level of Knowledge

Scope and Delimitation

The extent of the study is to identify the most significant factor that affects the level of compliance of nurses-on-duty to handwashing. With this study, nurses will be reminded that they have the lives of patients in their hands.

The target population is 30 nurses-on-duty in the morning shift (6 am to 2 pm) in all wards (charity and pay) of UERM Hospital. The data gathering is limited to 6 am to 2 pm shift since most of the nursing interventions or nursing care is done during the specified shift.

Standard precautions, specifically handwashing, and the factor that most affect the frequency of handwashing in relation to the independent variable which is manpower, will be discussed in the study.

This research will be accomplished in the year 2008. The time allotment of data collection is two weeks so that lesser chances of interruptions may occur such as programs that advertise standard precaution and increase in number of nurses that may alter the results of the study.

The researchers limit the population to nurses because they are patient-centered, the primary caregiver that is always there to attend to patients needs and they are in the same level of knowledge with the researchers regarding the concept of standard precautions. This will also be of great importance in the field of nursing especially for future nurses.

Emotional and personal preferences of the respondents are beyond the control of the researchers because such measures would necessitate a more immense scientific basis for the study.

D.

Definition of Terms Standard Precautions internationally accepted protocols designed to decrease the risk of transmission of microorganisms from both recognized and unrecognized sources of infection Handwashing vigorous, brief rubbing together of all surfaces of the hands lathered in soap, followed by rinsing under a stream of water Nosocomial Infections infections associated with the delivery of health care services in a health care facility Variable an attribute of an object that takes on different values Communicable disease any disease that can be transmitted from one person to another Blood-borne disease disease that can be spread by contamination with blood.

CHAPTER II REVIEW OF RELATED LITERATURE AND STUDIES

In 1996, the Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control (CDC) presented new guidelines for isolation precautions in hospitals, one of which is standard precautions. Standard precautions are designed to reduce risk of transmission of microorganisms from recognized and unrecognized sources. These precautions apply to blood, body fluids, excretions and secretions except sweat, non-intact skin and mucous membranes (Kozier et. al., 2004).

There are several skills under standard precautions; however, in the Philippines particularly in the UERM Hospital, the skill frequently used is handwashing.

The main skill under standard precautions as the focus of this study is handwashing. Handwashing is a vigorous, brief rubbing together of all surfaces of the hands lather in soap, followed by rinsing under a stream of water. The purpose is to remove soil and transient microorganisms from the hands and to reduce total microbial counts over time (Potter and Perry, 2005). Handwashing must be performed when there is direct contact with blood, body fluids, secretions and excretions or contaminated items, after removing gloves and between patient contacts.

Compliance to the different skills under standard precautions is important in preventing the spread of nosocomial infections, communicable diseases and blood borne diseases to both patients

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and health care providers. Surveys have shown that the use of universal precautions significantly decreased the number of incidents of occupational exposures to blood or any body fluids. (Motamed, N.,et al. 2004) One example is the study published in Journal of the American Medical Association (JAMA), which found a 50% reduction in the incidence of diarrhea among schoolchildren in Pakistan among compliance to the different standard precautions skills particularly handwashing. (Sansoni, B., 2004).

Non or low compliance to standard precautions, on the other hand, results to the spread or transmission of infections from patients to health care providers or vice versa. According to some studies, there are several effects of low compliance to standard precautions. Some of these state that Low compliance during the care of patients in intensive care units may also be a reason for the spread of multi-drug resistant organisms (Pittet, 2007). The predominance of gram-negative organisms as the cause of nosocomial pneumonia is thought to be due to contact with hospital flora. Likely, cause is transmission by unwashed hands of hospital personnel (Gingrich, 1990). This study will remind health care providers that they have the lives of patients in their hands, hence they should be acquainted, equipped, and guided by Florence Nightingales observation regarding patient care: The first responsibility to the patient is to do no harm. (Tasota, N.D.). With this principle in mind, an increase in their awareness may lead to their strict compliance to these precautions and further help in the reduction and elimination of nosocomial infections in their respective wards. One study which proves that reinforcing the awareness of nurses to standard precautions particularly handwashing was done in an urban hospital in Ireland. According to their study, a basic educational program can significantly improve the percentage of nurses who comply with hand hygiene guidelines. The studys method of collection was observation of 73

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health care professionals including nurses, doctors, physiotherapists and care assistants in ICU unit before and after implementing a program. In the program, they were given handouts that emphasized the importance of handwashing and hand hygiene guidelines and also 5 posters with similar information were posted around the nurses station. During the evaluation, nurses compliance jumped from 56% to 89%, indicating the success of the intervention.

Moreover, several studies have shown that there are numerous factors that affect the level of compliance of health care providers to Standard Precautions.

Suchitra JB, Lakshmi Devi N (2007) have categorized them into two, which are the group level barriers and the individual level barriers.

At the group level, the barriers to practice standard precautions (hand hygiene) are attributed to lack of education, high the work load especially when the ward was occupied to its full capacity, understaffing, working in the critical care units, lack of encouragement and lack of role model among senior staffs. At the individual level, the barriers perceived were the lack of knowledge and experience, lack of knowledge on guide lines set by the institution or being a refractory non-complier.

Along with Suchitra, several researchers have also noted some common factors that affect the level of compliance of health care providers to standard precautions, which includes the following:

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Recent data from an investigation by the Centers for Disease Control and Prevention indicate that understaffing may be a risk factor for nosocomial infections. When the patient-to-nurse ratio increases, the provision of routine nursing measures such as turning the patient, suctioning, and complying with aseptic technique may decline. (Tasota, et.al) One of the factors that can contribute to non-compliance is time limitation staff having to work in a hurry because shifts follow each other closely and because the time table has to be strictly adhered to. Other self-reported reasons for poor adherence with hand hygiene were: handwashing agents cause irritation and dryness, sinks are inconveniently located or absent, lack of soap or paper towels, high workload and understaffing, interference with patient care and the low risk of acquiring infection from patients. (Arenas, et al. 2005)

According to the study of Aiken, et al (2002), the optimal workload for a nurse was 4 patients, and increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission. A survey of the states nurses released on July 13 found that 90% of RNs believe the quality of patient care is suffering in hospitals due to poor ratios, with 77% reporting an increase in medication errors, 68% reporting an increase in complications and more than a third (34%) reporting patient deaths directly attributable to having too many patients to care for (Schildmeier, 2005). However, current research cannot determine the optimal nurse-to-patient ratio because there is just too much variation in the severity of cases, staff skills, nurses experience, and a host of other variables for there to be a single, one-size-fits-all ratio. What research can determine is that patient outcomes can likely be improved at least somewhat with more nurses (Tannenwald, 2005).

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In the course of our preliminary data gathering, the researches have found out that these factors can be correlated or further be strengthened using some existing theories.

An example of which is using the Law of Supply and Demand theory in explaining how the patient-to-nurse ratio affects the level of compliance to standard precautions which is the supply being the nurses population and the demand coming from the patients. If the ward population is at its maximum, therefore the demand for healthcare providers is also at its maximum. If the nurses population is limited only to a couple of patient therefore, quality of care may suffer. (Policarpio.2006). According to Karen Robert, a nurse in the United States, baby boomers are going but not everyone outside nursing knows that nurses are on the endangered species list. As more and more nurses retire, there will be an even greater shortage of skilled professionals. By the year 2030, US population of those over age 65 will jump from the current of 13% to around 20%. Nurses are already overworked and burned out, what more if another 30 million patients will be added? The law of supply and demand dictates that a commodity in short supply is made more valuable by its shrinking availability.

Another is using the Time- Management theory. In nursing management, a systematic application of common sense strategies and techniques is used to help nurses to become more effective in their profession. The promise is to become more productive and faster. Thus, decreasing the anxiety and pressure they about feel about time. (www.higher-self-improvementpursuits.com/time-management, N.D.)

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When there is too much time, it builds a habit of idling along which are hard to break when work demands suddenly builds up. (Dayton, 1997) To enumerate such things, here are some:

Lack of information about the pending work load causes nurses to slow down while they wait for the next assignment, poor scheduling analysis can create peaks and valleys. Improper sequencing of events can leave people waiting for others to complete their task, failure to delegate or to obligate clearly, may keep nurses from recognizing that they have work to do and lastly, lack of training keeps nurses from doing things they could have done if they knew how. (Dayton, 1997)

This theory also states that most people function at different levels of effectiveness at different times. Their effectiveness may vary depending on the amount of sugar in the blood, the length of time since they last took a break, routine distractions, stress, discomfort, or a range of other factor, which is evident that it affects the rhythms of alertness and energy.

Concluding this review of related literature, the researchers have evaluated that most of the studies reveal a low level of compliance to standard precautions (specifically handwashing) in the healthcare settings due to factors in relation to manpower such as: the patient to nurse ratio like understaffing, level of knowledge and years of practice. The effects of low compliance in the healthcare settings may lead to increased incidence of nosocomial infections, such as pneumonia. Standard precautions, such as handwashing, must be strictly complied to promote the healing process of patients and prevent further complications and costs in hospital stay and equipments.

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CHAPTER III THE RESEARCH METHODOLOGY

Research Design The research design applicable in this study is descriptive-survey design. In using this design, the researchers used the survey as the instrument in collecting data. In each of the specified wards, a survey was conducted as to determine the compliance level of the selected health care providers to standard precaution, the factors affecting it and the most significant among them. In this design, the researchers collected data and information needed to prove their hypothesis. These data will comprise the descriptive design. The data were gathered to particularly depict and describe the variables included in the research.

This specific research design is considered as the weakest among all the other designs because this design lacks a controlled setting. Therefore, many factors may affect the result of the study. (Polit et. al., 2004) However, this design can be considered as less time consuming and easier because of the fact that data can be collected in bulk during a single time frame. Thus, evaluation of data is faster.

The variables in the study were utilized in a way that the actual population determines their level of compliance and the factors affecting it.

The manner preferred by the researchers to control the internal validity is through the selection of participants who are in the same level of knowledge regarding standard precautions.

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Since they all belong to one classification which is health care providers, then the data gathered would generally be similar than with various results. Another manner is through the strict imposition of the data collection time frame. Since data collection would last only for two weeks, lesser chances of interruptions may occur. A good example of it would be, if data collection would happen in a month, there are chances where programs that advertise standard precaution may alter the attitudes of the participants toward the research problem.

In addition, control of the external factors should also be done. The researchers should maintain an objective outlook. Emotional, personal preferences and biases should be avoided. Such actions would entail a stronger scientific basis for the study. As well, experimental arrangements should be properly controlled. In this study, the time where the survey sheets will be passed is one of the factors being controlled. They will be passed at the end of the shift. In this way, the subjects will evaluate their practices during the said shift with no alterations such as doing their activities consciously which may weaken the study outcome.

The ethical considerations in this research design include stipulation of awareness to the right of privacy and confidentiality of the participants. It also requires that the researchers secure consent in order to protect the rights of the participants. Names, age or personal descriptions should not be forcefully asked to the participants and the answered surveys should be viewed only by the researchers in full confidentiality.

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Setting

This study was conducted in all wards of the UERM Hospital, a private hospital located at Aurora Boulevard, Quezon City.

Subjects The target population was randomly selected and was consisted of 30 nurses-on-duty in all wards in UERM Hospital. The method used in selecting the research participants is the simple stratified random sampling. The stratum used is the scheduled shift of the nurses, specifically the morning shift.

Instrument

The instrument used in this study was surveying through questionnaires. The questionnaire consists of 10 questions regarding the populations personal level of compliance on handwashing in connection to the three variables of the study namely, the patient-to-nurse ratio, level of knowledge and years of practice. Validity is evident in the questionnaires. The questions are direct to the point and are all related to the purpose of the research and research problem. This instrument is considered to be reliable because it can be used in different times and clinical setting. The homogeinity of such is clearly depicted in the questions wherein these items are related to each other, focusing on one idea which is the factors affecting the health care providers compliance to standard precautions. Also, the answers to be generated from the instrument will be of the same kind, though different

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population will answer such, thus, the data to be gathered will still be congruent with the purpose of the research.

Ordinal scale measurement is applicable in this study. This level of measurement shows relative ranking of objects or events (Wood, 1994). The quantity of the attribute possessed can be identified (Burns, 1997). It only reflects magnitude and has no equal intervals or an absolute zero point (Basavanthappa, 1998). In relation to this study, the levels of compliance are ranked according to the quantity of answers in each category, which resulted from the collected data.

Data Gathering

Data collection started from the submission of an informed consent to the chief nurse of UERM Hospital, Ms. Agbayani for approval. After letter was approved, the group proceeded to the actual data gathering. The group was divided into 5 sub-groups; each sub-group was assigned to the specified wards in the morning shift to collect data. The giving out of questionnaires was done at the end of the morning shift. A maximum of five minutes was allotted for answering the questionnaires.

Data Analysis

In this study, the statistical treatment used was the correlation coefficient specifically the pearsons r. This statistical treatment is used to express relationships between variables by computing the correlation coefficient. This coefficient has an index with values ranging from

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-1.00 (pefect negative correlation) to 1.00 (perfect positive negative correlation). In determining which factor has a significant relationship to the compliance level of the respondents to hand washing, the value of the correlation coefficient is determined. The higher the value, disregarding the sign, the stronger the relationship (Polit et. al 2004). Once the three correlation coefficients are obtained, the final comparison will be done to determine which of the factors have relationship to the compliance of respondents to hand washing.

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CHAPTER IV PRESENTATION AND ANALYSIS OF DATA Level of Compliance of 30 Nurses in all the wards of UERM hospital 1 - low compliance = handwashing before and after the shift only 2 - average compliance = handwashing as needed only 3 - high compliance = handwashinhg before and after handling each patient

This pie chart shows the general level of compliance of all nurses in UERM hospital with regards to the practice of handwashing. It is clearly seen that 19 out of 30 respondents perform handwashing only as needed. 10 out of 30 however, answered that they do handwashing before and after handling each patient and only 1 answered that they hand wash before and after the shift only. This data shows that in general the compliance level of nurses in the morning shift is average or performing handwashing as needed only.

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Computation of Results Variables: x patient to nurse ratio in their respective wards y number of nurses who answered in that compliance level I. Patient to Nurse Ratio Low Compliance
x 3 8 10 12 14 16 y 0 0 0 0 1 0 x-x -7.5 -2.5 -0.5 2.5 4.5 6.5 ( x- x )2 56.25 6.25 0.25 6.25 20.25 42.25 y-y -0.17 -0.17 -0.17 -0.17 0.83 -0.17 ( y y )2 0.03 0.03 0.03 0.03 0.69 0.03 (x x) (y y) 1.28 0.43 0.09 -0.43 3.74 -1.11

=131.5 x = (3+8+10+12+14+16) / 6 = 10.5 y = (0+0+0+0+1+0) / 6 = 0.17 rxy = (x-x) (y-y) (x-x)2 (y-y)2 = 4 (131.5) (0.84) = 4 110.46 = rxy = 0.38 4 10.51

=0.84

=4

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Average Compliance
X 3 8 10 12 14 16 Y 2 4 5 2 3 2 x-x -7.5 -2.5 -0.5 2.5 4.5 6.5 ( x- x )2 56.25 6.25 0.25 6.25 20.25 42.25 y-y -1 1 2 -1 0 -1 ( y y )2 1 1 4 1 0 1 (x x) (y y) 0 5 14 -9 0 -13

=131.5

= 8

= 3

x = (3+8+10+12+14+16) / 6 = 10.5 y = (2+4+5+2+3+2) / 6 = 3 rxy = (x-x) (y-y) (x-x)2 (y-y)2 = 3 (131.5) (8) = 3 1052 = rxy = 0.09 3 32.43

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High Compliance
X 3 8 10 12 14 16 Y 1 0 4 2 1 3 x-x -7.5 -2.5 -0.5 2.5 4.5 6.5 ( x- x )2 56.25 6.25 0.25 6.25 20.25 42.25 y-y -0.83 -1.83 2.17 0.17 -0.83 1.17 ( y y )2 0.69 3.35 4.71 0.03 0.69 1.37 (x x) (y y) 6.23 4.58 -1.09 0.43 -3.74 7.61

=131.5

= 10.84

=14.02

x = (3+8+10+12+14+16) / 6 = 10.5 y = (1+0+4+2+1+3) / 6 = 1.83 rxy = (x-x) (y-y) (x-x)2 (y-y)2 = 14.02 (131.5) (10.84) = 14.02 1425.46 = rxy = 0.037 14.02 37.76

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II. Level of Knowledge x score of respondents to the test question y number of nurses who attained the given score Grade equivalents 1 = 1-2 pts 2 = 3-4 pts 3 = 5 pts
X 1 2 3 Y 6 24 0 x-x -1 0 1 ( x- x )2 1 0 1 y-y -4 14 -10 ( y y )2 16 196 100 (x x) (y y) 4 0 -10

= 2

= 312

=-6

x = (1+2+3) / 3 = 2 y = (6+24+0) / 3 = 10 rxy = (x-x) (y-y) (x-x)2 (y-y)2 = -6 (2) (312) = -6 624 = rxy = -.24 -6 24.98

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III. Years of Practice Variables x years in service of the respondents y - number of nurses who answered in that compliance level Low Compliance
Range 0-1 2-5 6-10 10-20 X .5 3.5 8 15 Y 0 0 0 0 x-x ( x- x )2 y-y ( y y )2 (x x) (y y)

Low compliance showed no further computations since none of the respondents answered in this category.

Average Compliance
Range 0-1 2-5 6-10 10-20 X .5 3.5 8 15 y 11 5 3 2 x-x -6.25 -3.25 4.25 8.25 ( x- x )2 39.06 10.56 18.06 68.06 y-y 5.75 0.25 -2.25 -3.25 ( y y )2 33.06 0.06 5.06 10.56 (x x) (y y) -35.94 -0.81 -9.56 -26.81

= 135.74 x = (0.5+3.5+8+15) / 4 = 6.75 y = (11+5+3+2) / 4 = 5.25 rxy = (x-x) (y-y) (x-x)2 (y-y)2 = -73.12 (135.74) (48.74) = -73.12 6615.97 = rxy = - 0.90 -73.12 81.34

= 48.74

= -73.12

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High Compliance
Range 0-1 2-5 6-10 10-20 X .5 3.5 8 15 y 4 4 0 1 x-x -6.25 -3.25 1.25 8.25 ( x- x )2 39.06 10.56 1.56 68.06 y-y 1.75 1.75 -2.25 -1.25 ( y y )2 3.06 3.06 5.06 1.56 (x x) (y y) -10.94 -5.69 -2.81 -10.31

= 119.24

= -12.75

= -29.75

x = (0.5+3.5+8+15) / 4 = 6.75 y = (4+4+0+1) / 4 = 2.25 rxy = (x-x) (y-y) (x-x)2 (y-y)2 = - 29.75 (119.24) (-12.75) = -29.75 -1520.31 = rxy = 0.76 -29.75 -38.99

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Interpretation of Correlation Coefficients of the Three Factors Patient to Nurse Ratio 1 2 3 Average Coefficient Coefficients 0.38 0.09 0.37 0.28

The table revealed that there is a low compliance of nurses in performing hand washing due to an increase in number of patients since the value of 0.38 is the highest value among the three compliance level. Getting the average of the three compliance levels was done to get the correlation coefficient of the patient to nurse ratio vs the compliance level of the respondents. The average of 0.28 will be compared to other factors to determine which among the three affects the respondents compliance to handwashing. The graph, on the other hand showed a moderate positive correlation which means that the higher the value of the coefficient the stronger the relationship to the dependent variable which is the level of compliance of nurses in performing hand washing.

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Level of Knowledge

Coefficient -0.24

The table revealed that the level of knowledge have a strong negative correlation. The strong negative correlation indicates that there is relationship between the two variables (Level of Compliance vs the repondents knowledge on handwashing). Therefore, the level of knowledge of respondents affects their compliance to handwashing especially in the clinical setting.

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Years of Practice 1 2 3 Average Coefficient

Coefficients 0 -0.90 0.76 0.05

Based on the table, the grade of 2 had the highest correlation coefficient which indicates that there is an average level of compliance of nurses in performing hand washing, meaning, majority of the nurses only do hand washing as needed. The average of the three levels of compliance which is 0.05 only indicates that the years of practice have minimal relation to the compliance of the respondents to handwashing The graph shows a weak negative correlation that means that there is a minimal relationship between the two variables. Therefore, the relationship of the level of compliance of nurses in performing hand washing and the years of practice of nurses is minimal.

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Comparison of the Correlation Coefficients of the Three Factors Patient to Nurse Ratio Level of Knowledge Years of Practice 0.28 -0.24 0.05

Among the three variables identified, the average coefficient signifies that Patient to Nurse Ratio mostly affects the level of compliance of nurses in performing hand washing in their respectful wards. Since, the average coefficient of the patient to nurse ratio revealed have the highest value, hence, it is the most significant factor affecting the level of compliance of nurses in performing hand washing.

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CHAPTER V CONCLUSION AND RECOMMENDATION

Conclusion: After the research was conducted, the researchers discovered that majority of the nurses in the UERM Hospital is affected mainly by the patient-to-nurse ratio and the level of knowledge, respectively in their level of compliance to handwashing. Among the different factors identified, majority has a average compliance to handwashing due to patient-to-nurse ratio This study is significant because it will further enhance the awareness of health care providers, especially nurses, in rendering care to patients. It will also motivate other nurses to adhere to handwashing more effectively than before.

Recommendation: In this study, the researchers identified the variables that affect the level of compliance of nurses to handwashing. They considered three factors: patient-to-nurse ratio, level of knowledge and years of practice, in order to come up with an accurate and reliable study. Future researchers, who wish to focus on studying hand washing, should also focus on other factors that could affect the level of compliance of nurses to hand washing to enhance their knowledge regarding the study. Future researchers should also conduct their studies in other hospitals for them to gather more information and compare the differences that can be helpful to their research. A good research instrument should be developed so that the researchers would be able to obtain accurate results. Further studies should also be significant in improving the awareness of healthcare providers in the

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importance of compliance to standard precaution, specifically hand washing. The researchers recommend further researches to study in terms of infection control and standard precaution.

BIBLIOGRAPHY 34

Aiken, Linda, et al. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. Journal of American Medical Association. 2002; 288: 1987-1993. Arenas, M D et al. A Multicentric Survey of the Practice of Hand Hygiene in Hemodialysis Units: Factors Affecting Compliance. Nephrology Dialysis Transplantation 2005 20(6): 11641171. Available: http://ndt.oxfordjournals.org/cgi/conetnt/full/20/6/1164 Basavanthappa, B. T. (1998). Nursing Research. India: Jaypee Brothers, Inc. Burns, Nancy and Susan K. Grove. (1997). The Practice of Nursing Research, Conduct, Critique and Utilization. Pennsylvania: WB Saunders Company. Dayton, Edward R. (1992). Tools for Time Management: Christian Perspectives on Managing Priorities. Mandaluyong: OMF Lirterature Inc. Gingrich, Dennis. Infections in the Hospitalized Elderly. Hospital Physician, No.1, Vol. 26, January 1990. Kimball, Jack. (N.D.) Definition of Cause and Effect. Available: www.fauxpress.com/kimball/w/9.html Kozier, Barbara F., et al. (2004). Fundamentals of Nursing: Concepts, Process, and Practice. 7th ed. Jurong: Pearson Education South Asia Pte Ltd. Motamed, N.,et al. Knowledge and Practices of Health Care Workers and Medical Students Towards Universal Precautions in Mazandaran Province. 2004 Available: www.emro.who.int/Publications/EMHJ/1205/PDF/Article20.pdf Pittet, Didier. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Available: http://www.cdc.gov/ncidod/eid/vol7no2/pittet.htm 35

Pittet, Didier, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Available: http://www.ncbi.nlm.nih.gov/pubmed/11073019?dopt=Abstract Policarpio, Jonas D. (2006). Economics in Health for the Allied Health Sciences. Quezon City: C&E Publishing, Inc. Polit, Denise F., and Cheryl Tatano Beck. (2004). Nursing Research: Principles and Methods. 7th ed. Lippincott Williams and Wilkins. Potter, Patricia, and Anne G. Perry. (2001). Fundamentals of Nursing. 5th ed. Singapore: Elsevier Science Pte Ltd. Sansoni, Brian. Joint Statement: The Soap and Detergent Association and the Cosmetic, Toiletry, and Fragrance Association, JAMA Study on Positive Effects of Available: www.sdahq.org/whatsnew/06-01-04.cfm Schildmeier, David. New Study Finds Lower RN-to-Patient Ratios a Cost Effective Measure for Saving Lives and Improving Safety in Hospitals. Available: www.massnurses.org/News/2005/08/new_study.htm Suchitra JB, and Lakshmi Devi N. Impact of education on Knowledge, Attitudes and Practices Among Various Categories of Health Care Workers on Nosocomial Infections. Indian Journal of Medical Microbiology [serial online] 2007 [cited 2008 February 27]; 25:181-7. Available: www.ijmm.org/text.asp?2007/25/3/181/34757 Tannenwald, Robert, et al. Nurse-to-Patient Ratios: Research and Reality. NEPPC Conference Report Series No. 05 1 July 2005 Available: http://www.bos.frb.org/economic/neppc/conreports/2005/conreport051.pdf. Handwashing.

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Tasota, Frederick J., et al. Protecting ICU Patients from Nosocomial Infections: Practical Measures for Favorable Outcomes. Critical Care Nurse No.1, Vol.18, nd. pp. 54-67. Thompson, Bert. The Bible and the Laws of Science: The Law of Cause and Effect. Available: www.apologeticpress.org/articles/2005 Wood, Geri L., and Judith Haber. (1994). Nursing Research, Methods, Critical Appraisal and Utilization. 3rd ed. Missouri: Mosby-Yearbook, Inc. www.higher-self-improvement-pursuits.com/time-management

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Appendix

Questionnaire Objectives: 1. To determine the level of compliance of nurses of UERMMMC to handwashing. 2. To determine if handwashing are affected by these factors: a. b. c. 3. I. 1. 2. What is the patient to nurse ratio in your ward? _______ Rate your level of compliance to handwashing given this number of patients ____a. 1 - Low (refers to hand washing before and after the shift only) ____b. 2 - Average (refers to hand washing as needed only) ____c. 3 - High (refers to hand washing and after handling each patient) Patient to nurse ratio Level of knowledge Years of practice

To determine the factor that affects the most in the degree of compliance of nurses to handwashing.

II. Check your answer before the number 1. What is handwashing? a. A fundamental part of standard precaution procedure and disease control. This reduces or prevents infection and the transfer of microorganisms among people and objects. b. The act of cleansing the hands with water or other liquid with or without inclusion of soap and other detergent. The purpose is top remove microorganisms. c. By handwashing, it kills 99% of germs on contact 2. How long should handwashing be done? a. 5 seconds b. Minimum of 10 seconds max of 30 seconds c. 5 minutes 3. As you wet your hands at the start of medical handwashing, you should hold your hand on what position? a. The fingertips below the wrist b. The fingertips above the wrist c. The wrist should be on the same level as the fingertips 4. What is the position of the hands and arm when rinsing soap from it in medical handwashing? a. Fingertips pointing downward, elbows above the waist and below eye brow b. Fingertips pointing upward , elbows above the waist and below eyebrow c. Arms straight forward 5. All but one are true about handwashing (aseptic tecnique) a. In handwashing, friction and rubbing mechanically loosen and remove bacteria b. When wetting start from the cleanest (fingertips) to least clean (wrist) c. When drying, start from the cleanest (fingertips) to least clean (wrist) III. How long have you been working as a nurse at UERM hospital? a. Less than 12 months to 1 year b. 2-5 years c. 6-10 years d. 10-20 years

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2.

Evaluate your over-all compliance to hand washing since you started as a nurse at UERM hospital up to the present.. ____a. 1 - Low (refers to hand washing before and after the shift only) ____b. 2 - Average (refers to hand washing as needed only) ____c. 3 - High (refers to hand washing and after handling each patient)

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