Intensive care unit nurses’ knowledge, attitudes and practices of COVID-19 infection prevention and control

Background Intensive care units (ICUs) had to rapidly adapt infection prevention and control (IPC) practices during the coronavirus disease 2019 (COVID-19) pandemic. Objectives To determine ICU nurses’ COVID-19 IPC-related knowledge, attitudes, practices, and perceptions. Method A mixed-methods study was conducted at the Groote Schuur Hospital ICU, Cape Town, South Africa (20 April 2021 and 30 May 2021). Participants completed anonymous, self-administered, knowledge, attitudes and practices (KAP) questionnaires. Individual interviews were conducted regarding nurses’ lived experiences and perceptions of COVID-19 IPC in critical care. Results In total, 116 ICU nurses participated (93.5% response rate) including 57 professional nurses (49%), 34 enrolled nurses (29%) and 25 enrolled nursing assistants (22%); young females (31–49 years) predominating (n = 99; 85.3%). Nurses’ overall COVID-19 IPC knowledge scores were moderately good (78%); professional nurses had greater knowledge of COVID-19 transmission (p < 0.001). Intensive care unit nurses’ attitude scores towards COVID-19 IPC were low (55%), influenced by limited IPC training, insufficient time to implement IPC and shortages of personal protective equipment (PPE). Respondents’ scores for self-reported COVID-19 IPC practices were moderate (65%); highest compliance rates were for hand hygiene after touching patient surroundings (68%). Only 47% ICU nurses underwent N95 respirator fit-testing despite working in a COVID-19 ICU. Conclusion Regular COVID-19 IPC training is needed to equip ICU nurses with the knowledge and skills to prevent healthcare-associated COVID-19 transmission. Enhanced IPC training and consistent PPE availability may support more favourable attitudes and better IPC practices. Comprehensive IPC and occupational health support should be offered to ensure ICU nurses’ wellbeing during pandemics. Contribution Enhanced IPC training and consistent PPE availability may support better attitudes and IPC practices.


Introduction
Coronavirus disease 2019 (COVID-19) is a severe respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel β-coronavirus emerged in Wuhan, China, in late 2019 and rapidly spread worldwide. 1 COVID-19 is a highly infectious disease spread primarily through respiratory aerosols from human to human. 1 Although most COVID-19 infections are mild or even asymptomatic, up to 5% of patients will require hospital care. 2 Severe COVID-19-associated pneumonia is the leading indication for admission to the intensive care unit (ICU). 2 As a result of the COVID-19 pandemic, the working conditions for ICU staff globally became increasingly difficult. The pandemic resulted in surges in ICU bed demand, higher patient-tonurse ratios and increased staff absenteeism because of COVID-19 infection-related sick leave. Furthermore, ICU nurses were particularly at risk of developing mental health problems, including depression, anxiety and burnout during the pandemic. 3 South African healthcare facilities follow the national Infection Prevention and Control (IPC) strategic framework published in March 2020 including those specifically developed for COVID -19 IPC in April 2020, which outline the recommended IPC measures for different clinical areas, clinical activities and staff. 4,5 These guidelines are intended to provide direction for healthcare workers (HCWs) to ensure both occupational and patient safety in the care of patients with infectious diseases. Specific recommendations in the ICU setting include the use of the closed endotracheal tube and patient suctioning, bed spacing of 3 m and dedicated patient care equipment. 4 Intensive care unit nurses' understanding, acceptance and implementation of national and local COVID-19 IPC practice guidelines are key to ensuring safe ICU working environments, as they carry the primary responsibility for IPC policy implementation and practices. 6 Acknowledging the key role of ICU nurses in attaining COVID-19 IPC compliance, several studies from low-and middle-income countries (LMICs) surveyed HCWs' knowledge, attitudes and practices (KAP) during the COVID-19 pandemic. 1,7,8,9 Studies from Uganda, Ethiopia and Nepal concluded that HCWs in LMIC settings had adequate knowledge and a positive attitude to IPC during the COVID-19 pandemic, but to our knowledge at the time of our study, none had included interviews with ICU nurses. 8,9,10,11 Intensive care unit nurses are highly qualified, skilled and experienced in caring for acutely ill patients and represent a cadre of healthcare workers with high exposure to COVID-19 and high risk for suffering adverse work-related mental health effects during the pandemic. 12 We aimed to describe ICU nurses' KAP and lived experiences of COVID-19 IPC at a tertiary hospital, dedicated COVID-19 ICU in Cape Town, South Africa.

Study setting and population
This study was conducted in the COVID-19 dedicated ICUs at Groote Schuur Hospital (GSH), Cape Town, South Africa. Groote Schuur Hospital is a 991-bed academic hospital situated in the City of Cape Town Metropolitan health district, which was the epicentre of COVID-19 infection in the Western Cape province during the first, second and third infection waves. 13 Groote Schuur Hospital has 10 ICUs (with six beds each and one isolation unit with seven beds), of which seven were designated for COVID-19 patients (total bed capacity 43) since 05 April 2020. The seven COVID-19 ICUs were staffed by 120 permanent nurses and four sessional nurses. Every nurse was responsible for implementing IPC in the ICU. The nursing categories consisted of professional nurses (PN), enrolled nurses (EN) and enrolled nursing assistants (ENA). 14 Professional nurses are senior nurses with a 4-year nursing degree who supervise EN and ENA, perform skilled nursing procedures, administration of patient medication as well as administrative duties. Each PN was responsible for the care of two ventilated patients, executing doctors' orders and administering intravenous infusion medication. Enrolled nurses have a 2-year nursing diploma programme and cared for nonventilated COVID-19 patients and administered oral medications only. Enrolled nursing assistants have a 1-year diploma and provide supportive duties for the PN and ENA, personal hygiene care for patients and assisted with environmental cleaning in the ICU.
Groote Schuur Hospital has an on-site Unit for IPC employing three IPC nurse specialists and one nursing clinical facilitator. Prior to the COVID-19 pandemic, the ICU clinical facilitator conducted in-service training every two weeks for ICU nurses. From the onset of the COVID-19 pandemic, a single face-to-face COVID-19 IPC in-service training session was held for each ICU, and nurses were encouraged to watch a COVID-19 IPC video on the hospital computers. The limited training time for COVID-19 IPC resulted from the huge pressure of COVID-19 patient admissions to the ICU, which precluded ICU nurses from attending more in-service training sessions.
All patients admitted to the COVID-19 ICUs had nasopharyngeal swabs taken to confirm the presence of SARS-CoV-2 using reverse transcription polymerase chain reaction (RT-PCR) tests. The Occupational Health Service at GSH monitored HCWs' COVID-19 infection rates at the facility from April 2020 onwards.

Study design
This research was designed as a mixed-methods study, with simultaneous data collection for both study components between 20 April 2021 and 30 May 2021. 11 The questionnaire and interviews were used to explore ICU nurses' knowledge, attitudes and practices related to COVID-19 IPC. Quantitative data were collected using a self-administered anonymous, 33-item questionnaire to assess participants' KAP regarding COVID-19 IPC, as well as participants' demographics (nursing category, work experience and risk factors for severe COVID-19 disease). We developed a semi-structured interview questionnaire comprising six open-ended questions to further explore and provide insights into the three quantitative constructs covered in the quantitative assessment (see Appendix 1).

Sampling strategy
A convenience sampling strategy was employed, enrolling PN, EN and ENA staff categories from the COVID-19 ICUs. The principal investigator (PI) visited all seven COVID-19 dedicated ICUs five times during the study period (including day and night shifts) to explain the purpose of the study and to invite all the nurses working in the COVID-19 ICU to participate. Nurses completed the questionnaires manually, in English, providing written informed consent, and the questionnaires were collected after each 12-h shift by the study PI.
Purposive sampling was used to select participants to interview for the qualitative arm of this study. 15 The sample included all the nursing categories (PN, EN and ENA) working in COVID-19 ICUs with varying years of work experience, gender (female and male), and education level (diploma and degree). The participants included staff from the day and night shifts. The purpose of the study was explained to each participant. Interviews were conducted in English in a private room. The data were transcribed, analysed, coded and triangulated with the quantitative data.

Measurement instruments
Self-administered questionnaire A survey instrument was designed based on previous KAP studies of healthcare-associated infection. 10 The instrument was adapted and modified to assess the ICU nurses' KAP of COVID-19 IPC. The closed-ended questionnaire consisted of four parts: participant demographics (10 questions), knowledge (9 questions), attitudes (15 questions) and practices (8 questions). Scoring criteria were set, giving a score of '1' for a correct answer and a score of '0' for an incorrect answer. Knowledge questions assessed nurses' understanding of COVID-19 IPC measures, attitude questions sought to determine the ICU nurses' attitudes level towards COVID-19 IPC measures, while practice questions collected nurses' self-reported practices regarding prevention of COVID-19 infection (see Appendix 2). The assessment of the correlation relationship between variables of knowledge, attitude and practice scores was conducted using Spearman's rho correlation test. A pilot study was conducted to assess the validity and reliability of the questionnaire before using it. Two experts in infectious disease and public health evaluated the KAP questions. Pretesting of the instrument was done, and a questionnaire was completed by two operational managers and six ICU nurses who were excluded from the study sample.

Semi-structured qualitative question guide
The semi-structured qualitative guide was designed to complement the quantitative questionnaire and focused on exploring the lived experiences of COVID-19 IPC at the GSH dedicated COVID-19 ICUs. The semi-structured guide comprised six open-ended questions centred on experience in ICU, application of IPC measures during the COVID-19 pandemic, adaptation to new COVID-19 IPC guidelines, COVID-19 IPC training, COVID-19 precautions and how ICU nurses were coping in their daily practice and personal lives.

Data management and statistical analysis
Quantitative data from the manually completed questionnaires were entered into a RedCAP database by the PI and analyses were performed using Stata ® Statistical software version 15.0 (Stata Corp, College Station, Texas, United States). The categorical data were summarised using the frequency and percentages. The proportions for KAP were compared by nursing job category (EN vs ENA vs PN). The chi-square or Fisher's exact test was used for comparing categorical data. The Spearman's rho correlation test was used to find the relationship between knowledge, attitude and practices, following the conversion of individual items in the questionnaire to overall percentages of the correct answers (scoring 1 for correct and 0 for incorrect responses). The statistically significant level was set in all tests at p < 0.05.

Qualitative analysis
Qualitative data were obtained by posing six pre-specified open-ended questions to participants. Participants' responses were audio-recorded and transcribed verbatim, and a six-step thematic analysis approach was employed: familiarisation with data, generating initial codes, searching for themes, reviewing themes, defining, naming themes and producing a report. 16 Emerging themes developed from respondents' lived experiences while working with COVID-19 IPC precautions in the ICU, and direct participants' quotes that best reflected these emerging themes were selected.

Mixed methods integration
The interconnected themes from the qualitative data were integrated and aligned with the results of the quantitative data. 17 Themes that represented the knowledge, attitudes and practices of ICU nurses regarding COVID-19 IPC were identified, and conclusions were drawn in conjunction with the quantitative data.

Ethical considerations
Ethics approval was obtained from the Human Health Research Ethics Committee of the University of Cape Town (774/2020). All participants provided written informed consent.

Intensive care unit nurses' knowledge of COVID-19 infection prevention and control
Respondents' overall knowledge scores pertaining to COVID-19 transmission mechanisms and prevention measures in the ICU were moderate to good (78%). Professional nurses had significantly higher scores than other nursing categories regarding the role of aerosol transmission of the SARS-CoV-2 virus (p < 0.001, Table 2). Intensive care unit nurses had good knowledge (82%) regarding the importance of hand hygiene to remove COVID-19 viral particles from the skin; 78% of respondents believed that alcohol hand rub is as effective for decontaminating hands possibly contaminated with COVID-19, as handwashing with soap and water. Intensive care unit nurses had good knowledge (91%) of the indications for terminal cleaning and disinfection of hospital rooms. Most (84%) respondents were aware that all patients admitted to ICU were tested for COVID-19 infection.

Intensive care unit nurses' attitudes to COVID-19 infection prevention and control
Intensive care unit nurses' attitudinal scores with regard to COVID-19 IPC were marginally positive (55%), ( Table 3). Half of the respondents (51%) reported that ICU nurses had a generally positive attitude towards COVID-19 IPC. However, half of the respondents (50%) believed that they had received insufficient training in COVID-19 IPC measures before admitting infected patients to the ICU. Many respondents (72%), especially PNs (88%), (p < 0.005) believed that the high workload during the COVID-19 pandemic resulted in decreased time to adhere to standard IPC practices in the ICU. Professional nurses were more likely to agree with the statement that there was adequate availability of PPE in the ICU, compared to EN and ENA (70.2% vs 56% and 52%; p = 0.048).

Intensive care unit nurses' practices for COVID-19 infection prevention and control
Respondents' overall self-reported practice scores were moderate (65%). The highest reported compliance was for the performance of hand hygiene after touching the patient's surroundings (68%), as well as the performance of hand hygiene before and after touching COVID-19-infected patients (67%). Less than half of respondents (47%), especially ENAs (40%), p = 0.039 (Table 4), had undergone N95 respirator fittesting, despite working in a high-risk environment for COVID-19 transmission. One-third of staff (30%) reported for duty despite having symptoms of possible COVID-19 infection. Self-reported adherence to protective measures was low to moderate with only 66% wearing all recommended PPE when nursing COVID-19-infected patients. Only 56% reported adhering to transmission-based precaution signs in the ICU. Intensive care unit nurses reported low uptake rates for the annual influenza vaccination in 2019-2020 (46%). Table 5 shows the relationship between COVID-19 IPC KAP. There was a significant positive correlation (r = 0.484,  http://www.sajid.co.za Open Access p = 0.047) between higher knowledge scores and desired practices. There was also a significant positive correlation between positive attitudes and desired practices (r = 0.511, p < 0.001). However, the knowledge and attitudes scores were not significantly correlated (r = 0.207, p = 0.407). Thus, knowledge appears not to influence attitudes but does influence practices. Attitudes appear to influence practices.

Qualitative themes
In the qualitative arm of the study, 11 participants were recruited and were predominantly females (n = 7, 64%), aged 31-49 years (60%), including five PNs, three ENs and three ENAs. Half (50%) of the participants had over 10 years of experience in ICU nursing. Three interconnected themes comprising coping mechanisms and interventions to limit the occupational risk of COVID-19 infection emerged: inadequate IPC training during the COVID-19 pandemic, limited adherence to COVID-19 IPC practices, and emergence of coping methods, resilience and teamwork among ICU nurses during the COVID-19 pandemic.

Theme 1. Inadequate infection prevention and control training during the COVID-19 pandemic
A key theme that emerged from the qualitative data was that IPC training during the COVID-19 pandemic was considered inadequate for ICU nurses' needs. Many

Theme 3. Emergence of coping methods, resilience and teamwork among intensive care unit nurses during the COVID-19 pandemic
During the pandemic, ICU nurses had to balance the need to protect themselves and their families, while doing their best to ensure optimal patient outcomes under difficult circumstances at work and in their personal lives. Nurses expressed the strongest emotions regarding their care of patients with COVID-19 pneumonia or acute respiratory distress syndrome (ARDS) and expressed that they felt the weight of the responsibility of caring for these patients: Respondents appeared to have changed their behaviours within the workplace and home and adopted a range of coping strategies such as leaving their work clothes in the garage, not hugging their families, praying, exercising and other self-care measures: 'When working in the COVID ICU, we changed our clothes before and after the shift. We put on PPE, aprons and N95 masks. After the shift, we changed back to nursing uniforms. When arriving home, I leave my working clothes, shoes, and bag in the garage, take a full shower, and do hand hygiene. We are trying to protect my children and the rest of my family from COVID-19 infection'.
(Responder 08, male, PN) The high workload during the pandemic and the low patient survival rate diminished the morale of ICU nurses, and at times they became pessimistic about the care they provided to COVID-19 patients. The respondents were overwhelmed by the shortage of PPE and constantly changing IPC protocols and procedures. This negatively impacted their attitudes to and compliance with IPC measures. Yet, the ICU nurses shared sentiments like 'we will survive' and 'we are determined to serve our patients.' Intensive care unit nurses displayed resilience and coping mechanisms with the high workload of COVID-19 patients. Despite all the uncertainty, they remain committed to their frontline duties, returning to work each day to provide nursing care during the public health pandemic and displaying a high level of altruism and dedication, often at the expense of their own health: 'It's very stressful to work with COVID patients and the first precaution is to counsel yourself and be calm within, because if by any chance you are stressing, then you will miss out on a lot of things. Knowledge levels on the key concepts of COVID-19 IPC measures, such as hand hygiene, routes of infection transmission and environmental cleaning were good. Most respondents correctly understood that alcohol hand rub is an adequate measure to limit the direct and indirect contact spread of COVID-19 infection, with many describing hand hygiene as a 'key' mitigation measure. This is reassuring because a good knowledge of COVID-19 transmission patterns and prevention measures will improve ICU nurses' practices and thereby limit occupational risk. However, the respondents expressed concern about their working environment, especially the rapid changes in protocols and the severity of illness among their patients. These results are in keeping with the sentiments expressed in previous reports of COVID-19 IPC in ICUs. 10 20 We found a positive relationship between positive attitudes and practices suggesting that attitude influences the respondents' COVID-19 IPC practice. The self-reported compliance of ICU nurses with recommended COVID-19 IPC practice was moderate. Similar findings were reported from China regarding moderate to good compliance with COVID-19 IPC. 7 Less than half of respondents had performed N95 respirator fit testing despite their high-risk work environment. Similar results were reported in a recent study from Nigeria. 21 During the COVID-19 pandemic, qualitative fit testing was discontinued in Western Cape facilities (owing to the risk of cross-infection), and this may have contributed to the low numbers of staff who had been fit-tested.
Most respondents did not adhere to transmission-based precaution signs in the COVID-19 ICU. Factors for this low adherence did not emerge during the qualitative inquiry. The practice of effective preventative measures such as handwashing and donning of appropriate personal protective equipment (PPE) will ensure the safety of HCWs by reducing healthcare-associated COVID-19 transmission.
Qualitative data suggest that respondents were willing to adapt to rapid changes in COVID-19 IPC guidelines despite some having indicated that this added to their workload, which in turn had likely adversely affected their compliance with COVID-19 IPC recommendations. There was generally a positive attitude among the respondents towards COVID-19 IPC, and the respondents expressed a desire for more regular in-service training on new evidence-based COVID-19 IPC precautions. The infrastructure and shortage of nursing staff are long-standing issues, and the COVID-19 pandemic has compounded them. Their resolution requires interventions at an institutional level. 22 We found low attitudes and some non-compliant IPC practices in these ICU nurses with regard to the management of COVID-19. In planning for future pandemics, the provision of an uninterrupted supply of PPE, ongoing IPC training opportunities and timeous and clear communication of relevant information may assist in encouraging IPC compliance and more positive attitudes. Given the risk of staff burnout during health crises, employee wellness and support should remain a priority for healthcare employers and managers.
The study's major limitation is using self-reported rather than directly observed COVID-19 IPC practices. Reporting bias may have been introduced by the subjective nature of the survey. This was also a single-centre study, which limits generalisability of the findings. This study was performed before the COVID-19 vaccination was readily available in South Africa, which may have increased ICU nurses' adherence to IPC measures, in an effort to reduce their personal infection risk. The Johnson & Johnson COVID-19 vaccine initially rolled out to South African healthcare workers in February 2021, providing 72% protection against severe disease and death from COVID-19. 23 Future studies should evaluate COVID-19 vaccine uptake among ICU nurses, given their reported low uptake of the annual influenza vaccine.
This study has several strengths. To the authors' knowledge, this is the first mixed-methods assessment study performed in a resource-limited setting. The qualitative data gives meaning and explanation to the quantitative results. Data for this study were collected immediately after the second peak of the COVID-19 pandemic, the timing of which allowed for study participants to share fresh experiences with explicit examples. One of the strengths of this study is that there is unlikely to be selection bias, as the survey studied ICU nursing staff, and the majority responded.

Conclusion
Despite very limited specific training, ICU nurses' COVID-19 IPC knowledge was moderately good, whereas nurses' attitude scores towards COVID-19 IPC were low (55%). Nurses attitudes to COVID-19 IPC were influenced by limited IPC training, insufficient time to implement IPC precautions, and shortages of PPE. Inadequate training in IPC, difficulty in implementing COVID-19 IPC guidance and development of resilience in ICU nurses emerged as major themes in the qualitative study. This study highlighted the need for enhanced support in IPC and occupational health and safety to preserve the wellbeing of ICU nurses during the COVID-19 and future pandemics