This study investigated adherence to SPs using a survey and surveillance. The self-reported adherence investigated by the survey was 4.7 points out of 5 points, which means that most nurses responded that they always performed (5 points on the Likert scale) or often performed (4 points on the Likert scale) all SP items. The results were slightly higher than those of previous studies [6,13,21,22). However, the results from previous studies were also high, reporting around 4 out of 5 points. This might be attributed to the importance of infection control emphasized in overall healthcare settings after the MERS outbreak in South Korea. The excessively high results might also be attributed to the investigation method. As healthcare providers regard that adequate adherence to SPs is a healthcare providers’ obligation, self-reported adherence, which measured the intention to adhere to SPs might be higher than the actual adherence. Contrary to the intention, the actual performance, which was the observed adherence to SPs in this study, was low in this study, which appears to be consistent with the findings of other studies [17, 18].
Among the SP sub-strategies, although hand hygiene is a basic practice of infection control, the adherence to hand hygiene was the lowest (below 70 points) of all SP strategies. Most previous studies have also reported similar results regarding low compliance with hand hygiene [10, 23]. Moreover, in the case of no observers such as in video surveillance, hand hygiene adherence was more worse . Hence, real hand hygiene adherence might be extremely low because results that excluded the observer’s effect would be more realistic. Poor hand hygiene was revealed to be a risk factor for HAIs [10, 18, 25]. Therefore, an investigation of the barriers hindering the adherence of nurses’ hand hygiene and effective strategies to improve adherence is needed. The observed adherence to PPE use was much lower than the self-reported adherence as well and the difference between the two methods was as large as that for hand hygiene. Compared to hand hygiene and safe injection, PPE use is affected more by external factors such as equipment shortages and nurses’ workload . Thus, the observed adherence to PPE use in this study might have been affected by working conditions on the surveillance day. Among SP strategies, the adherence to safe infection practices had the highest self-reported and observed scores. Since safe infection practice has the most direct effect on patients, scores should be increased as close to 100 points as possible by implementing various strategies.
As mentioned earlier, healthcare providers recognize the importance of perfect adherence to SPs and have a high intention to do that , consistent with the results of this study. Hence, their low performance can never be attributed to low knowledge or low awareness. We should identify other variables or barriers rather than knowledge or awareness. Recently, some studies reported organizational conditions such as overcrowding and emergencies as factors hindering the adherence to SPs by clinical nurses [26, 27]. This study also showed that the observed adherence was associated with work experience and work department in quantile regression, and patient safety climate in correlation analysis. Regarding work experience, the shorter the experience, the lower the adherence to SPs in this study. This finding corroborated that in a study by Murray, Sundin, and Cope (2018), which reported a theory-practice gap of SPs in newly graduated nurses . This gap has been attributed to the difficulties newly graduated nurses have in managing the pressure of limited time compared to experienced nurses working under the same conditions [28, 29]. When nurses with inadequate competency have to take care of many patients, they cannot adequately comply with SPs. Therefore, to improve adherence to SPs, nurse managers should set adequate workloads considering both each nurse’s competency and the work conditions. The work department was also an influencing factor in observed adherence to SPs in this study. In this study, we included nurses who worked in special units such as the ICU and ER and general units such as the integrated care unit and general wards. Nurses in the general ward showed the lowest adherence to SPs, which was significantly lower than that of the ICU nurses. Nurses in integrated care units in South Korea have more than twice the number of patients to care for as the nurses in general wards . Nurses in integrated care units are in charge of eight patients, whereas nurses in general wards are in charge of more than 15 patients [30, 31]. Hence, the primary organizational condition, called nurse staffing, influences an individual nurse’s performance. This result appears to be consistent with the findings of other investigations, showing that patients in understaffed units were more likely to develop HAIs [32–34]. HAIs is a nursing-sensitive outcome . If structure indicators such as adequate nurse staffing levels are not met, process indicators such as adherence to SPs will inevitably not be met at adequate levels . Consequentially, understaffing conditions and insufficient provision of nursing service lead to increases in HAIs. Therefore, setting an adequate level of nurse staffing should take precedence for ensuring adequate adherence to SPs.
In this study, we used quantile regression to investigate the factors associated with adherence to SPs. Through quantile regression, we identified the influencing factors that differed according to the performance level. In the 25% quantile, work experience was a significant factor, which means that clinical nurses need to be prepared to perform clinical practice. Several studies also have supported the need to enhance work readiness during the early stages of a nurse’s career under increased complexity of care and acutely ill patients . In the 50% quantile, the work department, which referred to how many patients a nurse should be in charge of, was a significant factor. Compared to the ICU, only the general ward showed statistically low adherence to SPs, while other departments such as the emergency room and integrated care unit did not show a significant difference. Some studies have reported that integrated care units in South Korea had a positive effect on patient-centered outcomes such as falls and pressure ulcers [37, 38]. In the integrated care unit, not only falls and pressure ulcers but also nurses’ adherence to SPs could be better than those in the general ward. Moreover, as better adherence to SPs would ultimately improve final outcomes, an integrated nursing care system should show positive effects on reducing HAIs. There were no significant factors affecting adherence to SPs in the 75% quartile because we could not include all variables related to SP adherence and most nurses showed very high adherence to the SPs.