INFECTION CONTROL PRACTICES AMONG

MIDWIVES
AND NURSES IN THE PREVENTION OF
HEALTHCARE ASSOCIATED INFECTIONS IN
LYING-IN CLINICS
OF SELECTED BARANGAYS IN CEBU CITY

A RESEARCH STUDY

Presented to the faculty of the college of Nursing;

SALAZAR COLLEGES OF SCIENCE & INSTITUTE OF
TECHNOLOGY

In Partial fulfilment of the requirements in Nursing

Research 2

By:

AL GINO B. BORINAGA

MARIO BRUCE SAMSON

CHAPTER 1
THE PROBLEMS AND ITS SCOPE
Background of the Study

Lying in clinics is an alternative facility for child delivery.

Thus, it is also considered as a health-care facility. Today,
healthcare associated infection is one of the most
challenging in the medical field.
Health-care associated infections that are not present at the
time of admission; it means that the infection was acquired
in the health care area. Health-care associated infection was
previously named as Nosocomial infection. However, it was
changed because it includes not only infections acquired in
the hospitals, but also in other health care settings such as
long-term care facilities, nursing homes, clinic center, home
care, and birth clinics.

Equipped with adequate knowledge and sufficient technical

skills in the subjects, research process, community health
Nursing and with strong motivation to complete this study,
the researcher had chosen this study for it was relatable,
realistic and achievable. Finally, the researcher, as a student
nurse and as a part of the complex health care system, felt
confident to contribute ideas in prevention of healthcare-
associated infections in lying in clinics of selected barangays
in Cebu City. Thus, the researcher were able to observe the
different infection control measures utilized in the health
care facilities.

With this in view the researcher were interested to identify

the infection control practices of the midwives and nurses in
the prevention of healthcare-associated infections in lying-in
clinics of selected barangays in Cebu City.

Review Related Literature

Hospital acquired infections (HAIs)/nosocomial infections
pose a real and serious threat to both the patients and
health care workers. Common pathogens may easily be
transmitted through health care workers hands, equipment,
supplies and unhygienic practices. Adherence to infection
prevention and control guidelines is critical to improving the
quality of hospital care based on their efficacy in reducing
the occurrence of infections that compromise patients
outcomes. However, it was uncertain how well the health
care workers at level four hospitals in Kenya adhered to
infection parenteral medications, cleaning, hygiene, feeding,
handling of patients beddings, dressing of wounds and
giving medications. Therefore, they are constantly exposed
to Health Care Acquired Infections (HCAI) such as
Tuberculosis, Human Immune Virus and Acquired Immune
Deficiency Syndrome (HIV/AIDS), Hepatitis B, diverse
bacterial infections among others. Strict adherence to
infection prevention protocol is critical to avoiding spread of
infection among hospitalized patients and health care
workers. The standard guidelines for infection prevention
include good hand hygiene, universal blood and blood fluids
precautions, cleansing and disinfection, sterilization of
equipment/instruments, surfaces decontamination, correct
use of disinfectants, aseptic techniques, safe disposal of
wastes, sharps, handling soiled linen and patient isolation.
Other measures that have been incorporated into CDC
guidelines include personal health & safety education,
placement evaluation, immunization programs such as
screening for hepatitis B and C, management of health care
workers illnesses and exposure as well as post exposure
prophylaxis. A variety of challenges face infection prevention
and control in healthcare institutions. This was evidenced by
the disparity in knowledge, attitudes, practice and
compliance by health care workers. Studies had shown that
poor decontamination of instruments and ineffective
infection prevention practices and control often led to
outbreaks of nosocomial infections. Therefore, the study was
important to establish whether there were any gaps in
compliance with infection prevention in order to take
corrective interventions by the hospital administration.
In developing countries, many women still deliver at home,
making prevention of infection at home and in the
community important, especially if family members and
traditional birth attendants are unaware of the need for
infection prevention. The provision of delivery care by health
professionals and in health facilities is expected, and indeed,
likely to decrease infection rates because of use of clean
practices, sterile gloves and instruments. Yet the tumultuous
history of puerperal sepsis and its association with
institutional delivery care and the birth attendant is well
recorded. Infective organisms causing puerperal sepsis are
often introduced when the birth attendant conducts invasive
procedures such as vaginal examination, instrumental or
caesarean delivery. When childbirth in hospitals became
more common in Western countries in the early 20 th century,
an increase in maternal mortality occurred, much of which
was due to spread of infection between women in labour by
the attending health professional and use of invasive
obstetric procedures . This occurred despite knowledge of
how infections were spread which dated back to the mid
19th century. Increasing concerns of hospital and healthcare
associated infections are also currently recorded across
many medical disciplines, even in high income, industrialised
countries. Given these experiences, the increasing use of
health facilities for childbirth in developing countries calls for
an attitude of watchfulness. In India, for example, the
national policy promotes institutional deliveries which have
steadily increased in the last 15 years from 26% to 41%.
Studies here have shown that sepsis could be responsible for
as much as 40% of maternal deaths. In Mexico, 84% of
deliveries occur in health facilities and rising Caesarean
section rates were over 27% in the public sector and 70% in
the private sector in 2005. Here, septic shock has been
documented to account for as much as 5 to 10% of mortality.
In Iraq, Skilled attendance during delivery Hygienic
conditions and proper medical assistance during delivery can
reduce the risk of complications and infection for both the
mother and the child, in 79.7% of women were delivered by
skilled attendants (doctor, Midwife or nurse) and 18.4% by
traditional birth attendants (TBAs).

According to estimates made for the year 2005,4 half a

million women most of them in developing countries die
each year of complications during pregnancy or childbirth.
The risk of death was highest in the WHO African Region,
where there were 900 maternal deaths per 100 000 live
births; compared with only 27 per 100 000 in the WHO
European Region. In fact, half of all maternal deaths occurred
in the WHO African Region and another third in the WHO
South-East Asia Region. Further analysis of the estimates
indicated that between 1990 and 2005, no WHO region
achieved the 5.5% annual decline in maternal mortality
necessary to attain the relevant MDG target.5 The WHO
South-East Asia Region, the WHO European Region and the
WHO Western Pacific Region showed annual declines of only
around 2.4%. There appeared to be stagnation or even a
possible worsening of the situation in both the WHO African
Region and the WHO Eastern Mediterranean Region.
Maternal mortality is the health indicator that shows the
widest gaps between richer and poorer, both between and
within countries.

Similar results were found in Indonesia and Bolivia. Each of

three districts in South Kalimantan, Indonesia, had one or
more government hospitals, but obstetricians were absent in
two of the three districts. Although one midwife was
available per 100-200 pregnant women, the midwives did
not have the supplies or equipment (or the regulations to
support them) to manage serious complications.
Resuscitation equipment and skills were notably lacking, as
was the skill to remove retained placenta, a common
complication. Less than 5 percent of pregnant women
delivered in the hospitals of the two districts for which there
were data (Achadi et al., 1994).
There is no direct evidence of infection rates rising as a
result of increasing institutional delivery rates. However, it is
plausible that increasing utilisation of under resourced health
facilities can result in stresses to the health system,
overcrowding, poor environmental conditions, overworked
health workers, shortages of drugs and supplies and sub
standard clinical practices. These falling standards of care
may include deteriorating infection control practices,
resulting in an increased risk of institutionally acquired
puerperal sepsis.

Theoretical framework
This study is grounded on Florence Nightingales
environmental theory as it is directly related to infection
control.
Nightingale emphasized the influence of the surroundings on
human and environment as major component of nursing
care. With this, she identified verification and warmth, light,
nose, variety, bed and bedding, cleanliness of rooms and
nutrition as major cases of the environment that the nurse
can control (Aligood, 2010)

The concept of cleanliness is a critical component of the

Environmental Theory. Nightingale noted that a dirty
environment was a source of infection through the organic
matter it contained. Even if the environment is adequately is
lit and ventilated, the presence of organic materials was
treated as a dirty area; therefore correct handling and
disposal of bodily excretions and sewage was required to
prevent contamination of the environment. (Allender, 2009)

Nightingales Environmental Model can be organized in the

client, nurse and environment equilibrium. The nurse is
responsible in manipulating the environment to satisfy or
balance the clients response to it. The nurse should give
emphasis in assisting the client in maintaining stability or
obtain balance with the environment. Thus, the clients
unstable energy with the environment will spend
unnecessary and vice-versa (George, 2008).

Midwives and nurses are part of the healthcare team; they

play an importance role in nursing the patient back to an
optimal level of functioning. In order to be effective, they
should provide an environment that prevents the transfer of
disease producing microorganisms from one person to
another.

The prevention of disease through the manipulation of the

environment is summarized in the infection control. This is
where healthcare provides anchor their interventions in
providing a safe environment for their clients.

Prevention and control of infections is of vital importance to

the client as well as to the health care personnel. To be able
to understand the components of infections and the methods
to control the cycle of infection consists of six links; each link
must be present in a sequence to produce sickness,
removing one link will control the cycle of infection or will
break the chain of infection. Thus, a disease will not occur
(Kozier and Erb, 2008).

Infectious microorganisms (agent) are the pathogens that

cause communicable diseases. The reservoir (source) is the
person or animal that has the disease. After a
microorganisms leaves its source, it requires a means of
transmission. The made of escape refers to the route by
which the infectious microorganisms escapes the reservoir.
Modes of escapes are the respiratory tract, gastrointestinal
tract and the skin.

Made of transmission varies by type of organism and some

infectious agents may be transmitted by more than one
route. Transmission or mode of transfer occurs through five
mechanisms: direct contact, indirect contact, droplet
transmission, airborne transmission, and vector
transmission.

Direct contact is the physical contact with an infected person

to another person without contaminated intermediate object
or person. Indirect contact is the transfer of infectious agent
through a contaminated intermediate object or person (food,
water, liners, instruments, utensils, injections). Droplet
transmission is the inhalation of droplets or large particle
droplets (larger than 5mm in size) contaminated with
infectious agents. Airborne transmission is the dissemination
of airborne droplet nuclei 5 um or smaller containing
infectious agents that remain infective over time and
distance. Vector transmission is the infected creature, such
as mosquito, fly, rodents, insects, or flea transmits by biting
uninfected host.

The principles of transmission control used in the Standard

Precautions are accentuated. When possible, the patient
requiring contact isolation is placed in a private room to
facilitate hand hygiene and protection of garments from
environmental contamination. Masks are not needed and
doors do not need to be closed. (Smeltzer and Bare, 2004).

According to research done in 2009 entitled Emergency

Room Infection Control Practices related research study.
Transmission of health-care associated pathogens from one
patient to another via the hands of the health care workers
requiring the following sequence of events:

Organisms presents on the patients skin, or that has been

shed onto inanimate objects in close proximately to the
patient, must be transferred to the hands of health care
workers.

These organisms must then be capable of surviving for at

least several minutes on the hand of the personnel.

Next hand washing or hand antisepsis by the worker must be

inadequate or omitted entirely or the agent used for hand
hygiene must be inappropriate.
Finally, the contaminated hands of the caregiver must come
in direct contact with another patient, or with an inanimate
object that will come into direct contact with another patient.

Essential of the standard precautions to be used in the care

of all patients:
Hand washing. Wash hands after touching blood, secretions,
excretions and contaminated items, whether or not gloves
are worn. Wash hands immediately after gloves are
removed, between patient contacts. Use a plain soap for
routine hand washing. Use an antimicrobial agent for specific
circumstances.
Glove. Wear gloves when touching blood, body fluids,
excretions, secretions and contaminated items. Put on clean
gloves just before touching mucous membranes and non-
intact skin.
Mask, eye protection and face shield. Wear a mask and eye
protection or face shield during procedures and patient care
activities that are likely to generate splashes or sprays of
blood body fluids, secretions and excretions.
Gown. Wear a gown during procedure and patient-care
activities that are likely to generate splashes or sprays of
blood, body fluids, secretions and excretions.
Patient-care equipment. Ensure that reusable equipment is
not used for the care of another patient until it has been
cleaned and reprocessed appropriately.
Environmental control. Ensure that the hospital has
adequate procedure for the routine care, cleansing, and
disinfection of environmental surfaces.
Linen. Handle used linen, soiled with blood, body fluids,
secretions and excretions in a manner that prevents skin and
mucous membrane exposures, and that avoids transfer of
microorganisms to other patients and environments.
Occupational health and blood borne pathogens. Take care to
prevent injuries when using needles, scalpels, and other
sharp instrument or devices. Use ventilation devices as an
alternative to mouth-to-mouth resuscitation methods.

Place of care of the patient. Place a patient who

contaminated the environment or who does not assists in
maintaining appropriate hygiene in a isolated (or separate)
room. Infection control is a form of health prevention and
therefore, means of health promotion. It is for this reason
that the researchers selected the Nurses and midwives as
the subject of the study to evaluate the infection control
practices that will uphold the responsibility and
accountability for prevention control of infection and improve
health promotion. This study will also serve as in presenting
infection control practices are designed to prevent spread of
infection form clients healthcare providers or visitors are an
important part of every action the nurses and midwives
performs. Thus, and evaluation of the infection control
practices is taken in to consideration in this study. (Caindoy
L.R., et.al. 2009)

Infection control Preventing Healthcare

practices in selected Associated infection
lying-in clinic, cebu City among Midwives and
Nurses

Orems Self Care Theory:

Midwives and nurses should be responsible of their own self care. Healthcare
starts with them. In addition to that for any inadequate medical supply, they
should be the first ones to make sure that there is more than enough care
and supply to be given to the patient.

Tannahills Model
Health education, health protection and prevention co relates to each other in
this theory. These three factors can be controlled by midwives and nurses all
around the world. Enhancement programs are being done to improve the
settings of these clinics.

Florence Nightingales Environmental theory

Infection control practices are being passed on by Florence Nightingale. She
noticed that because of the poor hygienic practices patients take longer to
heal. Prevention is better than cure as they say, provided with enough supply
and knowledge to practice infection control midwives and nurses will be able
to stand their role in the medical field.

THE PROBLEM

Statement of the Problem

This study aims to determine the level of compliance

on infection control practices among midwives and nurses in
the prevention of healthcare associated infections in lying-in
clinics of selected barangays in Cebu City. The findings will
serve as basis for proposed enhancement program.

Specifically, the study aims to answer the following

questions:

1. What is the profile of the respondents in terms of:

 1.1 Age

1.2 Gender

1.3 Highest educational attainment

1.4 Years of experience as midwives/nurses in lying-in

clinic

2. What are the levels of compliance of midwives and nurses

in terms of:

2.1 Hand hygiene

2.2 Aseptic Technique

2.3 Environmental Asepsis

3. Is there a significant relationship between Infection control

practices in selected lying-in clinic and Preventing
Healthcare Associated infection among Midwives and
Nurses??

4. What are the factors that have contributed to the non-

compliance of infection control practices?

Inadequate water supply

Inadequate soap supply

Inadequate hand sanitizer

Lack of knowledge on proper waste disposal

Insufficient supply of scrub suit

Inadequate supply of clean and surgical gloves

 Bonnet

Facemask

Eyewear

5. What enhancement programs can be proposed based on

the findings of the study?

Significance of the Study

This study is important because it evaluates the practices of

midwives and nurses in reducing and preventing the
incidence of healthcare-associated infections in lying-in
clinic. Specifically, this study is significant to the following
groups of people:

Patients- They will be provided with an improved quality of

service that protects them from acquiring infection.

Midwives & Nurses- The outcome of the study will help

identify good practices which need further improvement.
Moreover, this study will provide them updates on the
currents trends on infections in order to improve their level
professional competence.

Students- The outcome of the study will decrease the

exposure of students from communicable diseases.

Health Practitioners- They will be provided with current data

on infection control practices of lying-in clinics and could
therefore use the results to serves as basis for future
implementation on infection control practices.

Local Health Officers- This would serve as reference of a

study that describes infection control practices of lying-in
clinics, and could serve as basis for future programs related
to the study.

Department of Health- This study will give them basis for

implementing an infection control program that would
promote quality care.

Community- They will be engaged in promoting health-

enhancing behaviours and they will be aware of basic and
simple hygienic practices in preventing the spread of
infections.

Researcher- The researcher will be updated about the

infection control practices of lying-clinics in the prevention of
healthcare-associated infections while using Florence
Nightingales Environmental Theory which serves to improve
her competence as a student-nurse.

Future Researcher- They will be able to utilize this study as

reference and help them improve their future theory based
study.
Scope and Limitations

Scope

This study will focus on level of compliance on infections

control practices among midwives and nurses in the
prevention of healthcare associated infections in lying-in
clinics. The birthing centers are the following: Daisy Birthing
Center, Margarita Birthing Center, Agnes Birthing Center and
San Roque Health Center. The infection control practices
pertain to activities that prevents healthcare associated
infection such as hand hygiene practices, aseptic technique,
and wearing of personal protective equipment as well as a
environmental sanitation.

Limitations

Only respondents who qualify the given criteria are included

in the study. Identified limitations attributes like honesty of
the response, environmental and emotional conditions of the
respondents before and after giving the questionnaires and
before interviewing. Also, the researcher had to depend on
the work schedule of healthcare workers.

RESEARCH METHODOLOGY
Research Design
The methodology that will be use is a descriptive survey on
the infection control practices of midwives and nurses in
selected barangays in Cebu City. The study determines the
level of compliance of infection control practices of nurses
and midwives in preventing healthcare-associated infections.
Research Environment
This study will be conducted in four different lying-in clinics
in selected barangays in Cebu City. These lying-in clinics
consists of the Daisy Birthing Centers, Margarita Birthing
Clinic, Agnes Birthing Clinic and San Roque Health Center.
They have been selected because the school is affiliated with
the two of the selected lying-in clinics. Daisy Birthing Center
and San Roque Health Center.

Sampling Technique
The respondents of the study were registered midwives and
nurses of lying-in clinics in selected barangay in Cebu City.
Only nurse and midwives who are employed with the facility
for at least 6 months are included in the study. In Daisys
Birthing Center the respondents were only two midwives. In
San Roque, Margarita Birthing Center, and Agnes Birthing
Center they have one nurse and two midwives. The total
respondents were eleven. A purposive sampling was utilized
and samples of respondents were taken from the target
population.
Statistical tool

The researcher utilized simple percentage as a statistical treatment To

determine the profile of the respondents. Weighted mean will be use to
determine the level of compliance on infection control practices nurses
and midwives in lying-in clinics.
The fomula for simple percentage is as follows:
Where:
P=FN X 100
Where:
P= percentage N= total number of population/
group
F=frequence 100= constant
X=fw
n
where:
X is the weighted mean
is the summation
f is the frequency
x is the weight
n is the number of respondent

Parameters
SCORE RANGE INTERPRETATION
4 3.26-4.0 ALWAYS
3 2.51-3.25 SOMETIMES
2 1.76-2.50 RARELY
1 1.00-175 NEVER

DEFINITION OF TERMS

The following terms are operationally defined in the study:

Healthcare-associated infections-refers to the infections
that may be acquired by patients having delivery in the
lying-in clinics.
Hand hygiene- refers to the washing of hands deliberately
with soap and running water for about 15-20 seconds
covering every area and parts of hands.
Environmental asepsis- refers to the environment that is
free of microorganisms in which to keep patient free from
acquiring infection from the environment.
Infection Control Practices- refers to the procedures done
by the midwives and nurses in health care setting in
preventing cross contamination of infection among clients in
lying-in health clinics.
Level of Compliance- refers to the ability of midwives and
nurses to adhere to the standards of infection control
practices mandated by the Centers for Disease Control. It is
categorized as the following:
-Always- refers to the compliance of 85-100% on infection
control practices done by the nurses and midwives during
standard interventions.
-Sometimes refers to compliance of 65-84% on infection
control practices done by the nurses and midwives during
standard interventions.
-rarely refers to compliance 64% on infection control
practices done by the nurses and midwives during standard
interventions.
-Never refers to compliance on infection control practice by
the nurses and midwives.
Chapter 2
 PRESENTATION, ANALYSIS AND INTERPRETATION OPF DATA
The chapter shows a presentation of tables based on the
items stipulated in the problem statement, its analysis and
interpretation of data.
Table 1.1 shows the age profile of health workers in lying-in
clinics of selected barangays in Cebu City. The table shows
that the majority of the age range of 21-25 years old which
is 54.55%. The age range of 26-35 years old has 9.09%. the
age range of 36 and above has 27.27%. The majority are
considered young and less experience in health practices.
This also reveals that working in lying-in clinics serves as
entry job to gain more years of experience prior to have
more opportunity to work on bigger and reputable
institutions. Lying-in clinics are probably having more job
openings cater to registered midwives than registered
nurses.

Table 1.1 age Profile of respondents

N-11

Age Category f %
21-25 6 54.55%
26-30 1 9.09%
31-35 1 9.09%
36 and above 3 27.27%
Total 11 100%
Table 1.2 presents the gender profile of health workers in
lying-in clinics of selected barangays in Cebu City. The table
shows only one male worker out of ten female workers. One
male worker has 9.09% while female percentage has 90-91%.
Registered midwives specialize in lying-in clinics, thus they
are most commonly found in birthing centers. This reveals
that women are more inclined to work as health workers in
the lying-in clinics. Also, woman feel more comfortable to
have a womans assisting during the delivery process since
the perception is that the woman understand the pain and
hardship of child bearing therefore hey are understandable.

Table 1.2 Gender Profile of the respondents

N=11
Male % Female % Total
1 9.09 10 90.91 100
Based on the table 1.3, ht health workers in the lying-in
clinics are majority registerd midwives with twi-year
associated degrees. Out of 11 respondents taken from the
sample population. There are 8 registered midwives and only
three registered nurses. It shows that 73% are registered
midwives than 27% of registered nurses. It is well-known
that registered midwives are legally entitled to operate lying-
in clinics and own one and it-s up to the owners prerogative
to hire registered nurses based on the needs patients they
have.

Table 1.3 educational attainment of respondents

N=11
High educational Frequency Percentage
attainment
College level 2 Year
Associate 8 73%
(diploma in
Midwifery)
College Graduate
Bachelors degree 3 27%
(Bachelor of science
in Nursing)

Total 11 100%
Table 1.4 presents the years of experience of the health care
workers. It is explicitly shown that majority of these health
workers are young, as shown in the table 1. It follows in
terms of experience in wrking as health workers were lesser
than expected. The result shows that in terms of years of
experience, 64% fall in the range of 1-5year, whreas, there is
only 9% who 21 to 25 years of experience are. Although, less
experience workers do not imply higher chances of
malpractices but can still be effective workers under proper
supervision.

Table 1.4 Years of Experience

N=11
Years of experience Frequency %
1-5 7 64%
6-10 0 0%
11-15 2 18%
16-20 1 9%
21-25 1 9%
TOTAL 11 100%
Table 2 Level of Compliance on Infection Control Practices
Infection Control Weighted Mean Interpretation
Practices
Hand hygiene 3.86 Always
Aseptic Technique 3.63 Always
Environmental 3.72 Always
technique
the study entitled Infection control practices among
midwives and nurses in the prevention of healthcare-
associated infections in lying-in clinics of selected Barangays
in Cebu City. A survey will be given to evaluate the infection
control practices of each facility. The researches got the
profile of the midwives and nurses and utilized a
questionnaire as a tool. Descriptive survey research design
was used in the entire study. An enhancement programs on
infection control will be done based on the findings of the
study.