CHAPTER TWO
LITERATURE REVIEW
This chapter attempts to discuss the views of other researchers in relation to the current research
topic with particular emphasis Conceptual Review, Theoretical Review and Empirical Review.
2.1 Conceptual review
The hospital is not just only a place where sick people recover from their illness, but also where
the healthy can get infected (David & Famurewa, 2020). Workplace exposure and hazards could
cause devastating effects on the health and quality of life. There are many different types of
accidental injuries in the health industry but needle stick injury remains the commonest of all
(Oguntona et al., 2020). Occupational exposure to the body fluid can result from percutaneous
injury or sharps injury, mucocutaneous injury (splash of blood or other body fluids into the eyes,
nose or mouth or body contact with non-intact skin which can all cause substantial health
consequences and psychological stress for health care workers and their loved ones (Rampal et
al., 2019; Oguntona et al., 2020).
Health care workers such as medical doctors, nurses, laboratory staff and aides who work in the
hospitals, clinics and other health care settings are frequently exposed to infectious diseases.
Some of these infectious diseases have no available vaccination or cure; consequently, this blood
borne infections are a major cause of anxiety for health care workers (Honda et al., 2021). Health
care workers are at risk of exposure to diseases like hepatitis B virus (HBV), hepatitis C virus
(HCV), human immunodeficiency virus (HIV) and other blood borne disease as they are in direct
contact with patients and frequently handle sharps in the course of their work (Rampal et al.,
2019; Oguntona, et al., 2020; Nduka et al., 2021).Globally about three million, health care
workers experience percutaneous exposure to blood borne pathogens each year with 2 million of
these exposed to HBV, 0.9 million to HCV and 170,000 to HIV. These injuries may result in
15,000 HCV, 70,000 HBV and 1000 HIV cases with more than 90 percent of these infections
occurring in developing countries (Oguntona, et al., 2020; Sreedharan, et al., 2021).
The fact that blood and other fluids from patients are becoming increasingly hazardous to those
who provide care for them has become of great concern to health professionals the world over
(Omiepirisa, 2019), as workers in developing countries account for the highest rate of needle
stick injuries (Oguntona, et al., 2020). Needle stick injury is the non-intentional puncture of the
skin caused by an injection needle while sharp injuries are caused by puncture of the skin by a
sharp object or instrument (Akeem et al., 2021).
Health care workers especially the nursing staffs are prone to needle stick injuries which may
result in blood borne infections with serious consequences, including long term illness, disability
and even death (Akeem et al., 2021). With the discovery of HIV and (acquired
immunodeficiency syndrome) AIDS, and the recent incidence of Ebola in West Africa, the
medical community began to recognize widely the dangers of serious illnesses spreading through
contact with contaminated blood and body fluids, it is now recognized that more infection
control precautions are needed as all body fluids are potentially infectious (Omiepirisa, 2019;
Adebimpe, 2019).
Knowledge of Hospital Acquire Infection
Certain groups of health care workers are at greater risk than others because of the nature of their
work in contacting disease at work (Oguntona, et al., 2020). A number of studies from
developing countries have examined the knowledge, attitude and compliance of doctors and
nurses towards standard precautions (Omiepirisa, 2019). Numerous studies have found nurses to
be the commonest group of health care workers experiencing needle stick injuries (Rampal, et
al., 2020), as needle stick injuries are reported as the most common occupational health hazards.
Various studies in health institutions in Nigeria have reported poor knowledge of preventive
measures of nosocomial infection among health workers; this is in line with the World Health
Organization estimates that about 2.5 percent of HIV cases and 40 percent of HBV and HCV
cases among health care workers worldwide are the result of exposure at work. Various studies
carried out among different categories of health care workers found that exposure to blood or
other body fluid was approximately 9.3 percent (Vaz, et al., 2019). 81.2 percent had knowledge
that preventive measures of nosocomial infection should be observed in all patients (Kalu &
Odunsayan, 2021) while needle stick injury to the surgeons has been shown to occur every 20-40
operations.
Many cases of needle stick injuries have been found to go unreported. The review of the
literature does establish a significant risk of blood borne infectious disease among medical and
healthcare personnel in Nigeria in addition to a poor application and practice of preventive
measures of nosocomial infection which is in contrast with the reported good awareness
(Omiepirisa, 2012).
Preventive of Hospital Acquired Infection
Four standard practices are recommended; these include hand washing, use of protective barriers
to prevent direct contacts, safe handling and disposal of sharps and safe decontamination of
instruments and other contaminated equipment (Omiepirisa, 2019). Where injuries and blood
splashes occur reporting centers should be made available. Research has indicated that sharp
injury may be under reported by 39.4 percent to 75 percent (Honda et al., 2019). Some health
care workers are not seriously concerned about infection by sharp injury and forget to report
accidents (Honda, et al., 2019) many cases of needle stick injuries go unreported and use of
preventive measures of nosocomial infection is poor.
Hand Washing
The hand is the most common vehicle for microbial transmission (Omiepirisa, 2019). Hand
washing has been proven as an essential and the single most effective method used in preventing
the spread of infections and infectious agents (David & Famurewa, 2020; Kalu & Odunsayan,
2019). Hand washing reduces the number of potentially infectious microorganisms in the hand
and decrease the incidence of infection transmission in the health care facility (Omiepirisa,
2019). Hygienic hand washing involves the use of antiseptic and / or detergents to wash the hand
for as little as about 10-15 seconds or to use an alcohol based agents to disinfect the hands
(Omiepirisa, 2019). The hands and other skin surfaces should be washed immediately and
thoroughly if contaminated with blood and other body fluids to which preventive measures of
nosocomial infection apply or potentially contaminated articles (Omiepirisa, 2019). Hands
should be washed after gloves are removed even if the gloves appear to be intact. Hand washing
should be done using the appropriate facilities such as utility or restroom sinks. Hands should
always be washed with soap and running water following contact with blood or other potentially
infectious body secretions even if gloves have been used for the task (Omiepirisa, 2019).
Use of protective Barriers
Protective barriers reduce the risk of exposure of the health care workers skin or mucous
membranes to potentially infectious materials and the risk of exposure to blood and other body
fluids to which preventive measures of nosocomial infection apply by preventing contact with
potentially pathogenic microorganisms by creating a physical barrier between the potentially
infectious materials and the health care workers (Vaz, et al., 2019). Generally, surgeons have
been shown to report infrequent use of protective strategies which increases the risk of exposure.
Health care workers must endeavor to wear personal protective equipment to guard against blood
borne pathogens if there is a reasonable anticipated exposure to blood and other potentially
infectious materials. If splashing is anticipated, protective eye wear should be worn along with
an impervious gown or apron which provides an effective barrier to splashes. Plastic bags should
be available for removal of contaminated items from the site of the spill, shoes and boots can
become contaminated with blood in certain instances. The personal protective devices include
gloves, apron, masks, goggles and boots (Kalu & Odunsayan, 2020).
i. Gloves. Since medical history and examination cannot reliably identify all patients
harboring blood borne pathogens, preventive measures of nosocomial infection during
exposure to blood and body fluids are mandatory. Gloves which should be worn for direct
contact with blood or body fluids and for direct contact with non-intact skin or mucous
membrane, should fit well and be made of latex (Omiepirisa, 2019). Gloves can be
disposable or non-disposable depending on what procedure is to be carried out.
ii. Gloves must be worn as single use item to prevent contamination of health care workers
hand if anticipating direct contact with blood or body fluids, mucous membranes and non-
intact skin (Omiepirisa, 2019). - Goggles. Protective eyewear should be worn when there is
risk of splash or spilling of blood or body fluids. Doctors who used eye protection regularly
had less blood contacts via conjunctiva than surgeons who seldom or never used such
protection. - Aprons. Plastic aprons should be worn during delivery, surgical procedures
and cleaning if splashing is anticipated.
iii. Masks. Masks are recommended to avoid blood or body fluid splashing into the mouth and
nostrils. Cuts and abrasions on the hands and forearms should be covered with waterproof
dressing.
2.2 Theoretical Review
The theoretical review for this study was based on the health belief model (HBM) hence the
Rosenstock’s health belief model was adapted. The health belief model (HBM) was developed in
the early 1950s by social scientists at the U.S. Public health service in order to understand the
failure of people to adopt disease prevention strategies or screening tests for the early detection
of disease. Later uses of HBM were for patients' responses to symptoms and compliance with
medical treatments. The HBM suggests that a person's belief in a personal threat of an illness or
disease together with a person's belief in the effectiveness of the recommended health behavior
or action will predict the likelihood the person will adopt the behavior (Jones, et al., 2015).
According to Jones et al., (2015) the HBM contains several primary concepts that predict why
people would take action to prevent, to screen for or to control illness conditions.
The main constructs of the model are (Jones, et al., 2015);
Modifying factors: include personality variables; patient satisfaction; sociodemographic
factors/variables.
Perceived susceptibility: This refers to a person's subjective perception of the risk of acquiring an
illness or disease (Jones, et al., 2015). There is wide variation in a person's feelings of personal
vulnerability to an illness or disease.
Perceived severity. This refers to a person's feelings on the seriousness of contracting an illness
or disease (or leaving the illness or disease untreated). There is wide variation in a person's
feelings of severity, and often a person considers the medical consequences (e.g., death,
disability) and social consequences (e.g., family life, social relationships) when evaluating the
severity (Jones, et al., 2015).
Perceived benefits. This refers to a person's perception of the effectiveness of various actions
available to reduce the threat of illness or disease (or to cure illness or disease). The course of
action a person takes in preventing (or curing) illness or disease relies on consideration and
evaluation of both perceived susceptibility and perceived benefit, such that the person would
accept the recommended health action if it was perceived as beneficial (Jones, et al., 2015).
Perceived barriers. This refers to a person's feelings on the obstacles to performing a
recommended health action. There is wide variation in a person's feelings of barriers, or
impediments, which lead to a cost/benefit analysis (Jones, et al., 2015). The person weighs the
effectiveness of the actions against the perceptions that it may be expensive, dangerous (e.g., side
effects), unpleasant (e.g., painful), time-consuming, or inconvenient.
Cue to action. This is the stimulus needed to trigger the decision-making process to accept a
recommended health action. These cues can be internal (e.g., chest pains, wheezing, etc.) or
external (e.g., advice from others, illness of family member, newspaper article, etc.).
Self-efficacy. This refers to the level of a person's confidence in his or her ability to successfully
perform a behavior. This construct was added to the model most recently in mid-1980. Self-
efficacy is a construct in many behavioral theories as it directly relates to whether a person
performs the desired behavior (Jones, et al., 2015).
Application of the HBM to the study The constructs of the HBM and how it could influence and
how it could affect the practice of Universal Precaution is described below.
Modifying factors. Include student nurses’ personality variables such as knowledge, awareness,
perceptions and attitudes towards preventive measures of nosocomial infection; patient
satisfaction; and the role of socio-demographic variables on the practice of preventive measures
of nosocomial infection (Jones, et al., 2015). The HBM postulates that if nurses are aware and
have adequate on knowledge on universal precaution, it increases the likely hood of adherence to
universal precaution guidelines.
Perceived susceptibility. This refers to nurses’ perceptions of the risks of contracting Hospital
Acquired Infections (HAI). And the risks associated with the noncompliance with universal
precaution guidelines (Jones, et al., 2015). Interventions involves defining student nurses’ risk
levels and heightening perceived susceptibility if too low.
Perceived severity. Even when one recognizes personal susceptibility, action will not occur
unless the student perceives the severity to be high enough to have serious organic or social
complications (Jones, et al., 2015). Interventions involves specifying consequences of non-
adherence to universal precaution guidelines.
Perceived benefits. This refers to nurses perceived effectiveness and/or relevance of the use and
adherence to preventive measures of nosocomial infection during the course of providing care or
dispensing nursing duties (Jones, et al., 2015). Interventions involves defining action to take;
how, where, when; clarify the positive effects to be expected.
Perceived barriers. This refers to student nurses’ perceived barriers to the implementation of
standard precautions during the course of dispensing their duties. Some perceived barriers could
include time factor, non-availability of protective supplies such as gloves, face masks etc.
Interventions involves identifying and reducing barriers, through reassurance, incentives and
assistance (Jones, et al., 2015).
Cues to action. This refers to student nurses’ desire/motivation to comply with universal.
precaution guidelines, and the belief that people should do what, this could be influenced by past
experiences, advice from colleagues and significant others, past history of colleague with HAIs
etc. In this light intervention involves providing how-to information, promoting awareness, and
reminders on preventive measures of nosocomial infection.
Self-efficacy. This refers to student nurses’ confidence on their ability to competently use
preventive measures of nosocomial infection in the delivery of care. The HBM postulates that
student nurses will to adhere to universal precaution unless they believe they are competent
enough to practice it (Jones, et al., 2015). Intervention involves providing training, guidance in
performing universal precaution guidelines.
Application of the theory to the study
Application of the HBM to the study is described below.
Modifying factors. Include student nurses’ personality variables such as knowledge, awareness,
perceptions and attitudes towards preventive measures of nosocomial infection; patient
satisfaction; and the role of socio-demographic variables on the practice of preventive measures
of nosocomial infection. The HBM postulates that if nurses are aware and have adequate on
knowledge on universal precaution, it increases the likely hood of adherence to universal
precaution guidelines.
Perceived susceptibility. This refers to nurses’ perceptions of the risks of contracting Hospital
Acquired Infections. And the risks associated with the noncompliance with universal precaution
guidelines. Interventions involves defining student nurses’ risk levels and heightening perceived
susceptibility if too low.
Perceived severity. Even when one recognizes personal susceptibility, action will not occur
unless the student perceives the severity to be high enough to have serious organic or social
complications. Interventions involves specifying consequences of non-adherence to universal
precaution guidelines.
Perceived benefits. This refers to nurses perceived effectiveness and/or relevance of the use and
adherence to preventive measures of nosocomial infection during the course of providing care or
dispensing nursing duties. Interventions involves defining action to take; how, where, when;
clarify the positive effects to be expected.
Perceived barriers. This refers to student nurses’ perceived barriers to the implementation of
standard precautions during the course of dispensing their duties. Some perceived barriers could
include time factor, non-availability of protective supplies such as gloves, face masks etc.
Interventions involves identifying and reducing barriers, through reassurance, incentives and
assistance.
Cues to action. This refers to student nurses’ desire/motivation to comply with universal.
precaution guidelines, and the belief that people should do what, this could be influenced by past
experiences, advice from colleagues and significant others, past history of colleague with HAIs
etc. In this light intervention involves providing how-to information, promoting awareness, and
reminders on preventive measures of nosocomial infection.
Self-efficacy. This refers to student nurses’ confidence on their ability to competently use
preventive measures of nosocomial infection in the delivery of care. The HBM postulates that
student nurses will to adhere to universal precaution unless they believe they are competent
enough to practice it. Intervention involves providing training, guidance in performing universal
precaution guidelines.
2.3 Empirical Review
Adeola (2018) on knowledge and compliance with hospital-acquired infection prevention among
nursing students in Southwestern Nigeria. This study assessed the knowledge and compliance
with hospital-acquired infection (HAI) prevention protocols among undergraduate nursing
students in Southwestern Nigeria. A cross-sectional survey involving 300 students was
conducted using structured questionnaires. The data revealed that 65% of the respondents
demonstrated good knowledge of infection prevention, while only 50% adhered to hand hygiene
practices. Chi-square analysis showed a significant relationship between knowledge levels and
compliance with infection prevention practices (p = 0.02). The study concluded that while
knowledge levels were relatively high, compliance with preventive measures remained
suboptimal. It recommended incorporating practical infection control modules into the nursing
curriculum and reinforcing supervision during clinical placements.
Babalola, (2019) on factors influencing knowledge of infection control practices among nursing
students in Northern Nigeria. This research explored the factors influencing nursing students'
knowledge of infection control practices in Northern Nigeria. A sample of 250 nursing students
from three tertiary institutions participated in the study. Results from multivariate logistic
regression analysis indicated that access to training resources (OR = 2.5, 95% CI = 1.8–3.2) and
previous clinical exposure (OR = 1.9, 95% CI = 1.4–2.7) were significant predictors of high
knowledge levels (p < 0.05). The findings revealed that 58% of the students demonstrated
adequate knowledge, but significant gaps remained. The study concluded that improving access
to infection control training resources could enhance knowledge, recommending that hospitals
and nursing schools provide regular workshops on infection prevention.
Nwafor (2020) on evaluation of undergraduate nursing students' knowledge and practice of
infection prevention in South-Eastern Nigeria. This study evaluated undergraduate nursing
students’ knowledge and practice of infection prevention protocols in South-Eastern Nigeria. A
total of 400 students were randomly selected, and the study employed a descriptive cross-
sectional design. Results indicated that 72% of the students had high knowledge of infection
prevention, but only 46% adhered to proper hand hygiene practices during clinical rotations. T-
test analysis showed a significant difference between knowledge and practice (t = 3.45, p =
0.001). The study concluded that despite adequate knowledge, there was a gap in the practical
application of infection control measures. It recommended increasing supervision during clinical
practice and creating a reward system to encourage compliance with infection control guidelines.
Adebayo (2021) on assessment of knowledge and attitude toward hospital-acquired infection
prevention among nursing students in a Nigerian Teaching Hospital. This study assessed the
knowledge and attitudes of undergraduate nursing students toward hospital-acquired infection
prevention in a teaching hospital in Lagos, Nigeria. Using a sample of 350 students, the study
utilized a structured questionnaire and interviews. Findings showed that 80% of students had
adequate knowledge of infection control, but only 55% expressed positive attitudes toward
consistent use of personal protective equipment (PPE). Pearson correlation analysis revealed a
positive relationship between knowledge and attitude (r = 0.62, p < 0.001). The study concluded
that while knowledge was high, attitude toward consistent use of preventive measures was
moderate. It recommended enhancing the clinical orientation of students to instill better attitudes
toward infection prevention.
Okeke (2022) on knowledge and adherence to hospital infection prevention protocols among
nursing students in Nigeria. This multi-center study examined the knowledge and adherence to
hospital infection prevention protocols among nursing students in five universities in Nigeria. A
total of 500 nursing students were surveyed. Results showed that 68% of the students had good
knowledge of infection prevention practices, and 60% adhered to basic protocols such as hand
hygiene and proper waste disposal. Regression analysis indicated that knowledge was a
significant predictor of adherence (β = 0.45, p < 0.01). The study concluded that while students
had satisfactory knowledge, adherence to infection prevention measures could be improved. It
recommended continuous monitoring and evaluation of students’ infection control practices
during clinical postings.
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