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American Journal of Infection Control 42 (2014) 254-9

Contents lists avai

American Journal of Infection Control

journal homepage: www.aj ic journal .org

American Journal of Infection Control

Major article

Knowledge, perceptions, and practices of methicillin-resistantStaphylococcus aureus transmission prevention among health careworkers in acute-care settings

Dorothy J. Seibert PhD, RN a,*, Karen Gabel Speroni PhD, RN b, Kyeung Mi Oh PhD, RN a,Mary C. DeVoe RN b, Kathryn H. Jacobsen PhD c

a School of Nursing, George Mason University, Fairfax, VAb Inova Fair Oaks Hospital, Fairfax, VAcDepartment of Global & Community Health, George Mason University, Fairfax, VA

Key Words:AttitudesHealth personnelInfection controlInpatientsHealth care-associated infectionNursing personnel

* Address correspondence to Dorothy J. Seibert,George Mason University, 4400 University Dr, MS 3C4

E-mail address: dseibert@gmu.edu (D.J. Seibert).This project was supported by a grant from the E

Theta Tau, the Honor Society of Nursing.Conflicts of interest: None to report.

0196-6553/$36.00 - Copyright � 2014 by the Associahttp://dx.doi.org/10.1016/j.ajic.2013.09.005

Background: Health care workers (HCWs) play a critical role in prevention of health care-associatedinfections such as methicillin-resistant Staphylococcus aureus (MRSA), but glove and gown contact pre-cautions and hand hygiene may not be consistently used with vulnerable patients.Methods: A cross-sectional survey of MRSA knowledge, attitudes/perceptions, and practices among 276medical, nursing, allied health, and support services staff at an acute-care hospital in the eastern UnitedStates was completed in 2012. Additionally, blinded observations of hand hygiene behaviors of 104 HCWswere conducted.Results: HCWs strongly agreed that preventive behaviors reduce the spread of MRSA. The vast majorityreported that they almost always engage in preventive practices, but observations of hand hygiene foundlower rates of adherence among nearly all HCW groups. HCWs who reported greater comfort with tellingothers to take action to prevent MRSA transmission were significantly more likely to self-reportadherence to recommended practices.Conclusions: It is important to reduce barriers to adherence with preventive behaviors and to help allHCWs, including support staff who do not have direct patient care responsibilities, to translate knowl-edge about MRSA transmission prevention methods into consistent adherence of themselves and theircoworkers to prevention guidelines.

Copyright � 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved.

Drug-resistant health care-associated infections (HAIs) such asmethicillin-resistant Staphylococcus aureus (MRSA) are a growingconcern in acute-care settings. HAIs cause a significant burdenon the health care system as a result of extended hospital stays,expensive treatments, and increased mortality rates.1,2 For example,the costs and length of stays doubled for MRSA infections.2,3

Health care workers (HCWs) may contribute to the spread ofMRSA and other HAIs within a hospital and to the communitythrough failure to adhere to recommended practice guidelines.Prevention efforts in a variety of patient care units, includingoutpatient clinics and intensive care units, have been shown to

PhD, RN, School of Nursing,, Fairfax, VA 22030-4444.

psilon Zeta chapter of Sigma

tion for Professionals in Infection

significantly reduce HAI-related MRSA.4-7 However, the frequency ofhand hygiene (washing with soap and water or using alcohol-basedhand sanitizers) and the consistent use of contact precautions, suchas the use of gloves and gowns, are often found to be suboptimal.8,9

The US Centers for Disease Control and Prevention guidelinesrecommend contact precautions for all interactions that may involvecontact with MRSA-infected or MRSA-colonized patients or withpotentially contaminated areas in a patient’s environment.10 TheWorld Health Organization also recommends consistent perfor-mance of hand hygiene before and after contact with the each pa-tient and his or her environment.11 Observed adherence of HCWswith these prevention practices has been found to be about 68%-82%for use of gloves, about 68%-77% for use of gowns, and about 48%-69% for hand hygiene after patient contact.8,9,12 HCWs may becomevectors of infection, transferring the infectious agent from 1 patientto another via contamination of skin, clothing, or equipment.13-15

HCWs may also become colonized with MRSA, and asymptomatic

Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Table 1Demographic characteristics of survey participants by health care worker (HCW)group

HCW group* Medical NursesAlliedhealth

Supportstaff Total

No. of participants 49 129 48 50 276Proportion of total

sample (%)17.8 46.7 17.4 18.1 100

Age in years (%)18-25 6.1 14.8 6.2 8.3 10.626-35 16.3 24.2 29.2 22.9 23.436-45 26.5 25.8 29.2 18.8 25.346-55 24.5 25.0 25.0 25.0 24.9�56 26.5 10.2 10.4 25.0 15.8

Sex (%)Women 47.8 91.3 72.9 77.1 78.0Men 52.2 8.7 27.1 22.9 22.0

Education (%)Doctoral degree 85.4 0.8 10.6 2.0 17.6Master’s degree 8.3 11.7 19.1 10.0 12.1Bachelor’s degree 6.2 57.0 29.8 20.0 36.6Associate’s degree/

diploma/certificate

0 27.4 38.3 38.3 26.3

High school or less 0 3.1 2.1 30.0 7.3Experience in yearsRange 0-45 0-43 0-33 0-30 0-45Mean � standard

deviation17.5 � 11.7 14.0 � 11.1 14.5 � 9.8 8.3 � 7.7 13.7 � 10.8

Work status (%)Full time 82.6 66.1 70.2 78.7 71.9Part time 17.4 21.3 23.4 12.8 19.5As needed 0 12.6 6.4 8.5 8.6

*HCW included medical staff: medical doctors (n ¼ 41); other medical staff, such asphysician assistants and nurse practitioners (n ¼ 8); nurses: registered nurses (n ¼112); other nursing staff, including certified nursing assistants and emergencymedical technicians (n ¼ 17); allied health: medical imaging staff (n ¼ 15);physical medicine and rehabilitation: physical therapists, occupational therapists,and speech therapists (n ¼ 10); laboratory staff (n ¼ 10); other allied health staff,including dietitians, pharmacists, respiratory therapists, and social services (n ¼13); support staff: patient registration/clerical (n ¼ 27); environmental services(n ¼ 10); and other support staff (n ¼ 13).

D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 254-9 255

carriers may inadvertently transmit the bacterium to patients.16-19

(About 4.6% of HCWs in the United States are MRSA carriers.13)HCWs can play a critical role in preventing HAIs caused by

MRSA.20,21 HCWs’ knowledge of and perceptions about MRSA maystrongly influence their willingness to routinely engage in preven-tive practices.10,22,23 Once knowledge gaps, barriers to adherence,and other factors that may inhibit adherence are identified, in-terventions to reduce MRSA transmission can be implemented.23-25

The goal of our study was to evaluate knowledge, perceptions, andpractices related to MRSA among a diverse sample of HCWsdmedical, nursing, allied health, and support services staffdat anacute care hospital. Understanding these factors will contribute toaction plans that include all HCWs in efforts to reduce MRSAtransmission in the acute care setting.

METHODS

Study population

As part of a comprehensive evaluation of HCW knowledge, at-titudes/perceptions, and practices/behaviors (KAP) aboutMRSA, weconducted a cross-sectional survey of HCWs at a 182-bed hospitalin the mid-Atlantic region of the United States from Septemberthrough November 2012. All HCWs with direct patient care andthose who enter patient care areas were asked to complete aquestionnaire, including medical staff (physicians, physician assis-tants, and nurse practitioners on medical staff), nurse staff (regis-tered nurses and other types of nurses), allied health professionals(such as cardiopulmonary therapists; physical therapists; occupa-tional therapists; speech therapists; social workers; and laboratory,medical imaging, and pharmacy staff), and support staff fromenvironmental services, foodservices, engineering, security, andpatient registration.

Data collection

HCWs were recruited via e-mail, staff newsletters, posters dis-played in employee locker rooms, and announcements on the hos-pital’s research Web page. Department managers were informedabout the survey at administrative meetings and asked to promotethe survey to their colleagues and distribute the e-mail invitation.Additionally, HCWs were informed about the survey during visits bythe research team to clinical departments. Responses to the 33-itemsurvey, which included 3 open-ended and 49 close-ended questions,could be submitted on paper forms deposited in survey collectionboxes located in the mailroom or could be submitted electronicallyvia a Zoomerang Web survey. Characteristics of participants aredescribed in Table 1.

Survey instrument

The questionnaire included 7 demographic questions; 4 multi-ple choice and 2 true/false questions about knowledge; 12 ordinalquestions about perceptions of MRSA; and a series of 6 yes/noquestions about practice adherence by self and other HCWs. Theperceptions of MRSA questions (with a 5-point Likert scale rangingfrom strongly disagree to strongly agree) rated susceptibility,severity, the benefit of practice adherence, self-efficacy, and cues totake action. Additional questions included 7 yes-or-no questionsabout barriers to adherencewith recommended practices related totime management, communication, access to equipment, theenvironment, and patient characteristics. Also included were12yes-or-no questions about resources and preferred educationmethods and 3 open-ended questions for reporting barriers, other

education methods, and suggestions for reducing transmission ofMRSA.

To improve the validity of the survey instrument, the ques-tionnaire included 17 questions about contact precautions, colo-nization, mode of transmission, bacterial viability, and handhygiene efficacy previously used by Burkitt et al24 in a large study ofHCWs at Veterans’ Administration health care facilities; 9 questionsfrom the study by Trigg et al25 of HCWs at a National Health Sys-tems hospital in the United Kingdom; and 3 questions regardingconcern about transmission, knowing someone with MRSA, andcommunity-acquiredMRSA adapted from a study of HCWs in NorthDakota by Koltes.22 The specific wording of the questions is pro-vided in Tables 2-4.

Survey validity

A pilot test of the survey by 6 HCWs from another hospital in thesame part of the country was conducted. Additionally, 12 infectionpreventionists, 2 nurse educators, and 6 HCW members of thehospital’s research council rated the relevance and clarity of eachitem on a 4-point scale (from not relevant to highly relevant andfrom not clearly written to clearly written). A content validity indexwas calculated from these scores. A content validity index score of0.80 (on a scale of 0 to 1) is desirable, and the assessors rated therelevance of the questions at 0.98 and the clarity at 0.97. After thequestionnaires were completed, Cronbach’s a was used to evaluatethe internal consistency of the survey items. The scores for internalconsistency of the perception variables, the knowledge scores, and

Table 2Methicillin-resistant Staphylococcus aureus (MRSA) knowledge by health care worker (HCW) group

Statement Correct answer

Selected correct answer (%)

Medical Nurses Allied health Support staff Total

Which of the following precautions should be taken before contactwith MRSA patients/items in their room? (Check all that apply)

Hand hygiene 100.0 98.4 100.0 98.0 98.9Gloves 100.0 100.0 100.0 98.0 99.6Gown 95.8 100.0 100.0 98.0 98.9All of the above 95.8 98.4 100.0 98.0 98.1

People who have (or carry) MRSA but do not have symptoms can spread MRSA True 97.9 86.5 95.6 74.0 87.7**How is MRSA most often spread to patients? Health care worker hands 89.6 75.4 71.1 64.0 75.1*How long can MRSA live outside the body on surfaces? Days 47.9 40.5 33.3 42.0 40.9Which hand hygiene method is most effective in killing MRSA? Alcohol-based hand rub 35.4 38.9 33.3 24.0 34.6

*P < .05 for statistically significant differences in correct responses by HCW type.**P < .005 for statistically significant differences in correct responses by HCW type.

Table 3Methicillin-resistant Staphylococcus aureus (MRSA) perceptions by health care worker (HCW) group

Category Statement

Strongly agree or agree (%)

Medical Nurses Allied health Support staff Total

Severity MRSA is a national problem 95.9 91.4 95.8 80.8 90.9MRSA is a problem in this hospital 55.1 52.0 41.3 36.0 47.8*

Benefit If I clean my hands and wear gowns and gloves as recommended,I will decrease my risk of getting MRSA

91.8 96.1 97.8 96.0 95.6

If I clean my hands and wear gowns and gloves as recommended,I will decrease my patients’ risk of getting MRSA

93.9 92.9 95.7 94.0 93.8

Self-efficacy When staff on this unit do not gown and glove before touching apatient with MRSA, I feel comfortable reminding them

85.7 83.7 89.6 84.0 85.1

When staff on this unit do not clean their hands, I feel comfortable reminding them 77.6 76.6 78.7 86.0 78.8I am comfortable with educating patients and their families about MRSA 83.3 78.3 69.6 48.0 72.2**

Susceptibility I am concerned that I will transmit MRSA to my family and/or friends at home 41.7 48.1 46.8 60.0 48.9When we are short staffed on my unit, MRSA is spread more than when we are fully staffed 44.9 34.6 34.0 18.0 33.3*

Cues to action I have received meaningful education regarding MRSA 71.4 72.7 82.6 66.0 72.9The news media influenced my attitude toward MRSA. 20.4 22.7 21.3 35.4 24.3Someone I know had MRSA and the experience influenced my attitude toward MRSA 26.5 18.6 24.4 22.0 21.6

*P < 0.05 for statistically significant differences in agreement level by HCW type.**P < .001 for statistically significant differences in agreement level by HCW type.

D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 254-9256

the practice scores were 0.602, 0.624, and 0.788, respectively. ACronbach’s a value of 0.7 or greater (on a scale of 0-1) indicates thatquestions within a series measured highly related constructs.

Hand hygiene observations

To complement the self-reported measures in the survey, a handhygiene observation study was conducted during September 2012.Blinded observations of hand hygiene behavior were conducted ac-cording to recommendations from the World Health Organization.11

Trained observers stationed in the corridors of inpatient andoutpatient service areas for 15 minutes to 2 hours took notes aboutHCWs’ hand hygiene compliance at unannounced randomly selectedtimes and places. (Because of patient security concerns, verbalpermission from the area manager was obtained before observa-tions.) HCWs were expected to engage in hand hygiene at 3 times:before touching a patient, after touching a patient, and after touchinga patient’s surroundings. For each observed opportunity to practiceappropriate hand hygienedwhether with soap and water or withalcohol hand rubsdthe observer noted if a hand hygiene action wasperformed or missed. To minimize the risk of Hawthorne effectbiasdthat is, increased adherence to recommended practice due toawareness of observations26dparticipants in the hand hygienestudy were not aware that they were being observed.

Statistical analysis

Descriptive statistics were used to compare individual self-report and observed behavior. Two-sided c2 tests and analysis of

variancewere used to compare responses to KAP questions by HCWtype. The associations of HCWgroup membership with knowledge,perceptions, and self-reported practices were analyzed. Logisticregression models were fit to identify the demographic and othervariables that were the strongest predictors of KAP responses. Allstatistical analyses were conductedwith SPSS version 20 (IBM-SPSSInc, Armonk, NY) and a significance level of a ¼ 0.05 was set.

Ethical considerations

The protocol was reviewed and approved by the study hospital’sinstitutional review board and the associated university institu-tional review board. Survey participants were provided with aninformed consent statement outlining the purposes and benefits ofparticipation. Participation was voluntary and no incentives wereoffered. To ensure anonymity of hand hygiene program partici-pants, observations were categorized by HCW group with noidentifiers related to observation unit. Because patient safety mustbe prioritized, brief verbal reports of hand hygiene adherence wereprovided to department managers immediately after hand hygieneobservations were completed.

RESULTS

Participants

Surveys were received from 276 HCWs of the potential 1,200HCWs, including 49 medical, 129 nurse, 48 allied health, and 50support staff. The participants are described in Table 1. In total,

Table 4Self-reported adherence to use of gloves, gowns, and hand hygiene, by health care worker (HCW) group

HCW group Medical Nurses Allied health Support staff Total

Self-report survey participants reporting all practices, n 48 123 44 47 262HCWs reporting all practices of peers, n 44 121 43 47 258Personnel observed, n 17 70 6 11 104Consistently wear gloves when entering a MRSA isolation room, %Self-report 97.9 95.2 100.0 89.8 95.5Report on peers 86.4 82.9 86.4 90.0 85.4Self-rated their compliance as higher than that of their peers 13.6 14.6 14.0 10.2 13.5

Consistently wear gowns when entering a MRSA isolation room, %Self-report 87.5 87.0 97.7 87.5 89.0Report on peers 75.6 70.5 86.4 82.0 76.2Self-rated their compliance as higher than that of their peers 11.1 18.2 14.0 10.4 14.8

Consistently perform hand hygiene before and after touching patients, %Self-report 95.8 93.5 95.5 97.9 95.1Report on peers 71.1 71.5 77.3 94.0 76.7Self-rated their compliance as higher than that of their peers 24.4 23.6 18.6 6.2 19.7

Consistently perform all 3 practices, %Self-report 85.4 79.7 95.5 85.1 84.4Report on peers 65.9 58.2 70.5 78.0 65.4Self-rated their compliance as higher than that of their peers 20.5 24.0 25.6 12.8 21.6

MRSA, Methicillin-resistant Staphylococcus aureus.

D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 254-9 257

183 (66.3%) of the surveys were submitted on paper and 93 (33.7%)via the Zoomerang Web site. A response rate of 55% of 330 papersurveys distributed and 23% of the potential population was real-ized. To be included in the analysis of preventive practices, all 3 ofthe practice questionsdasking about consistency in gowning andgloving for MRSA patients and performing hand hygiene before andafter touching patientsdhad to be answered. In total, 262 surveysmet this criterion. Additionally, 104 HCWs were observed foradherence with hand hygiene recommendations, including 17medical, 70 nurse, 6 allied health, and 11 support staff.

Knowledge

Nearly every HCW correctly identified appropriate precautionsfor preventing the spread of MRSA (Table 2). Most HCWs alsocorrectly identified that asymptomatic persons can spread MRSA,that MRSA is most often spread by hands, and that MRSA can occurin the community as well as in the hospital. However, more thanhalf of HCWs, includingmore than half of medical and nursing staff,did not know that MRSA can live on surfaces for days and did notknow that alcohol rubs are the most effective hand hygienemethodfor killing MRSA. There were significant differences in knowledgeacross HCW types, with medical staff demonstrating higher levelsof MRSA knowledge and support staff expressing lower levels ofknowledge (P < .001).

Perceptions

The questions about attitudes toward MRSA were grouped bytheme: severity of and susceptibility to MRSA, the benefit of be-haviors for preventingMRSA spread, comfort with educating othersabout MRSA and encouraging MRSA prevention, and cues to action(Table 3). More than 90% of participants agreed that MRSA was anational problem, but fewer than half believed that MRSA is aproblem in the hospital where they work. Support staff and alliedhealth staff were much less likely to think of MRSA as a localproblem than medical and nursing staff. Nearly all HCWs reportedbelieving that preventive measures would reduce their risk ofcontracting MRSA and would protect their patients. The majority ofHCWs reported feeling comfortable reminding others to glove,gown, and practice hand hygiene. About three-quarters of HCWsreported having received meaningful MRSA education and feelingcomfortable educating patients and their families about MRSA.

About half of participants were concerned about bringing MRSAhome from work. Only about one-third believed that being under-staffed increased the spread of MRSA in the hospital. Fewer thanone-quarter reported that media reports or knowing someonewithMRSA had influenced their attitude toward MRSA.

Observed and reported practices

More than 100 HCWs were observed for adherence to handhygiene recommendations. There were significant differences byHCW type: consistent performance of hand hygiene before andafter touching patients was observed for 94.1% of medical staff,88.6% of nurses, and 83.3% of allied health staff, but only 45.5% ofsupport staff. Alcohol rubs were used in 84.1% of the observed handhygiene actions; soap and water were used for only 15.9%. Becausethe surveys were submitted anonymously, we could not determineif an HCW under observation had submitted a completed ques-tionnaire. That means that it is not possible to make a directcomparison between these onsite workplace observations and theself-reported practices recorded by survey participants. However,the observed hand hygiene adherence rate appears to be inter-mediate between the high rates of self-reported hand hygieneadherence and the lower rates reported for peers (Table 4). (HCWsalso reported high rates of adherence to glove and gown use bythemselves and their coworkers, with self-adherence rates re-ported to be higher than those of peers.) The direct observationsnoted that support staff had significantly lower adherence to handhygiene recommendations, but the self-reported rates were higherfor support staff and their peers than for any other HCW group.

Predictors of recommended practice

Logistic regression models showed that the MRSA knowledgescore (out of 6 points) and most perceptions of MRSA were notstatistically significant predictors of self-reported adherence toMRSA transmission prevention guidelines. However, those whoreported greater self-efficacydthat is, a greater comfort withtelling others to take action to prevent MRSA transmissiondweresignificantly more likely to report self-adherence to recommendedpractices (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.01-1.40); P ¼ .04). When all variables with significance of P < .2 inbivariate analysis were included in 1 multiple logistic regressionmodel, 6 variables were found to have significant relationships

D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 254-9258

with adherence to recommended practices. These predictors ofhigh adherence included being a man, being in the allied HCWgroup, having a high school education, believing that adherence tothe recommended practices is beneficial, being influenced by theexperience of others with MRSA, and feeling comfortable remind-ing others to perform hand hygiene.

Barriers to recommended practice

The survey asked about 6 items that might influence trans-mission, and asked follow-up questions about potential barriersto adherence to recommended practices. The 2 most commonlyselected items that influence transmission were patient non-adherence to contact precautions (59.3%) and communication is-sues (48.9%). The other items included in the list were lack of timeto engage in hand hygiene and to put on gowns and gloves (36.9%),lack of environmental cleanliness (29.1%), workload issues (27.6%),and not having alcohol rubs or soap within easy reach (11.2%).When asked to identify 1 of the 6 items as the most influentialbarrier, communication was the most common response (30.2%).

The responses to the open-ended question about barriers yiel-ded 15 communication-related comments, 11 of which focused onthe need for better communication about which patients haveMRSA. Besides these comments, 25 education-related commentsnoted a lack of knowledge or experience and the need for additionaleducational opportunities. Additionally, 24 comments about con-tact precautions mentioned the need for more gowns and gloves tobe in stock and conveniently located (n ¼ 10), more equipment tobe available and more time allotted for cleaning equipment (n ¼ 6),and more isolation signs to be posted (n ¼ 5) and 11 commentsabout hand hygiene requested more alcohol hand rub stations(n ¼ 3) and more sinks (n ¼ 5).

DISCUSSION

The HCWs who participated in this study strongly agreed thatglove, gown, and hand hygiene precautions prevent the spread ofMRSA and rated the benefit of engaging in these actions as veryhigh for both HCWs and patients. The vast majority of participantsreported that they almost always engaged in these practices, butour study’s observations of hand hygiene found lower rates ofadherence among nearly all HCW groups. This gap between re-ported and observed preventive practices has been found in pre-vious studies that concluded that HCWs tended to overestimatehow well they apply their prevention knowledge to daily workactivities.27,28 This may be the result of HCWs not understandingwhen particular preventive actions should be taken. For example, ina study from the Netherlands, 87% of participating HCWs had astrong knowledge of MRSA prevention measures but only 45%correctly identified the scenarios in which such actions should betaken.28 Additionally, failure to engage in preventive behaviors mayresult from lack of knowledge or experience with recognizingappropriate actions or from barriers to adhering to recommendedpractices, such as having inconveniently located hand hygienesupplies, insufficient time, or poorly placed signs about which pa-tients have MRSA and require special precautions. Reducing bar-riers and making contact precautions and hand hygiene convenientfor staff will improve MRSA prevention.20,21,29

Two results from this part of our studymay point to action itemsfor improving adherence to recommended practice. First, theobserved rates of hand hygiene were particularly low among sup-port staff, such as janitorial staff, who have critical roles in patientsafety and MRSA prevention but are not involved in direct patientcare. Support staff also had lower knowledge of MRSA than otherHCW groups. However, they reported high rates of self- and peer

adherence to good practices, which means that they did notrecognize that they were not following current best-practice pro-tocols. Working with these essential personnel to improve theirknowledge of MRSA may be helpful in improving routine preven-tion practices, especially because support staff expressed willing-ness to remind other staff to engage in these practices. Previousstudies have found that health education increases comfort ofHCWs with reminding other staff and visitors about preventionbehaviors.24,28 Second, survey participants perceived their peers tobe considerably less vigilant at prevention practices than them-selves. This is similar to the results from the study by Koltes,22 inwhich 80% of participants reported that they consistently usedprecautions but only 52% reported that their colleagues did.22

Posting more reminders about recommended practices that high-light this discrepancy might improve personal practices as well asincrease peer pressure to use contact precautions and engage infrequent hand hygiene.

All groups of HCWs in our study had limited knowledge aboutthe lengthy duration of time that MRSA can live on surfaces andabout the effectiveness of alcohol rubs at removing MRSA from thehands. Additionally, few HCWs reported that knowing someonewith MRSA had influenced their attitudes toward the infection, andless than half believed that MRSAwas a problem in their workplaceor worried about bringing MRSA home from the hospital. Theperception that they are not at riskdbecause they believe MRSAorganisms die quickly in the environment or because they do notknow people who have been seriously affected by MRSAdmaycontribute to failure of some HCWs to practice hand hygiene orcontact precautions. Previous studies have found that HCWs whobelieve HAIs cause severe illness engage in better preventive be-haviors.22,23 Misperceptions about risk and severity could bechanged with appropriate educational outreach from infectioncontrol specialists. Multimedia resources that allow for participa-tive, interactive, and engaging learning experiences may be mosteffective for improving patient care practices.29-33

The strengths of our study include the use of both survey andobservational methods, the use of validated survey items for all ofthe KAP areas, and the inclusion of all types of HCWs rather thanlimiting participation to 1 group such as nurses. However, the re-sults must be interpreted conservatively because the participationrate suggests that self-selection bias may have occurred. BecauseHCWs who were not confident about their MRSA knowledge mayhave been less likely than others to submit a completed question-naire, the knowledge levels reported in the Results section may beoverestimates of the levels in the HCW population as a whole. Also,because the study was conducted at only 1 health care facility, thefindings may not be generalizable to other HCW populations.

Our findings point to the importance of helping all HCWsdmedical, nursing, allied health, and support staffdtranslate knowl-edge of HAIs such as MRSA into consistent adherence of themselvesand their coworkers to guidelines for contact precautions and handhygiene. Multidisciplinary educational interventions to increaseawareness of personal and patient risks paired with reductions ofbarriers to adherence may help to reduce MRSA transmission inacute-care settings.

References

1. Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan A, et al.Antimicrobial-resistant pathogens associated with healthcare-associated in-fections: summary of data reported to the National Healthcare Safety Networkat the Centers for Disease Control and Prevention, 2009-2010. Infect ControlHosp Epidemiol 2013;34:1-14.

2. Elixhauser A, Steiner C. Infections with methicillin-resistant Staphylococcusaureus (MRSA) in U.S. hospitals, 1993-2005. Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf. Accessed October 14, 2013.

D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 254-9 259

3. Cummings KL, Anderson DJ, Kaye KS. Hand hygiene noncompliance and thecost of hospital-acquired methicillin-resistant Staphylococcus aureus infection.Infect Control Hosp Epidemiol 2010;34:357-64.

4. Ahmed SS, McCaskey MS, Bringman S, Eigen H. Catheter-associated blood-stream infection in the pediatric intensive care unit: a multidisciplinaryapproach. Pediatr Crit Care Med 2012;13:e69-72.

5. Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream in-fections through the use of a central venous line bundle: epidemiologic andeconomic consequences. Am J Infect Control 2011;39:640-6.

6. Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, et al.Reducing ventilator-associated pneumonia in intensive care: impact ofimplementing a care bundle. Crit Care Med 2011;39:2218-24.

7. Wheeler DS, Giaccone MJ, Hutchinson N, Haygood M, Bondurant P, Demmel K,et al. A hospital-wide quality-improvement collaborative to reduce catheter-associated bloodstream infections. Pediatrics 2011;128:e995.

8. Clock S, Cohen B, Behta M, Ross B, Larson E. Contact precautions for multidrug-resistant organisms: current recommendations and actual practice. Am J InfectControl 2010;38:105-11.

9. Huskins WC, Huckabee CM, O’Grady NP, Murray P, Kopetskie H, Zimmer L, et al.Intervention to reduce transmission of resistant bacteria in intensive care.N Engl J Med 2011;364:1407-18.

10. Siegel J, Rhinehart E, Jackson M, Chiarello L. Healthcare Infections ControlPractices Advisory Committee. Management of multidrug-resistant organismsin health care settings, 2006. Am J Infect Control 2007;35(10 Suppl 2):S165-93.

11. World Health Organization. A guide to the implementation of the WHOmultimodal hand hygiene improvement strategy. 2009. Available from: http://www.who.int/gpsc/en/. Accessed October 14, 2013.

12. Manian F, Ponzillo J. Compliance with routine use of gowns by healthcareworkers (HCWs) and non-HCW visitors on entry into the rooms of patientsunder contact precautions. Infect Control Hosp Epidemiol 2007;28:337-40.

13. Albrich WC, Harbarth S. Health-care workers: source, vector, or victim ofMRSA? Lancet Infect Dis 2008;8:289-301.

14. Ben-David D, Mermel LA, Parenteau S. Methicillin-resistant Staphylococcusaureus transmission: the possible importance of unrecognized health careworker carriage. Am J Infect Control 2008;36:93-7.

15. Snyder G, Thorn K, Furuno JP, Perencevich EN, Roghmann M-C, Strauss S, et al.Detection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on the gowns and gloves of healthcare workers. InfectControl Hosp Epidemiol 2008;29:583-9.

16. Cimolai N. The role of healthcare personnel in the maintenance and spreadof methicillin-resistant Staphylococcus aureus. J Infect Public Health 2008;1:78-100.

17. Haill C, Fletcher S, Archer R, Jones G, Jayarajah M, Frame J, et al. Prolongedoutbreak of meticillin-resistant Staphylococcus aureus in a cardiac surgery unitlinked to a single colonized healthcare worker. J Hosp Infect 2013;83:219-25.

18. Kassis C, Hachem R, Raad II, Perego CA, Dvorak T, Hulten KG, et al. Outbreak ofcommunity-acquired methicillin-resistant Staphylococcus aureus skin in-fections among health care workers in a cancer center. Am J Infect Control2011;39:112-7.

19. Eveillard M, Martin Y, Hidri N, Boussougant Y, Joly-Guillou M. Carriage ofmethicillin-resistant Staphylococcus aureus among hospital employees: prev-alence, duration, and transmission to households. Infect Control Hosp Epi-demiol 2004;25:114-20.

20. Cheng VC, Tai JW, Chan WM, Lau EH, Chan JF, To KK, et al. Sequential intro-duction of single room isolation and hand hygiene campaign in the control ofmethicillin-resistant Staphylococcus aureus in intensive care unit. BMC InfectDis 2010;10:263.

21. Cromer AL, Latham SC, Bryant KG, Hutsell S, Gansauer L, Bendyk HA, et al.Monitoring and feedback of hand hygiene compliance and the impact onfacility-acquired methicillin-resistant Staphylococcus aureus. Am J Infect Con-trol 2008;36:672-7.

22. Koltes LA. Healthcare workers’ attitudes, understanding and perceived risk ofmethicillin-resistant Staphylococcus aureus [dissertation]. Fargo (ND): NorthDakota State University; 2009.

23. Sax H, Uçkay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherenceto hand hygiene among healthcare workers who have extensive exposure tohand hygiene campaigns. Infect Control Hosp Epidemiol 2007;28:1267-74.

24. Burkitt K, Sinkowitz-Cochran R, Obrosky D, Cuerdon T, Miller L, Jain R, et al.Survey of employee knowledge and attitudes before and after a multicenterVeterans’ Administration quality improvement initiative to reduce nosocomialmethicillin-resistant Staphylococcus aureus infections. Am J Infect Control2010;38:274-82.

25. Trigg D, Timmons S, Pynegar C. An audit of healthcare workers’ knowledge ofmeticillin resistant Staphylococcus aureus (MRSA) against current infectioncontrol standards. Br J Infect Control 2008;9:30-3.

26. Maury E, Moussa N, Lakermi C, Barbut F, Offenstadt G. Compliance of healthcare workers to hand hygiene: awareness of being observed is important.Intensive Care Med 2006;32:2088-9.

27. McLaughlin AC, Walsh F. Individual differences in judgments of hand hygienerisk by health care workers. Am J Infect Control 2011;39:456-63.

28. Van Gemert-Pijnen J, Hendrix MG, van der Palen J, Schellens PJ. Performance ofmethicillin-resistant Staphylococcus aureus protocols in Dutch hospitals. Am JInfect Control 2005;33:377-84.

29. Carboneau C, Benge E, Jaco MT, Robinson M. A Lean Six Sigma team increaseshand hygiene compliance and reduces hospital-acquired MRSA infections by51%. J Healthc Qual 2010;32:61-70.

30. Engum SA, Jeffries PR. Interdisciplinary collisions: bringing healthcare pro-fessionals together. Collegian 2012;19:145-51.

31. Levett-Jones T, Gilligan C, Lapkin S, Hoffman K. Interprofessional education forthe quality use of medicines: designing authentic multimedia learning re-sources. Nurse Educ Today 2012;32:934-8.

32. Mikkelsen J, Reime MH, Harris AK. Nursing students’ learning of managingcross-infectionsdscenario-based simulation training versus study groups.Nurse Educ Today 2008;28:664-71.

33. Lee T, Moore C, Raboud J, Muller M, Green K, Tong A, et al. Impact of amandatory infection control education program on nosocomial acquisition ofmethicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol2009;30:249-56.