Nosocomial infection (NI) is one of the most serious problems in medical centers worldwide. NI is defined as any type of infection that develops during hospitalization or other health care settings where patients were not in an infection incubation period and did not present with the infection on admission (Cunha, 2010). According to the World Health Organization, the pooled prevalence of such infections in various patient populations was nearly 7.6% in high-income areas of the world such as Europe and North America. Although nearly two thirds of developing countries did not provide sufficient information to determine the prevalence in these regions, it is estimated that hospital-wide prevalence of NI in these areas ranges from 5.7% to 19.1% (World Health Organization, 2011). In Iran, studies of health care settings indicate that approximately one individual is affected by NI for every 10 individuals referred to inpatient health care (Nosrati et al., 2010; Zahraei, Eshrati, Masoumi Asl, & Pezeshki, 2012). In particular, these infections are more prevalent among those who need special care during hospitalization (Zorgani, Abofayed, Glia, Albarbar, & Hanish, 2015).
The risk of developing an NI in the intensive care unit (ICU) is considerably higher than the risk in other hospital wards. Nearly 30% to 40% of patients admitted in these units may contract at least one such infection (Esen & Leblebicioglu, 2004; World Health Organization, 2011). The situation for low-income countries compared with industrialized countries is significantly worse, such that the cumulative incidence in developed countries has been reported to be 17 episodes per 1,000 patient-days compared with 42 episodes per 1,000 patient-days in developing countries (Bardossy, Zervos, & Zervos, 2016; World Health Organization, 2010). The use of invasive care methods in ICU settings, such as insertion and maintenance of urinary catheters, intravenous lines, and endotracheal tubes, is much more common than in other hospital areas and helps to explain the high prevalence of NI in these units. In addition, patients who receive care in the ICU usually have less ability for self-care and are highly dependent on health care personnel. This, along with an often prolonged length of stay in the hospital, further increases the risk of NI (Cunha, 2010).
The health care providers, especially nurses, play a major role in preventing and control of NI because the promotion of protective behaviors is a key to decreasing such infections. Several studies have found that the knowledge, attitude, and practice (KAP) of nurses regarding NI needs improvement. In a study that evaluated nurse KAP regarding NI, the authors found that only 61% had acceptable knowledge, whereas attitudes also needed improvement (Kriari, Galanis, Diakoumis, Passa, & Theodorou, 2018). Other studies have found that nurses often have insufficient knowledge, poor attitudes, and poor practices regarding infection control strategies (Arafa, Mohamed, & Anwar, 2016; Egwuenu & Okanlawon, 2014). In a study that examined adequate knowledge on different aspects of NI for pediatric ICU nurses, 34% to 91% of participants had this knowledge. Nevertheless, a health education program was effective in improving knowledge in these participants (Galal, Labib, & Abouelhamd, 2014).
Many education departments in health care settings use classic educational sessions for in-service training of nurses. This approach, although useful for influencing KAP among nurses, has certain requirements such as time for participation that may interfere with usual health care duties, needed space, trainers to conduct these education sessions, and supportive media (Correia, 2017). The cost-effectiveness of such methods may be questioned. In addition, such strategies may be inefficient in training large numbers of personnel given that it places limits on the number of nurses who can be involved at one time. As a result, many health care institutions are now seeking alternative ways to overcome these barriers (de Godoy, Costa Mendes, Hayashida, Nogueira, & Marchi Alves, 2004). One possible way to accomplish this is through e-learning. A large and growing body of literature confirms the effectiveness of this method (Lahti, Hätönen, & Välimäki, 2014).
Using short text messages (SMS) as a way to conduct e-learning has been examined in several studies in health care settings, with promising results. For example, researchers have found this method to be effective in improving medication adherence in people with chronic disorders and enhancing disease screening among those at risk (DeKoekkoek et al., 2015; Lee, Koopmeiners, Rhee, Raveis, & Ahluwalia, 2014; Saffari, Ghanizadeh, & Koenig, 2014). Alipour, Moini, Jafari-Adli, Gharaie, and Mansouri (2012) designed a similar education-based intervention using text messages to improve knowledge of breast cancer among 25 gynecology residents. In that study, investigators compared participants' knowledge acquired through reading a booklet with knowledge gained from text messaging. Participants reported the SMS method was a more interesting way of learning than reading from a booklet (Alipour et al., 2012). In Senegal, a mobile learning service that included text messaging along with interactive voice responses was used to deliver family planning information to 20 public-health sector nurses. Investigators reported that participant knowledge increased significantly from baseline to follow up (Diedhiou et al., 2015).
Gill et al. (2016) conducted a randomized controlled trial to assess the effectiveness of an educational intervention via SMS to improve medical knowledge among community health workers. They formed three study groups, including a control group (routine training) and two intervention groups (passive and interactive SMS groups). Passive and interactive groups did not show an increase in knowledge compared with the control group. Although the authors concluded that the SMS training did not have an advantage over traditional education methods for improving medical performance, they indicated that it may be a feasible and readily acceptable teaching method used to supplement current methods (Gill et al., 2016). However, there is limited information on how this tool may be used for staff training or improving professional skills in health care workers. Therefore, the current study assessed an educational intervention by SMS among ICU nurses to determine its effectiveness as an e-learning tool to improve nurses' KAP with regard to NI.
Materials and Method
Design and Sample
This study involved a single-group experimental design to assess the effectiveness of brief educational texting on KAP among ICU nurses in a general hospital located in Tehran, Iran. The study was conducted between March and May 2018. We used a cluster multistage sampling to identify a random sample of 32 nurses. First, a list of all active ICUs in the hospital was obtained. Then, a random sample of three units was identified from the six ICUs chosen. Second, from 88 nurses working on the three selected ICUs, 32 nurses were invited to participate in the study, again based on a simple random sample. If a selected participant refused to participate, another person from the sampling frame was identified randomly to replace that individual. Only 6% of the sample was replaced using this method. Sample size was calculated based on a formula suggested by Rosner (2011) with these parameters: α = 0.05, β = 0.20, effect size = 0.50, and SD (Δ) = 1.00. Inclusion criteria were at least 2 years of work experience in the ICU, no participation in a current educational program on NI, and no plans for retirement or worksite shift during the 6 months from the study's beginning. Nurses who did not use SMS on their cell phones were excluded. Participants were aware of the study objectives and participation was voluntary. A written informed consent was obtained from each participant in the sample. The ethics committee of the Baqiyatallah University of Medical Sciences approved the study design.
A demographic questionnaire collected information on age, sex, work experience in the ICU, work experience as a nurse, education level, work time per month, history of participation in the educational courses on NI, and date of participation in NI courses, along with activity as a nursing trainer. Data on KAP related to NI were collected using the following questionnaire, along with a single question asking about participant satisfaction with the intervention: “How do you appraise the current intervention as an alternative method for in-service training of the nursing staff?”
Two standard previously developed questionnaires were modified for this study. We adopted knowledge and practice items from a questionnaire developed for nurses and physicians on NI, although only the items relating to nurses were used (Zhou et al., 2014). Items from a second questionnaire were also used to supplement these questions (Kamunge, 2013). First, permission for use and modification was obtained from the developers. Next, an expert panel was convened to integrate these measures together following guidelines recommended by Beaton, Bombardier, Guillemin, and Ferraz (2000) in the translation process. Third, after forward–backward translation, the face validity of the tool was assessed by 20 nurses who were separate from the main study sample. Finally, the expert panel examined the content of the questionnaire using qualitative methodology. After this process was completed, test–retest reliability of the questionnaire was assessed after a 1-week interval, which demonstrated acceptable results (intraclass correlation coefficient was equal to 0.78 to 0.84 for items with the same response format). The final questionnaire included three parts: knowledge regarding NI was assessed with 24 multiple choice questions (with one or more correct answers); attitudes were assessed with eight questions, with Likert-type responses ranging from completely disagree (1) to completely agree (7); and practices were measured with 13 questions (both multiple choice and Likert-type responses). Each of the items, then, had a response range that differed. Total scores for each of the KAP domains ranged from 0 to 60, 8 to 56, and 0 to 179, respectively. Higher scores indicated better KAP. The knowledge domain included seven subscales: core concepts, NI pathogens, NI sources, hand hygiene, protective equipment, work safety, and isolation precautions. These subscales may be scored from 0 to 100 by multiplying the total score of each section by the crude score and dividing the result by 100.
Based on an initial assessment using the KAP questionnaire (pretest), domain deficits were identified as areas in need of improvement. Using guidelines provided by the U.S. Centers for Disease Control and the World Health Organization on how to handle NI, 63 text messages were developed by the research team. Using the expert panel described earlier (made up of the research team and experts on educational media, public health, nursing, infectious diseases, and health promotion), a total number of 46 text message were decided on and the size and content of the messages was determined. Each message was composed of 15 to 25 words and was texted to participants at a predefined time between 9 a.m. and 11 a.m. on work days (i.e., Monday through Friday, not on weekends or holidays) during a 2-month period. All participants received the messages privately on their cell phones (all costs were covered by the sender). Sample texts were:
- “Did you know that E. coli, Staphylococcus aureus, Acinetobacter, Enterococcus, Pseudomonas aeruginosa, Bacillus cereus, and Legionella are among the most common nosocomial pathogens?”
- “Patients at highest risk for nosocomial infections are those with open surgical wounds and patients with obstructive pulmonary disease.”
- “The nurse's uniform, stethoscope, thermometer, sphygmo-manometer cuff, patients' mattress and pillow are among the most common sources of nosocomial infections.”
Two weeks after sending the last text message (10 weeks after the beginning of the study), participants completed the posttest questionnaire.
According to the hospital's policy, all nurses are allowed to keep their cell phones with them while working. However, they usually use the cell phones during their rest breaks and/or during light duty times. A delivery report system was used to indicate whether participants received the text messages. In addition, before beginning the program, researchers emphasized the importance of the study and the necessity of attending to all text messages. Therefore, given that participation was voluntarily and participants are aware of the purpose of the study and its importance, it was assumed that delivered messages were attended to by the participants. We assigned a personal code to each participant so that participation was confidential. Questionnaires were completed on the ICU wards, although participants were asked to complete the questionnaire during their breaks and an examiner was present to monitor process of data collection. However, the examiner did not interfere with questionnaire completion by respondents and was present only to collect the questionnaires and answer any questions raised by respondents. Respondents were completely free to answer questions or leave them blank. Researchers had no professional relationship with nurses participating in this study.
Categorical data were presented as numbers and percentages, and quantitative data were calculated as means and standard deviations. To assess differences between pretest and posttest sections of the questionnaire, the paired t test was used. The normality assumption for dependent variables was assessed using Kolmogorov-Smirnov test. When the distribution is normal, this test should be nonsignificant (p > .05). The skewness and kurtosis of the data were examined by dividing the scores by their standard errors. When obtained values are within ± 1.96, the distribution may be considered normal and parametric tests such as the paired t test can be used. An alpha level of .05 or lower was established as level of statistical significance, without correction for multiple comparisons given the exploratory nature of these analyses.
The mean age of participants was 43.3 ± 9.6 years and most participants were male (69%) (Table 1). The average number of years working in the ICU was 12.4 ± 7.0; the average participant work experience as a nurse was 16.8 ± 9.6 years. Ten percent of participants (n = 3) had a master's degree in nursing, and the remainder had an associate or baccalaureate degree. The mean number of hours worked per month was 212.9 ± 71.1. Two participants (6%) reported no prior involvement in an educational course on NI.
Sample Characteristics (N = 32)
Table 2 presents the participants' mean scores on KAP at baseline and follow up. On the standardized scale, scores increased by 17%, 3%, and 9% for knowledge, attitude, and practice, respectively. Change in the attitude domain was lower than for the knowledge and practice sections (p =.01 versus p < .001).
Knowledge, Attitude, and Practice of Participants From Baseline to Follow Up
Changes in the various subsections of the knowledge domain are displayed in Table 3. Although all subsections revealed significant changes from baseline to follow up, the average changes for hand hygiene, protective equipment, and work safety were smaller than for others (p < .05 versus p < .001). Changes in knowledge regarding NI sources, core concepts, and NI pathogens were smaller compared with changes in other areas.
Standardized Scores on Knowledge Domains of Participants Regarding Nosocomial Infection (NI)
Regarding participant satisfaction with the intervention, 72% (23 of 32 participants) evaluated the intervention as a good alternative for in-service training, whereas only 6% (2 participants) believed this method of e-learning was inappropriate. Seven participants (22%) indicated that brief text messaging was an excellent educational strategy for staff training.
This study examined the impact of brief text messaging on improvement in KAP determined to be necessary for reducing health care-related NI among ICU nurses. We found that text messaging via cell phones is a good alternative for changing nurses' KAP that may lead to NI prevention. Knowledge improvement was greater than improvement in the other domains, whereas attitude improved the least. Among knowledge components, greater improvement was observed in the areas of infection sources and in core conceptual knowledge regarding the definition and identifying of pathological processes. This e-learning method of in-service training (SMS) was evaluated by 94% of participants to be an appropriate educational strategy for this purpose.
In the current study, we improved participant knowledge by 17%, which is comparable with outcomes in a similar study designed to increase the knowledge of public health sector nurses regarding family planning via mobile teaching, which increased by 23% (Diedhiou et al., 2015). Other studies also have been successful in improving knowledge via SMS (Goodarzi, Ebrahimzadeh, Rabi, Saedipoor, & Jafarabadi, 2012; Lee et al., 2014). However, using SMS to change attitude has been examined only rarely. Goodarzi et al. (2012) used SMS to change KAP related to self-care measures in patients with type 2 diabetes. Although they found that the intervention was useful for improving knowledge and practice, it did not change attitude when compared with a control group. Investigators explained that changing attitude requires a much longer time and may not be demonstrated in only a 3-month intervention (Goodarzi et al., 2012). In another study, researchers compared the impact of reading a pamphlet with that of text messaging (SMS) on changing attitude toward breast cancer prevention. The authors reported no significant difference between groups on change of attitude; however, those who were taught via SMS showed greater attitude change than did controls (Safari, Afzali, Ghasemi, Sharafi, & Safari, 2016). When comparing these findings with our finding of a small but significant change in the attitude, we surmise that SMS may be effective in changing attitude in some cases, but not in all, unless perhaps the intervention is conducted over a longer period than 2 to 3 months or is used as a supplemental method of education. Glanz, Rimer, and Viswanath (2008) suggested that attitude change needs direct personal interaction between those who have a positive attitude and those who have negative attitudes, and that confrontation between attitudes is necessary to initiate change. Hence, group discussions or role-playing as part of a comprehensive program that includes SMS may allow for the exchange of opposite viewpoints that may facilitate replacing old attitudes with new ones.
Self-reported measures of practice/behavior may not be as accurate as objective assessments of behavior such as direct observation, but they provide useful information at the level of participant perception. Only a few studies have examined the effectiveness of SMS interventions on behavior change among health care providers. A recent study found that using SMS to teach nurses how to educate patients in the area of breast cancer screening improved self-report practice to a similar degree as found in the current study (Alipour, Jannat, & Hosseini, 2014). In a review of studies in this area, Broom, Adamson, and Draper (2014) concluded that SMS was a usefulness technique for educating health care personnel in order to achieve behavioral change. Nevertheless, we believe that they underestimated the ability of this method as a practical way of training health professionals while at work. Our findings suggest that text messaging may be an important way of increasing knowledge that may ultimately result in a positive change in attitude and practice.
A new finding in this study was that there were changes in different knowledge components as a result of the SMS intervention. For example, we found that there was greater improvement in the cognitive domains such as core concept and knowledge about NI pathogens, NI sources, and isolation precautions, compared with hand hygiene, work safety, and protective equipment. According to Bloom's taxonomy of cognitive domains of learning, issues such as core concepts of NI and NI pathogens may be categorized as the initial stages of learning (e.g., remembering and understanding), whereas issues such as hand hygiene and work safety are primarily associated with higher cognitive domains, such as application and analysis (Bloom, 1956). Therefore, components that are in the earlier stage of learning may transmit easier via SMS interventions than information requiring higher cognitive skills.
Another point that should be considered when comparing our findings with those of other studies is that most participants in the current study were men (70%), whereas the nursing profession is more generally made up of women. Because of gender differences in learning styles and preferences (Atlasi, Moravveji, Nikzad, Mehrabadi, & Naderian, 2017), results may be different in female providers, thus affecting application of the current findings to hospital nurses more generally.
Another issue has to do with the sustainability of interventions of this type over time. According to Glanz et al. (2008), any type of education, especially those that do not include skill-based components, need to have booster sessions repeated periodically. Because the SMS method is particularly effective for enhancing the knowledge component of learning, this educational tool may have limited durability. However, encouraging participants to reinforce their learning through repetition of such text messaging reminders may increase the effectiveness of such methods. One strategy for doing so may be to design job skill training so that it is broken up into small tasks and communicating these tasks via a serial text messaging. Doing so may introduce the SMS as a beneficial tool for supporting the psychomotor elements of learning, as well as providing theory-based concepts. Furthermore, measuring the objective outcomes of such interventions (including the NI rates) may help to further document the effectiveness of e-learning tools such as SMS.
A final point that should be considered is the setting in which our research was performed. We attempted to conduct this study on site in the ICU. Therefore, the findings from this study may be applicable in the real world in which ICU nurses must work every day. However, this may not be generalizable to hospital nurses in other settings where this educational approach may not be as appropriate. Furthermore, there is the issue of whether the hospital administration will give permission to staff to use their cell phones during work and how patients may react to caregivers working with cell phones while they are providing care. Answers to these questions may help in the application of these methods on a broader scale. Before applying these results on a broader scale, hospital policy needs to be reviewed and the educational strategy of text messaging must be further compared to more established educational methods.
The current study has several limitations. First, a single-group experimental design without a control group was used to assess the effectiveness of our intervention. Although this design is not ideal for establishing causality, we chose this design because finding ICU nurses was challenging and randomizing subjects was beyond the resources available for this study. Increasing our sample size to include participants from different sites in a randomized controlled trial in future studies would help in determining the efficacy of this educational strategy. Second, we did not assess the degree to which nurses actually read the text messages they were sent, only whether they received them. Future studies should include methods that allow for determination of whether text methods are actually attended to. Third, the results of this study are not generalizable to other health care professionals, such as physicians and axillary health care workers. Including other health care professionals in future studies would help determine whether this educational approach might be applied to different health providers and specialties in the ICU and other hospital settings. Fourth, we used only subjective measures to examine outcomes, whereas using objective measures such as direct observation may improve the accuracy of findings. Fifth, we did not assess the potential influence of nurses in the study working alongside nurses who were not in the study, which might be addressed in a future randomized controlled trial. Finally, it would be useful to conduct a comparison between SMS and other electronic or traditional methods for education, which would be helpful in determining the effectiveness of this intervention in different settings and within different populations.
In-service education for ICU nurses via SMS (brief text messaging) may help to improve knowledge and practices concerning NI prevention. Although there may be changes in attitude, SMS interventions may not be sufficient alone to produce such changes. As a result, we recommend that SMS be used as part of a comprehensive education program that includes traditional methods and group interaction. Furthermore, SMS may be more suitable for education on simple theoretical concepts not complicated knowledge that requires higher cognitive skills. Further studies are necessary to assess the effectiveness of SMS interventions in different settings and populations.
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Sample Characteristics (N = 32)
| < 35||7 (21.9)|
| 35 to 45||10 (31.3)|
| ≥ 45||15 (46.8)|
| Male||22 (68.8)|
| Female||10 (31.2)|
| Bachelor||29 (90.6)|
| Master||3 (9.4)|
|Work experience as nurse (years)|
| < 10||10 (31.3)|
| 10 to 20||10 (31.3)|
| ≥ 20||12 (37.4)|
|Work experience in ICU (years)|
| < 5||7 (21.9)|
| 5 to 10||7 (21.9)|
| ≥ 10||18 (56.2)|
|Work hours (per month)|
| < 150||5 (15.6)|
| 150 to 250||21 (65.6)|
| ≥ 250||6 (18.8)|
|Prior education on NI prevention|
| Yes||30 (93.8)|
| No||2 (6.2)|
|Prior education time|
| < 6 months earlier||7 (23.3)|
| 6 to 12 months||9 (30)|
| ≥ 12 months earlier||14 (46.7)|
|Has a role in training nursing students|
| Yes||6 (18.8)|
| No||26 (81.2)|
Knowledge, Attitude, and Practice of Participants From Baseline to Follow Up
|Variable||Baseline, M (SD)||Follow-Up, M (SD)||Comparison|
|Knowledge||101.4 (13.2)||128.4 (9.7)||p < .001, t = −8.72, CI [−33.4, −20.6]|
|Attitude||44.7 (5.3)||47.4 (4.2)||p = .013, t = −2.69, CI [−4.7, −0.6]|
|Practice||123.5 (18.0)||140.0 (14.5)||p < .001, t = −5.75, CI [−22.3, −10.6]|
Standardized Scores on Knowledge Domains of Participants Regarding Nosocomial Infection (NI)
|Knowledge Domain||Baseline, M (SD)||Follow Up, M (SD)|
|Core concept||50.3 (13.3)||71.7 (8.03)**|
|NI pathogens||58.1 (15.0)||79.6 (9.4)**|
|NI sources||46.0 (13.3)||70.0 (11.3)**|
|Hand hygiene||88.5 (11.0)||95.2 (5.6)*|
|Protective equipment||76.4 (15.1)||87.0 (15.2)*|
|Work safety||88.2 (13.0)||95.4 (6.7)*|
|Isolation precautions||70.0 (13.3)||86.5 (10.2)**|