Research design and setting

A hospital-based cross-sectional survey was conducted during the third wave of COVID-19 pandemic (from May to August 2021) among nurses at AMUH which is the largest referral hospital and is located in the El-azareta district, in Alexandria city, which is the second-largest city in Egypt. AMUH provides specialized healthcare to people in Alexandria and nearby governorates.

Participants

All registered nurses with employment duration at AMUH of at least 1 year were included. Of the 373 eligible nurses, 354 (94.9%) agreed to participate in the study in which 133 nurses were from internal medicine departments including cardiology (n = 51), endocrinology (n = 5), rheumatology (n = 9), diabetology (n = 12), geriatric medicine (n = 8), tropical medicine (n = 8), nephrology (n = 8), hepatology, hematology, and gastroenterology departments (n = 32). While 221 nurses were from surgical and emergency department, neurosurgery and intensive care unit (n = 34), ophthalmology (n = 11), ENT (n = 14), genitourinary (n = 32), head and neck (n = 15), surgical gastroenterology (n = 20), vascular (n = 11), cardio-thorax (n = 19), colorectal (n = 12), oncology (n = 13), anesthesia (n = 3), plastic surgery (n = 14), and emergency department (n = 23).

Research tool

Data was collected using a pre-tested structured interviewer-administered questionnaire adopted from the previous studies, as well as the Centers for Disease Control and Prevention (CDC) and the WHO guidelines for healthcare IPC measures during the COVID-19 pandemic [7,8,9,10,11]. The questionnaire included 56 questions in five sections.

  • Section (I) included nine questions to collect sociodemographic data (gender, age, and educational level) and occupational data (affiliation, employment duration, working hours/day, work schedule, and the number of night shifts/month).

  • Section (II) included 15 questions to evaluate the compliance with the PPE usage, hand hygiene, and specific IPC measures. This section covered the frequency and extended use of various types of PPE (9 questions); compliance with the recommended steps for donning and doffing PPE while performing routine care (droplet precautions) or AGPs, and hand wash based on a detailed description of the technique (steps) (3 questions); and compliance with specific IPC measures namely not coming to work when having fever or symptoms, maintaining physical distancing (6 feet) at work even in non-patient care areas, and postponing elective time-off during the pandemic (3 questions). Each question was scored “1” for a response compliant with the recommendations, and “0” for a response not compliant and the total score was ranging from 0 (the minimum) to 15 (the maximum). The median was used as a cutoff point (7.5) to determine good compliance (median ≥ 7.5) and poor compliance (median < 7.5) [19].

  • Section (III) included nine questions to evaluate nurses’ perception of the risk of COVID-19 infection using a 5-point Likert scale where strongly disagree scored “1” and strongly agree scored “5”. The total points ranged from 5 (the minimum) to 45 (the maximum). The perception assessment included their belief in the high risk of COVID-19 infection at their workplace, serious consequences of the disease, and minimizing the risk by PPE usage, hand washing, and hand sanitizer use.

  • Section (IV) included eight questions to evaluate nurses’ knowledge about PPE usage and hand hygiene. The assessment covered the type of PPE used for routine care or while performing AGPs, disposable PPE and PPE that could be used for an extended period, donning and doffing PPE, indications of hand hygiene at work, and recommended steps and duration of hand wash. A score of “1” was given for a correct response and “0” for an incorrect response. The total knowledge scores ranged from 0 (the minimum) to 8 (the maximum).

  • Section (V) included 15 questions to assess the availability of PPE, receiving relevant training and factors that enhance compliance with PPE usage. Each factor was assessed on a 10-point Likert scale with responses ranging from “not at all” scored “1” up to “very much” scored “10”.

Statistical analysis

The SPSS v.20 (IBM Corp. Released 2011. IBM SPSS Statistics for Mac, Armonk, NY, USA) was used for data entry and analysis. The quantitative variables were expressed as the mean with standard deviation and qualitative variables as the frequencies and percentages. The reliability of the generated scale was tested using the Cronbach Alpha analysis [22]. Factors enhancing compliance with PPE usage (as perceived by nurses) were prioritized by the mean score for each factor.

In this study, analytic statistics included the parametric (Student’s t test) and non-parametric tests (chi-square test, Fisher’s exact test, and Monte-Carlo tests). A case-control approach analysis was conducted including a univariate logistic regression to find out potential sociodemographic, personal, and occupational factors associated with good compliance and calculate the odds ratio (OR) and the 95% confidence interval (95%CI).

Multivariate logistic regression analysis was conducted to model compliance as a function of the aforementioned factors to study their independent effect on compliance. The model included all participants (n = 354) and 11 factors namely gender, age, educational level, knowledge level, perception, history of COVID-19 disease, having a colleague or relative who had COVID-19 disease, department of affiliation, working hours/day, working schedule, and receiving training program. Collinearity was tested with variance inflation factors (VIF); a VIF value of 10 was considered large enough for problematic multicollinearity [23], and accordingly, employment duration was excluded from the model (VIF=12). The explained variance of logistic regression models was determined by Nagelkerke’s R2 and the Hosmer and Lemeshow goodness-of-fit test. All statistical analyses were judged at a level of significance of 5% (α=0.05).

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