Infection control and management of MRSA: assessing the knowledge of staff in an acute hospital setting.
ABSTRACT Much of the recent work in tackling meticillin-resistant Staphylococcus aureus (MRSA) has focused on hygiene in hospitals, but it is unclear how much hospital staff know about the treatment and management of patients who are colonized or infected with MRSA. The aim of this study was to assess the knowledge and perceived practice of staff regarding MRSA and its management in an acute hospital setting. A further aim was to determine what staff felt was needed in terms of information or education on the risks, management and treatment of MRSA. A questionnaire survey was carried out through group administration during a study day and by face-to-face interviews. Subjects included in the questionnaire were infection and colonization, treatment, and the availability of local support and advice. There were 174 responses, divided equally between doctors and nurses. Knowledge on many aspects of MRSA and its management was deficient, although the majority of participants who felt that they required additional information about MRSA acknowledged this. The survey confirmed that assumptions should not be made about adequate knowledge and expertise of staff in relation to MRSA. Gaps in awareness of aspects of care and management were highlighted and information and educational needs identified.
- [Show abstract] [Hide abstract]
ABSTRACT: Control of infection and prevention of healthcare associated infections is an ongoing issue worldwide. Yet despite initiatives and strategies to reduce the burden that these infections cause, healthcare workers' practice is still reported as suboptimal and these infections persist. Much of the research to date has primarily focused on predicting infection prevention behaviours and factors associated with guideline compliance. While this has given valuable insight, an investigation aiming to understand and explain behaviours that occur in everyday practice from the perspective of the actors themselves may hold the key to the challenges of effecting behaviour change. This study questioned "How can nurses' infection prevention behaviour be explained?" This paper presents one of three identified themes 'Rationalising dirt-related behaviour'. This interpretative qualitative study uses vignettes, developed from nurses' accounts of practice, to explore nurses' reported infection prevention behaviours. Registered nurses working in an acute hospital setting and had been qualified for over a year. They were recruited while studying part-time at a London University. Twenty semi-structured interviews were undertaken using a topic guide and vignettes. Interviews were transcribed verbatim and analysed using the framework method. The findings demonstrate that participants were keen to give a good impression and present themselves as knowledgeable practitioners, although it was evident that they did not always follow procedure and policy. They rationalised their own behaviour and logically justified any deviations from policy. Deviations in others were criticised as irrational and explained as superficial and part of a 'show' or display. However, participants also gave a presentation of themselves: a show or display that was influenced by the desire to protect self and satisfy patient scrutiny. This study contributes to the identification and explanation of nurses' infection prevention behaviours which are considered inappropriate or harmful. Behaviour is multifaceted and complex, stemming from a response to factors that are outside a purely 'scientific' understanding of infection and not simply understood as a deficit in knowledge. This calls for educational interventions that consider beliefs, values and social understanding of dirt and infection.International journal of nursing studies 07/2013; · 1.91 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The purpose of this study was to evaluate nurses’ knowledge of infection prevention procedures, the degree to which they were applied correctly, and whether length of service affected either knowledge or application. Nurses with over five years of experience had significantly increased understanding of infection prevention (p=0.009) and significantly increased application of knowledge to practice (p=0.001), compared to nurses with five years or less experience. In particular, understanding of hand hygiene and use of personal protective equipment (PPE) was poor although application was compliant, while knowledge of care of patients with meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile was poor, which was reflected by substandard application of knowledge to practice. The results of this study suggest that focusing infection prevention education around patients with specific infections, such as MRSA and C. difficile, rather than on individual standard precautions may more effectively increase knowledge and therefore application of infection prevention practices.Journal of Infection Prevention 01/2012; 13(3):92-96.
- [Show abstract] [Hide abstract]
ABSTRACT: This cross-sectional study aimed to assess knowledge of routes of transmission, awareness of MRSA control guidelines and reasons for non-adherence to guidelines among medical staff at Alexandria University hospitals. A random sample of 158 physicians and 47 nurses answered a self-administered questionnaire. Overall awareness of MRSA control guidelines was 67.3%, and nurses were significantly more aware than physicians (91.5% versus 60.1%). The lowest awareness level was among anaesthesiologists; only 54.4% knew the correct transmission routes. Among medical staff overall, 70.0% accepted the necessity of screening measures for high-risk patients and 35.8% of doctors accepted the use of the same pair of gloves when caring for different body sites on an individual patient. Lack of resources was the most common justification for suboptimum adherence. The study showed low awareness levels of MRSA-related guidelines. Sensibilisation aux recommandations de l'Organisation mondiale de la Santé sur la lutte contre Staphylococcus aureus résistant à la méthicilline dans des hôpitaux universitaires d'Alexandrie RÉSUMÉ La présente étude transversale visait à évaluer la connaissance des voies de transmission, la sensibilisation aux recommandations sur la lutte contre Staphylococcus aureus résistant à la méthicilline et les motifs du non respect de ces recommandations par le personnel médical des hôpitaux universitaires d'Alexandrie. Un échantillon randomisé de 158 médecins et 47 infirmières ont répondu à un auto-questionnaire. Globalement, la sensibilisation aux recommandations sur la lutte contre Staphylococcus aureus résistant à la méthicilline était de 67,3 %, et le personnel infirmier était beaucoup plus sensibilisé que les médecins (91,5 % contre 60,1 %). Le niveau de sensibilisation le plus faible a été retrouvé chez les anesthésistes. Seuls 54,4 % de ces derniers connaissaient les voies de transmission correctes. Au sein du personnel médical globalement, 70,0 % avaient accepté la nécessité de mesures de dépistage pour les patients à haut risque mais 35,8 % des médecins reconnaissaient utiliser une seule paire de gants même lors de soins prodigués sur différents sites corporels d'un même patient. Le manque de ressources était la justification la plus fréquente pour le respect insuffisant de ces recommandations. L'étude a mis en évidence les faibles niveaux de sensibilisation aux recommandations sur la lutte contre Staphylococcus aureus résistant à la méthicilline.
Infection control and management of MRSA:
assessing the knowledge of staff in an acute
P.M. Eastona,*, A. Sarmab, F.L.R. Williamsc, C.A. Marwickd,
G. Phillipse, D. Nathwanif
aDirectorate of Change and Innovation, Tayside NHS Board, Dundee, UK
bNinewells Hospital and Medical School, Dundee, UK
cSection of Public Health, Division of Community Health Sciences, University of Dundee, Dundee, UK
dInfection Unit; East Block, Ninewells Hospital and Medical School, Dundee, UK
eMedical Microbiology, Ninewells Hospital and Medical School, Dundee, UK
fInfection Unit, East Block, Ninewells Hospital and Medical School, Dundee, UK
Received 17 July 2006; accepted 15 December 2006
Available online 20 February 2007
lococcus aureus (MRSA) has focused on hygiene in hospitals, but it is unclear
how much hospital staff know about the treatment and management of pa-
tients who are colonized or infected with MRSA. The aim of this study was to
assess the knowledge and perceived practice of staff regarding MRSA and its
management in an acute hospital setting. A further aim was to determine
what staff felt was needed in terms of information or education on the risks,
through group administration during a study day and by face-to-face inter-
views. Subjects included in the questionnaire were infection and coloniza-
tion, treatment, and the availability of local support and advice. There
on many aspects of MRSA and its management was deficient, although the
majority of participants who felt that they required additional information
about MRSA acknowledged this. The survey confirmed that assumptions
should not be made about adequate knowledge and expertise of staff in
Much of the recent work in tackling meticillin-resistant Staphy-
* Corresponding author. Address: Directorate of Change and Innovation, Tayside NHS Board, Kings Cross, Clepington Road, Dundee
DD3 8EA, UK. Tel.: þ44 01382 424191; fax: þ44 01382 424.
E-mail address: email@example.com
0195-6701/$ - see front matter ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Journal of Hospital Infection (2007) 66, 29e33
relation to MRSA. Gaps in awareness of aspects of care and management
were highlighted and information and educational needs identified.
ª 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights
Staphylococcus aureus (MRSA) has focused on hy-
giene in the healthcare environment.1,2Awareness
of the risks of colonization and subsequent infec-
tion, effective treatment and the appropriate use
of antibiotic prescribing remain as high priorities.
Even when procedures are routine, knowledge
and expertise of staff should not be assumed. This
measurement, which found that many nurses did
not understandor perform the techniqueproperly.3
Similar findings were reported with radiation expo-
sure and treatment of pressure ulcers.4,5
There is some information about healthcare
workers’ knowledge and attitudes in relation to
these areas.6,7The success of MRSA protocols was
examined in five Dutch hospitals using a question-
naire and a practical test. Results identified ade-
quate knowledge of, and attitude to, protocols but
tical application. This study also highlighted that it
pital staff due to the different decisions staff have
to take according to circumstances.8
In Tayside, specific training and publicity aimed
formulary and sepsis protocol have led to improve-
ment in the management of sepsis among junior
doctors.9It is unknown whether this understanding
of antibiotic prescribing is applicable to MRSA
in relation to physicians’ adherence to clinical
practice guidelines.10In a review of barriers to phy-
sicians’ adherence to clinical guidelines, Cabana
et al. concluded that behaviour change based on
influencing knowledge and attitudes is probably
more sustainable than indirect manipulation of be-
in the process, stating that when physicians comply
with practice guidelines they must first become
aware of the guidelines, then intellectually agree
with them; decide to adopt them in the care they
provide, and then regularly adhere to them at
work to eradicatemeticillin-resistant
appropriate times.12If, as previous studies suggest,
it is unlikely that good practice will follow.3e8With
this in mind, the present study was developed.
A questionnaire was developed to establish knowl-
edge of the nature of Staphylococcus aureus; risk
factors for MRSA, common sites of colonization,
infection and clinical complications, screening,
decolonization and treatment, and knowledge of
information and advice resources to support infec-
tion control. Demographic data were also col-
lected including post, specialty, age group and
time since professional qualification. All but one
question, which was open-ended, invited the
selection of answers from a range of options.
The questionnaire had face and content valid-
ity, having been developed in consultation with
a group of experts on questionnaire design and on
infectious diseases. The questionnaire was piloted
face-to-face with 10 doctors and nurses, by one of
the interviewers (A.S.), in order to check compre-
hension and clarity of the questions.
Data were analysed using SPSS v.11.5. Correct
answers were identified from the local guidelines,
from the literature if appropriate; all questions
were verified with our local Infectious Diseases
Consultant (D.N.). Proportions of correct responses
or correct combinations of responses were calcu-
lated with 95% confidence intervals (CIs) and dif-
ferences between staff groups were compared
using a Chi-squared test (P < 0.05).
Settings, participants and data collection
A convenience sample was recruited from two
acute hospitals in Tayside, Scotland. All partici-
pants attending an infection study day completed
questionnaires and returned them during the
session; face-to-face interviews were carried out
by two of the authors (A.S. and C.M.) with staff in
medical and surgical wards over a three-month
period from September to December 2004, using
the same questionnaire.
30P.M. Easton et al.
The two methods of administration of the
questionnaires were adopted to gain an appropri-
ate sample size over the three-month period.
Required sample size was calculated with the
advice of a statistician. A sample of 95 was plan-
ned in order to estimate a proportional response in
the region of 50% with a 95% CI of ?10.
In order to be able to measure differences
between doctors and nurses, it was agreed to
continue for the three-month period and interview
as close as possible to that number for each group.
The resulting sample of 87 doctors and 87 nurses
allowed the estimation of a proportional response
for each group in the region of 50% with a 95% CI
of ?10.5 and an estimation of the difference be-
tween responses in the two groups with a 95% CI
of ?14.9 (for proportions near 50%).
The purpose of having the questionnaires com-
pleted at the time of distribution or interview was
so that answers were spontaneous, without the use
of reference materials such as textbooks or Inter-
net websites. Doctors and nurses were recruited
opportunistically from medical and surgical wards.
Staff are required to attend an infection study day
once a year and this particular day fell within our
study period, providing an opportunity to gain
responses from a number of staff in a range of
posts and specialties. Completion of the question-
naire was presented as a required part of the study
day. This augmented the face-to-face interviews
which covered a considerable number but used
a method which is much more time-consuming.
One hundred and twenty-seven face-to-face inter-
views were carried out and 47 self-completed
questionnaires were returned. Staff who attended
the study day did not have any characteristics that
Most respondents (63%) were aged <35 years;
the previous five years and more than two-thirds
were received from a wide range of specialties
within medical and surgical wards but numbers
representing individual specialties were small.
There was considerable variation in responses
between doctors and nurses answering correctly
(Table I). No significant differences were found
between interview and self-completed responses so
icant differences were found between interviewers,
across age groups or time since qualification.
The majority of respondents (83%) correctly
identified S. aureus as a Gram-positive organism,
although significantly more doctors than nurses
did so (P< 0.001) (Table I). Thirty-six percent of
nurses compared with 30% of doctors identified
the correct anatomical sites for MRSA colonization
but this difference was not significant (Table I).
The majority of respondents (70%) could not
identify local infection control measures for MRSA
colonization, and although nurses were more likely
to answer correctly, the difference was not signif-
icant. The availability of infection control advice
24 h a day was known by 64% of respondents but
25% thought that advice was available during work-
ing hours only (Table I).
Few respondents (12%) identified all four risk
factors for MRSA colonization and infection. Regard-
ing individual risk factors, doctors were more likely
to recognize recent antibiotic usage as a risk factor
(P¼ 0.001). Urinary catheterization risk was identi-
fied by a greater proportion of nurses (P¼ 0.004).
The majority of respondents (74%) failed to
identify the two most common sites for MRSA in-
fection, namely blood and wound/skin. Thirty-four
percent of doctors answered this question correctly
compared with 17% of nurses (P¼ 0.009) (Table I).
Doctors were more likely than nurses to identify
endocarditis and death as two important and com-
mon complications of MRSA bacteraemia, although
the difference was not significant. Forty-four per-
cent of the total sample believed MRSA to be more
likely to cause death than meticillin-susceptible S.
aureus (MSSA) and 34% did not know the answer to
this question. Fifty-six percent of doctors and 32%
of nurses believed MRSA to be a more likely cause
of death than MSSA (P< 0.001) (Table I).
Doctors were significantly more likely to state
that they would treat MRSA bacteraemia with
antibiotics (P< 0.001) (Table I). Doctors were also
significantly more likely to select the combination
of antibiotic treatment and nursing in a single
room as the best option for MRSA infection manage-
ment (P< 0.001) although less than one in six (16%)
of all respondents answered this correctly.
Seventy-nine percent of respondents correctly
selected either intravenous (IV) vancomycin or IV
vancomycin with rifampicin as the appropriate
treatment for MRSA bacteraemia, but only 9% of
respondents identified both teicoplanin and line-
zolid as alternative agents. Forty-six percent
identified 14 days as the appropriate duration of
treatment for uncomplicated bacteraemia. Doc-
tors were significantly more likely to identify the
first-line antibiotic choice (P ¼ 0.003), to identify
alternative agents (P ¼0.009) and to state the
correct duration of therapy (P< 0.001).
Infection control and management of MRSA31
An open-ended question asked when staff would
consider an alternative to their first-line choice of
antibiotic. Ten percent of doctors and 38% of nurses
were unable to give any answer. The main reasons
given for considering an alternative were lack of
Overall, only four respondents stated that they
would consult the two recommended locally pro-
duced and supported resources for infection man-
agement (Tayside Prescribing Guide and Sepsis
Protocol). A further six respondents stated that
they would consult these two resources along with
one or more other sources of information. Most
staff selected these other resources, such as the
British National Formulary, or asking an Infectious
Diseases Consultant, with a significant difference
in overall choices (P < 0.001) between doctors and
nurses, but no significant difference in those using
the recommended resources.
When asked if they felt that information or
education was required by staff within their
specialty on MRSA colonization, infection, viru-
lence and outcomes, risk factors, or general MRSA
management and drug treatment, 68% responded
that information or education was required for all
of these. Only two people felt that information or
education was not required on any of the topics.
On each individual topic, 80% or more of respon-
dents stated that further education was required
within their specialty. Ninety-two percent opted
for tutorials or lectures as a means of deliver-
ing this. There were no significant differences
between doctors and nurses in the responses.
We acknowledge that not all of the questions set
have clear-cut correct responses based on good
evidence. For example, there is still lack of clarity
and evidence about whether MRSA is more patho-
genic or virulent than MSSA and this may explain the
aetiology of meticillin-resistant Staphylococcus aureus (MRSA)
Summary of correct questionnaire responses from hospital clinical staff about the management and
Total (N¼ 174)
% (95% CI)
(N ¼87) %
(N¼ 87) %
P: doctors vs nurses
Is Staphylococcus aureus a Gram-negative
or Gram-positive organism?
Which sites would you swab to
detect MRSA colonization?
What methods of infection control
should be implemented in the management
of a patient colonized with MRSA?
When is infection control advice available?
Which of these are common risk factors for
MRSA colonization or infection?
Which of these are among the most common
sites of MRSA infection (not colonization)?
What are the two most common
complications of MRSA bacteraemia?
Do you believe that MRSA infection is more
likely to be a cause of death than MSSA?
Would you usually treat MRSA bacteraemia
What methods of infection control should
be implemented in the management of a
patient infected with MRSA?
What would be your first-line choice of
one antibiotic for the treatment of
Duration of therapy for bacteraemia
Are any of these agents alternatives
for treating MRSA bacteraemia?
Reasons given for considering alternative
to first-line choice antibiotic
Would consult recommended resources
only for infection management?
Information/education needed on all
suggested MRSA topics
32.8 (25.8e39.8)3036 NS
25.9 (19.4e32.4)34 17 0.009
41.4 (34.1e48.7)47 35NS
43.7 (36.3e51.1) 5632
74.7 (68.2e81.2)87 62
79.3 (73.3e85.3)89 700.003
76.0 (69.6e82.4)90 62
67.8 (60.9e74.7)6967 NS
MSSA, meticillin-sensitive Staphylococcus aureus; CI, confidence interval; NS, not significant.
32P.M. Easton et al.
proportion (44%) who believed that MRSA is more
has highlighted a range of knowledge deficiencies
in healthcare staff as well as significant inter-pro-
fessional differences in the key areas of infection
control and management, similar to findings else-
where.6e8A considerable proportion of the sample
had trained at a time of increasing awareness and
concern over MRSA but participants were not asked
about their source of knowledge of MRSA. Although
some differences are to be expected (for example,
nurses were more knowledgeable than doctors
demonstrated higher awareness of antibiotic choice
and duration of treatment), the need to improve
overall knowledge is evident. Although nurses’
knowledge of treatment was higher than expected
for a non-prescribing group, improving all clinicians’
awareness and encouraging use of local guidelines
and protocols will aid clarity and consistency in
tion and infection.
At the time of the study, MRSA guidelines were
available through the Tayside Area Prescribing
Guide in the form of a pocket-sized paper booklet,
but these did not include information about risk
advice on seeking specialist help. Senior medical
students and all junior doctors were sent copies,
along with the clinical departments, and their use
was promoted at educational meetings. However,
recommended sources for MRSA management. The
survey has stimulated the development of a co-
ordinated multi-professional educational strategy,
and information needs on MRSA.
MRSA guidelines are now available to all clinical
staff through the intranet and revised MRSA guide-
available at the time of clinical decision-making.
This will support clinicians, including GPs, seeking
advice on treatment as well as act as a standard of
care for a prescribing audit. The protocol will form
part of undergraduate and postgraduate medical
information of value.
While accepting the limitations of our survey,
the results confirm that assumptions should not be
made about staff knowledge or awareness of MRSA
control and management. If good infection prac-
tice is to occur amongst all non-specialist staff,
improving generic knowledge about MRSA and
better use of local guidance ought to be a priority.
The recently published national guidelines for
MRSA prevention, control and treatment will pro-
vide the evidence base for local adaptation,
adoption and training of healthcare staff.13,14
The authors thank Dr Simon Ogston for statistical
1. RamplingA,WisemanS,DavisL,etal.Evidence thathospital
hygiene is important in the control of methicillin-resistant
Staphylococcus aureus. J Hosp Infect 2001;49:109e116.
2. Aiello AE, Larson EL. What is the evidence for a causal link
between hygiene and infections? Lancet Infect Dis 2002;2:
3. Gillespie A, Curzio J. Blood pressure measurement: assess-
ing staff knowledge. Nurs Stand 1998;12:35e37.
4. Shiralkar S, Rennie A, Snow M, Galland RB, Lewis MH,
Gower-Thomas K. Doctors’ knowledge of radiation expo-
sure: questionnaire study. Br Med J 2003;327:371e372.
5. Gunningberg L, Lindholm C, Carlsson M, Sjoden PO. Risk,
prevention and treatment of pressure ulcers e nursing staff
knowledge and documentation. Scand J Caring Sci 2001;15:
6. Askarian N, Mirzaei K, Mundy LM, McLaws M. Assessment of
knowledge, attitudes and practices regarding isolation pre-
cautions among Iranian healthcare workers. Infect Control
Hosp Epidemiol 2005;26:105e108.
7. Pessoa-Silva CL, Posfay-Barbe K, Pfister R, Touveneau S,
Perneger TV, Pittet D. Attitudes and perceptions toward
hand hygiene among healthcare workers caring for critically
8. van Gemert-Pijnen J, Hendrix MG, van der Palen J,
Schellens PJ. Performance of methicillin-resistant Staphy-
lococcus aureus protocols in Dutch hospitals. Am J Infect
9. Ziglam H, Moitra S, Morales D, Webb K, Gray K, Nathwani D.
Antibiotic prescribing knowledge among junior doctors e
how can we improve it? Clin Microbiol Infect Suppl 2004;
10. Woolf SH. Practice guidelines: a new reality in medicine: III.
Impact on patient care. Arch Intern Med 1993;153:2646e
11. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians
follow clinical practice guidelines?: a framework for im-
provement. J Am Med Assoc 1999;282:1458e1465.
12. Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG.
The awareness-to-adherence model of the steps to clinical
guideline compliance: the case of pediatric vaccine recom-
mendations. Med Care 1996;34:873e888.
13. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL,
Warren RE. Guidelines for the prophylaxis and treatment of
methicillin-resistant Staphylococcus aureus (MRSA) infec-
tions in the UK. J Antimicrob Chemother 2006;57:589e608.
14. Coia JE, Duckworth GJ, Edwards DI, et al. Guidelines for the
control and prevention of meticillin-resistant Staphylococ-
cus aureus (MRSA) in healthcare facilities. J Hosp Infect
Infection control and management of MRSA33