Effectiveness of Preventive Nursing Program for Multidrug-Resistant Organism Transmission
Effectiveness of Preventive Nursing Program for Multidrug-Resistant
Organism Transmission: A Quasi-experimental Study
Ketsara Tanseng, Akeau Unahalekhaka,* Nongyao Kasatpibal, Nongkran Viseskul
Abstract: Multidrug-resistant organism infections are a major public health problem. Promoting
nurses’ practice in preventing multidrug-resistant infections can reduce hospital transmission.
This quasi-experimental study investigated the effectiveness of a preventive nursing program for
multidrug-resistant organism transmission. The study was carried out in the Department of Internal
Medicine in a tertiary hospital in south Thailand. Participants in this study were registered
nurses. Two wards were randomly selected as the experimental ward and two as the control
ward, then participants from each ward were purposively selected. Finally, there were 60 participants,
n = 31 from the experiment wards and n = 29 from the control wards. The experimental group
received a 4-week program, whereas the control group followed the usual practice. Then,
the practices in preventing multidrug-resistant organism transmission of the experimental and
control groups were assessed 4 and 12 weeks after the program ended. The instruments for
data collection included a demographic data form and a preventive practice observation form.
Data were analyzed using descriptive statistics and a chi-square test.
The results showed that, at 4 and 12 weeks after completion of the program, nurses
in the experimental group had a significantly higher proportion of correct practices (hand hygiene,
use of personal protective equipment, patient placement, patient transport, patient care equipment
management, environmental management, and linen and infectious waste management of
multidrug-resistant organism transmission) than before receiving the program and in the control
group. The findings suggest that the program effectively improves nurses’ correct practices in preventing
multidrug-resistant organism transmission. The program can be applied to promote and support
preventive practices among nurses. However, long-term follow-ups with the incidence of multi-
drug-resistant organism transmission should be further studied. In addition, as this study was
conducted with nurses working in the internal medicine wards of a tertiary hospital, it
is necessary to evaluate the program's effectiveness with different samples prior to its wider
implementation.
Keywords: Multidrug-resistant organisms, Nurses, Practices, Prevention, Transmission
Received 24 April 2023; Revised 10 June 2023; Ketsara Tanseng, RN, PhD (Candidate), Faculty of Nursing, Chiang Mai
Accepted 13 June 2023 University, Thailand. E-mail:
Correspondence to: Akeau Unahalekhaka,* RN, PhD, Professor, Faculty of
Introduction Nursing, Chiang Mai University, Thailand. E-mail:
Nongyao Kasatpibal, RN, PhD, Professor, Faculty of Nursing, Chiang Mai
The increasing of multidrug-resistant organisms University, Thailand. E-mail:
(MDRO) is a problem of concern in many countries, Nongkran Viseskul, RN, PhD, Associate Professor, Faculty of Nursing,
Chiang Mai University, Thailand. E-mail:
including Thailand. MDRO refers to microorganisms
736 Pacific Rim Int J Nurs Res. Vol.27, J Nurs Res • October-December
No.4,IntOctober-December
Pacific Rim 2023
2023. pp.736-752
DOI: 10.60099/prijnr.2023.262568
, Ketsara Tanseng et al.
with non-susceptibility to at least one agent in three Research has demonstrated a lower compliance rate of
or more antimicrobial categories.1 In the US, the Centers personal protective equipment (PPE) use and contamination
for Disease Control and Prevention (CDC) estimated during PPE removal due to incorrect sequences, the doffing
that over 2.8 million MDRO infections occur annually technique and the use of PPE.12 Besides, although
resulting in over 35,000 deaths.2 In the EU and environmental measures of environmental cleaning are
European Economic Area (EEA), there were 670,000 essential to reduce MDRO transmission, nurses who
MDRO infections and around 33,000 deaths caused care for cases with MDRO are confused about using
by such infections in 2020, with particularly high different disinfectants to clean in the post-discharge
percentages of resistance to third-generation cephalosporins period.13 In addition, many healthcare settings had
and carbapenem-resistant Klebsiella pneumoniae, limited isolation rooms for cohort placement and lacked
carbapenem-resistant Acinetobacter species, and isolation materials for patient placement.14 Therefore,
Pseudomonas aeruginosa in many countries.3 The it is essential to enhance nurses’ practice in preventing
magnitude and trend of MDRO infections among the transmission of MDRO infections.
hospitals in Thailand are high due to the rising rate of Several studies have investigated the efficacy
MDROs, especially multidrug-resistant gram-negative of interventions for preventing the transmission of
bacteria (MDR-GNB). The National Antimicrobial MDROs. Those interventions included multimodal
Resistance Surveillance Thailand (NARST) reported strategies comprising system change, education and
that the tendency of Acinetobacter spp., Klebsiella training, monitoring, audit and feedback, reminders
pneumoniae and Pseudomonas aeruginosa was rising, and culture change, persuasion, and role models to
with resistance to carbapenem.4 MDRO infections improve healthcare workers’ practice, leading to increased
cause multiple impacts on clients, family or caregivers, performance for preventing MDRO transmission.15,16,17
healthcare workers, hospitals, and countries. For individuals, Previous programs were not sufficiently based on
the impacts comprised increased morbidity and risk psychological behavior change theory. A systematic
of death and high mortality rate,5 severe complications,6 review of interventions for improving healthcare workers’
increased readmissions,7 and prolonged length of hospital hand hygiene compliance demonstrated that a program
stay.8 Therefore, practices to prevent MDRO transmission should have a rigorous basis on behavior change theory
are required, particularly among nurses. and consider social influence, attitude, and intention
Nurses are key to preventing and controlling to yield higher effectiveness.18 Therefore, intervention
infection in healthcare settings because they perform development should be based on a theoretical framework
most daily care procedures, which are close contact considering cognitive behavioral factors to approach
and carry risks of MDRO transmission. Implementing behavior change.
practices to prevent MDRO transmission is the role of
nurses, who must uphold suitable procedures for all Literature Review and Conceptual
clients throughout their hospitalization. Essential practices
are hand hygiene, contact precautions and environmental Framework
cleansing/disinfection. Even though hand hygiene is The practices of nurses in preventing the
widely considered the most critical activity for hospital transmission of MDRO infection include hand hygiene,
prevention that can significantly reduce MDRO infections, use of PPE, patient placement, patient transport, patient
studies indicate that overall hand hygiene compliance care equipment management, environmental management,
rate among nurses was only 39%.9,10 Hand hygiene management of linen and infectious waste management.19
compliance among nurses was low in some cases.11
Vol. 27 No. 4 737
, Effectiveness of Preventive Nursing Program for Multidrug-Resistant Organism Transmission
Hand hygiene refers to rubbing alcohol on the hands consists of three main concepts: attitude, subjective
or rinsing them with soap and water.20 Use of PPE includes norms, and perceived behavior control.28 According to
gown, mask, face shield or goggles, and gloves during Ajzen, human behavior is determined by intention. The
care activities that provide opportunities to transfer intention is determined by attitude toward the behaviors
MDROs to staff hands and clothing.19 Moreover, MDRO (negative or positive evaluations of behavior), subjective
infection cases should be placed in a single room.19 norms (prevailing societal approval or disapproval
Non-critical equipment should be used with a single of others’ behaviors), and perceived behavioral control
client. Equipment should be thoroughly cleaned and (individual’s perception of the ease or difficulty associated
disinfected if use with multiple clients is necessary.21 with executing the behaviors). Thus, increasing these
Healthcare workers should perform environmental three constructs (attitude, subjective norms, and perceived
cleaning and disinfecting of handled surfaces and behavioral control) will strengthen the intention to
equipment in the client’s immediate vicinity based on achieve healthy behavior outcomes. For prevention
the hospital guidelines.19 Staff handling contaminated and control of MDRO transmission, TPB was effective
linen should wear appropriate PPE. In the patient care in predicting healthcare workers’ compliance with
area, soiled linen should be carefully rolled up without infection control practices,29 and the intention and the
shaking and placed in a properly labelled, leak-proof hand hygiene behavior of healthcare workers.30 A
container. Hand hygiene should be practiced before systematic review suggested TPB as the improvement
application and after removal of PPE.2 Moreover, strategy in intervention to improve hand hygiene
infectious waste should be placed in a designated compliance.18 Thus, TPB is the potential in the interventions
receptacle for reprocessing or a special waste container. to change and improve the behavior of nurses for practice.
Staff must wear protective gloves when handling waste Understanding the effective interventions to encourage
and remove and dispose of them hygienically.2 From the prevention of MDRO transmission among nurses
a literature review, multiple factors have been reported is essential. A systematic review showed that combined
to be associated with the preventive practices of nurses. interventions, including education, feedback, and reminders,
The most critical factors are individual factors, which effectively enhanced nurses’ hand hygiene.18
include attitude toward the performance of the practice, The program for prevention of MDRO transmission
subjective norms, and perceived behavioral control.22,23,24,25 among nurses in this study was based on the TPB to
The attitudes toward infection prevention and control raise attitude, subjective norms and perceived behavioral
were significant predictors of compliance to preventive control with a combination of several interventions in
practice26 and the prevention of MDRO transmission.27 three main components. First, raising a positive attitude
Subjective norms directly affected nurses’ intention toward the preventive practice of MDRO transmission
to prevent and control MDRO22 and were associated involved providing knowledge through education and
with hand hygiene.24 Moreover, perceived behavioral training about the prevention of MDRO transmission
control directly affected adherence to guidelines to and group discussion about the consequences of incorrect
control MDRO among nurses in intensive care units and practices. Second, raising subjective norms included
nurses’ MDRO management and intention to perform perceived expectations and social pressures to prevent
this.22 Therefore, improving nurses’ practices in the MDRO transmission, contributing to the intention to
prevention of MDRO transmission should consider improve practice through group discussions. Lastly,
these influential factors of behavioral intention. raising perceived behavioral control involves the presence
The conceptual framework for this study was or absence of facilitators and barriers to MDRO prevention
based on the theory of planned behaviors (TPB), which by providing feedback on preventive practice, group
738 Pacific Rim Int J Nurs Res • October-December 2023
Effectiveness of Preventive Nursing Program for Multidrug-Resistant
Organism Transmission: A Quasi-experimental Study
Ketsara Tanseng, Akeau Unahalekhaka,* Nongyao Kasatpibal, Nongkran Viseskul
Abstract: Multidrug-resistant organism infections are a major public health problem. Promoting
nurses’ practice in preventing multidrug-resistant infections can reduce hospital transmission.
This quasi-experimental study investigated the effectiveness of a preventive nursing program for
multidrug-resistant organism transmission. The study was carried out in the Department of Internal
Medicine in a tertiary hospital in south Thailand. Participants in this study were registered
nurses. Two wards were randomly selected as the experimental ward and two as the control
ward, then participants from each ward were purposively selected. Finally, there were 60 participants,
n = 31 from the experiment wards and n = 29 from the control wards. The experimental group
received a 4-week program, whereas the control group followed the usual practice. Then,
the practices in preventing multidrug-resistant organism transmission of the experimental and
control groups were assessed 4 and 12 weeks after the program ended. The instruments for
data collection included a demographic data form and a preventive practice observation form.
Data were analyzed using descriptive statistics and a chi-square test.
The results showed that, at 4 and 12 weeks after completion of the program, nurses
in the experimental group had a significantly higher proportion of correct practices (hand hygiene,
use of personal protective equipment, patient placement, patient transport, patient care equipment
management, environmental management, and linen and infectious waste management of
multidrug-resistant organism transmission) than before receiving the program and in the control
group. The findings suggest that the program effectively improves nurses’ correct practices in preventing
multidrug-resistant organism transmission. The program can be applied to promote and support
preventive practices among nurses. However, long-term follow-ups with the incidence of multi-
drug-resistant organism transmission should be further studied. In addition, as this study was
conducted with nurses working in the internal medicine wards of a tertiary hospital, it
is necessary to evaluate the program's effectiveness with different samples prior to its wider
implementation.
Keywords: Multidrug-resistant organisms, Nurses, Practices, Prevention, Transmission
Received 24 April 2023; Revised 10 June 2023; Ketsara Tanseng, RN, PhD (Candidate), Faculty of Nursing, Chiang Mai
Accepted 13 June 2023 University, Thailand. E-mail:
Correspondence to: Akeau Unahalekhaka,* RN, PhD, Professor, Faculty of
Introduction Nursing, Chiang Mai University, Thailand. E-mail:
Nongyao Kasatpibal, RN, PhD, Professor, Faculty of Nursing, Chiang Mai
The increasing of multidrug-resistant organisms University, Thailand. E-mail:
(MDRO) is a problem of concern in many countries, Nongkran Viseskul, RN, PhD, Associate Professor, Faculty of Nursing,
Chiang Mai University, Thailand. E-mail:
including Thailand. MDRO refers to microorganisms
736 Pacific Rim Int J Nurs Res. Vol.27, J Nurs Res • October-December
No.4,IntOctober-December
Pacific Rim 2023
2023. pp.736-752
DOI: 10.60099/prijnr.2023.262568
, Ketsara Tanseng et al.
with non-susceptibility to at least one agent in three Research has demonstrated a lower compliance rate of
or more antimicrobial categories.1 In the US, the Centers personal protective equipment (PPE) use and contamination
for Disease Control and Prevention (CDC) estimated during PPE removal due to incorrect sequences, the doffing
that over 2.8 million MDRO infections occur annually technique and the use of PPE.12 Besides, although
resulting in over 35,000 deaths.2 In the EU and environmental measures of environmental cleaning are
European Economic Area (EEA), there were 670,000 essential to reduce MDRO transmission, nurses who
MDRO infections and around 33,000 deaths caused care for cases with MDRO are confused about using
by such infections in 2020, with particularly high different disinfectants to clean in the post-discharge
percentages of resistance to third-generation cephalosporins period.13 In addition, many healthcare settings had
and carbapenem-resistant Klebsiella pneumoniae, limited isolation rooms for cohort placement and lacked
carbapenem-resistant Acinetobacter species, and isolation materials for patient placement.14 Therefore,
Pseudomonas aeruginosa in many countries.3 The it is essential to enhance nurses’ practice in preventing
magnitude and trend of MDRO infections among the transmission of MDRO infections.
hospitals in Thailand are high due to the rising rate of Several studies have investigated the efficacy
MDROs, especially multidrug-resistant gram-negative of interventions for preventing the transmission of
bacteria (MDR-GNB). The National Antimicrobial MDROs. Those interventions included multimodal
Resistance Surveillance Thailand (NARST) reported strategies comprising system change, education and
that the tendency of Acinetobacter spp., Klebsiella training, monitoring, audit and feedback, reminders
pneumoniae and Pseudomonas aeruginosa was rising, and culture change, persuasion, and role models to
with resistance to carbapenem.4 MDRO infections improve healthcare workers’ practice, leading to increased
cause multiple impacts on clients, family or caregivers, performance for preventing MDRO transmission.15,16,17
healthcare workers, hospitals, and countries. For individuals, Previous programs were not sufficiently based on
the impacts comprised increased morbidity and risk psychological behavior change theory. A systematic
of death and high mortality rate,5 severe complications,6 review of interventions for improving healthcare workers’
increased readmissions,7 and prolonged length of hospital hand hygiene compliance demonstrated that a program
stay.8 Therefore, practices to prevent MDRO transmission should have a rigorous basis on behavior change theory
are required, particularly among nurses. and consider social influence, attitude, and intention
Nurses are key to preventing and controlling to yield higher effectiveness.18 Therefore, intervention
infection in healthcare settings because they perform development should be based on a theoretical framework
most daily care procedures, which are close contact considering cognitive behavioral factors to approach
and carry risks of MDRO transmission. Implementing behavior change.
practices to prevent MDRO transmission is the role of
nurses, who must uphold suitable procedures for all Literature Review and Conceptual
clients throughout their hospitalization. Essential practices
are hand hygiene, contact precautions and environmental Framework
cleansing/disinfection. Even though hand hygiene is The practices of nurses in preventing the
widely considered the most critical activity for hospital transmission of MDRO infection include hand hygiene,
prevention that can significantly reduce MDRO infections, use of PPE, patient placement, patient transport, patient
studies indicate that overall hand hygiene compliance care equipment management, environmental management,
rate among nurses was only 39%.9,10 Hand hygiene management of linen and infectious waste management.19
compliance among nurses was low in some cases.11
Vol. 27 No. 4 737
, Effectiveness of Preventive Nursing Program for Multidrug-Resistant Organism Transmission
Hand hygiene refers to rubbing alcohol on the hands consists of three main concepts: attitude, subjective
or rinsing them with soap and water.20 Use of PPE includes norms, and perceived behavior control.28 According to
gown, mask, face shield or goggles, and gloves during Ajzen, human behavior is determined by intention. The
care activities that provide opportunities to transfer intention is determined by attitude toward the behaviors
MDROs to staff hands and clothing.19 Moreover, MDRO (negative or positive evaluations of behavior), subjective
infection cases should be placed in a single room.19 norms (prevailing societal approval or disapproval
Non-critical equipment should be used with a single of others’ behaviors), and perceived behavioral control
client. Equipment should be thoroughly cleaned and (individual’s perception of the ease or difficulty associated
disinfected if use with multiple clients is necessary.21 with executing the behaviors). Thus, increasing these
Healthcare workers should perform environmental three constructs (attitude, subjective norms, and perceived
cleaning and disinfecting of handled surfaces and behavioral control) will strengthen the intention to
equipment in the client’s immediate vicinity based on achieve healthy behavior outcomes. For prevention
the hospital guidelines.19 Staff handling contaminated and control of MDRO transmission, TPB was effective
linen should wear appropriate PPE. In the patient care in predicting healthcare workers’ compliance with
area, soiled linen should be carefully rolled up without infection control practices,29 and the intention and the
shaking and placed in a properly labelled, leak-proof hand hygiene behavior of healthcare workers.30 A
container. Hand hygiene should be practiced before systematic review suggested TPB as the improvement
application and after removal of PPE.2 Moreover, strategy in intervention to improve hand hygiene
infectious waste should be placed in a designated compliance.18 Thus, TPB is the potential in the interventions
receptacle for reprocessing or a special waste container. to change and improve the behavior of nurses for practice.
Staff must wear protective gloves when handling waste Understanding the effective interventions to encourage
and remove and dispose of them hygienically.2 From the prevention of MDRO transmission among nurses
a literature review, multiple factors have been reported is essential. A systematic review showed that combined
to be associated with the preventive practices of nurses. interventions, including education, feedback, and reminders,
The most critical factors are individual factors, which effectively enhanced nurses’ hand hygiene.18
include attitude toward the performance of the practice, The program for prevention of MDRO transmission
subjective norms, and perceived behavioral control.22,23,24,25 among nurses in this study was based on the TPB to
The attitudes toward infection prevention and control raise attitude, subjective norms and perceived behavioral
were significant predictors of compliance to preventive control with a combination of several interventions in
practice26 and the prevention of MDRO transmission.27 three main components. First, raising a positive attitude
Subjective norms directly affected nurses’ intention toward the preventive practice of MDRO transmission
to prevent and control MDRO22 and were associated involved providing knowledge through education and
with hand hygiene.24 Moreover, perceived behavioral training about the prevention of MDRO transmission
control directly affected adherence to guidelines to and group discussion about the consequences of incorrect
control MDRO among nurses in intensive care units and practices. Second, raising subjective norms included
nurses’ MDRO management and intention to perform perceived expectations and social pressures to prevent
this.22 Therefore, improving nurses’ practices in the MDRO transmission, contributing to the intention to
prevention of MDRO transmission should consider improve practice through group discussions. Lastly,
these influential factors of behavioral intention. raising perceived behavioral control involves the presence
The conceptual framework for this study was or absence of facilitators and barriers to MDRO prevention
based on the theory of planned behaviors (TPB), which by providing feedback on preventive practice, group
738 Pacific Rim Int J Nurs Res • October-December 2023
