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Unit 4 reservoirs of infection and standard precautions

This unit has been developed to give you an understanding of the second link in the chain of infection. The previous unit considered the types of microbes that can cause infection and make life difficult or dangerous for us. This unit will discuss the main reservoirs in relation to infection. You will develop knowledge of standard precautions, the need for these precautions and the need for specific precautions and barrier nursing in relation to specific diseases.

Figure 4.1: The chain of infection

Image source: Adapted from Medical Dictionary (2016)

On successful completion of this unit, you will be able to:

identify reservoirs of infection explain the need for standard precautions discuss data in relation to a global pandemic

Apprenticeship information

For those of you who are studying this module as part of the Enhanced Clinical Practitioner Apprenticeship, completion of this module and the assessment will, as a minimum, support your development of the following knowledge, skills and behaviours (KSBs):

Knowledge: K1, K2, K3, K5

Skills: S1, S2, S3, S4, S5

Behaviours: B1, B2, B3

More information regarding each of these KSBs is available on the Institute for Apprenticeships and Technical Education website (IFATE, 2021).

In preparation for the end point assessment, as you work through the content of this module you are encouraged to reflect on, record and evidence your achievement of these standards in your Personal Journal (or another tool of your choice).

Reservoirs of infection

Reservoirs are the habitat that infection lives, grows and replicates in. Reservoirs provide a place for pathogens to persist over long periods of time to allow them to survive but not necessarily reproduce. An example of this is clostridium tetani (tetanus), which can survive for long periods in the soil as an endospore. Some viruses are more resistant than others, being able to exist outside of the host organism for longer periods of time. However, many are destroyed once they are in contact with air, water or detergents. These reservoirs include humans, animals (including insects) and the environment (water and soil). Health-care workers should also consider that their working environment can act as a reservoir for infection. This includes areas such as hard or soft surfaces and equipment, from beds to IV cannula and rubbish bags (figure 4.2). The reservoirs may or may not be the source from which the infectious agent is transferred to the host (Bloomfield et al., 2015). Figure 4.2: A hospital Ward

Image source:Pixabay (Accessed on 24.08.2023)

Some humans can transmit the pathogen without becoming symptomatic. These individuals are known as carriers. Carriers are further divided into passive carriers and active carriers. A passive carrier is, for example, a health-care worker who fails to wash their hands after handling body fluids and then provides care to another patient. An active carrier is someone who has the infection and may not show signs or symptoms but can transmit the disease to others during the period of incubation. An example of this would be an individual who has the SARS-CoV-2 (COVID-19) virus and transmits it to other people without knowing they have the virus.

Activity 4.1: identifying reservoirs of infection

Aim: To identify potential reservoirs of infection in your own working environment.

Duration: 20 minutes

Feedback: Self-reflection through reading the Discussion Board.

Step 1: Consider your own workplace environment and identify a minimum of ten potential reservoirs of infection. Share your thoughts and workplace (e.g. mental health unit, surgical ward, community, etc) on the Discussion Board.

Step 2: Read the posts of your peers. Do different workplace environments have different potential reservoirs of infection? Record your thoughts and reflections in your Personal Journal.

Breaking the chain

Breaking the chain of infection at this point is important as it can help to prevent the pathogen from spreading and causing illness or disease.

Figure 4.3: Broken chain

Image source:Pixabay (Accessed on 07.08.2023)

Regular cleaning and decontamination of equipment will reduce the number of pathogens in the environment and on equipment. Routine cleaning is the process whereby regular cleaning is done through scheduling rather than in an ad hoc way.

The NHS produced National Standards of Healthcare Cleanliness (2021). These standards state that health-care establishments must be able to demonstrate:

how and to what standard they are being cleaned.

(NHS England, 2021)

Cleaning can occur through a variety of methods, including disinfection, sterilisation and decontamination. Cleaning should be carried out in a methodical way from top to bottom with floors being cleaned last. Frequent touch points such as door handles and light switches should be cleaned more often than other areas. Many health-care systems operate a colour-coding system developed by the British Institute of Cleaning Science (BICSc) (n.d.), as shown in table 4.1, for all cleaning materials and equipment to reduce cross-contamination.

Table 4.1: Cleaning colour coding scheme

Source: Adapted from British Institute of Cleaning Science (Accessed on 07.08.2023)

Spillage of body fluids and substances should be cleaned in adherence with local policy and procedures and staff must be trained in these procedures.

All staff should wear a clean uniform for every shift and, ideally, it should only be worn whilst on duty in the workplace. However, this can be more difficult for those working in the community setting.

Cleaning services can also be audited as part of infection prevention and control policies and procedures. You may want to consider using an audit of cleaning in your summative assessment.

The World Health Organization (WHO, 2023) states that:

those who clean are the first line of defence against health care associated infections and support efforts to reduce anti-microbial resistance.

The WHO has produced a guide specifically aimed at health-care facilities in low- and middle-income countries where basic equipment and facilities may not be readily available.

Activity 4.2: supervision

Aim: To identify your own role as a supervisor in infection prevention and control.

Duration: 20 minutes

Feedback: Peer and tutor feedback via the Discussion Board.

You are working on a ward and a new health-care worker has started today. You are his supervisor. He arrives on the ward and his trousers are visibly dirty, with staining. He is wearing a large amount of jewellery and a wristwatch as well as numerous badges on his lanyard. He is also wearing nail polish.

Step 1: Consider what you would do in this situation and how you would communicate with him? Write your thoughts (maximum 100 words) on the Discussion Board. Consider whether there are any resources you might use to help you have this difficult conversation.

Step 2: Read the posts of your peers and comment on at least one other. Consider the communication skills and resources they might use as part of this conversation, noting whether they have identified things you have not thought of.

At this point in the module, we are going to start exploring data relating to infection. Understanding data will help you when you are considering the findings from the audit on which you are basing your summative assessment. It will also support you in understanding the importance of effective infection prevention and control.

Covid 19 exploring data

In March 2020 the world`s population entered a global pandemic which claimed the lives of billions of people, caused an economic downturn - the effects of which are likely to be felt for many years - and created a health-care crisis. The health-care crisis was not only due to the pressure on hospital resources as health-care systems tried to cope with the number of people ill from COVID-19 but also due to cancelled and delayed procedures and appointments.

Severe acute respiratory syndrome or SARS-CoV-2 belongs to the family of coronaviruses which causes the respiratory illness known as COVID19. As a virus, COVID-19 evolves to create new variants. This can make tracking and treating the illness extremely difficult. As new waves of the variant emerge in the population, public health responses are adjusted to cope with them (WHO, 2023a).

All health-care practitioners need to be able to use and interpret data. From audits to complex budgeting calculations, health-care systems are built on data analysis. Weber and Talbot (2021) suggest that understanding data is one of the key principles of quality improvement in health-care systems. They continue to argue that data is itself part of the change process required for quality improvement. Data enables us to learn about the efficiency of the current systems and processes and helps us to identify where improvements can be made.

Activity 4.3: data analysis

Aim: To develop skills in data analysis.

Duration: 30 minutes

Feedback: Peer and tutor feedback via the Discussion Board.

Step 1: Access the coronavirus pandemic data from the `Our World in Data` website.

Step 2: Select the icon labelled `Vaccinations`.

Step 3: Set the date line at the bottom of the graph from December 2, 2020 to the current date and answer the following questions:

1. On which date were the most vaccinations delivered across the world?
2. Can you suggest why the number of vaccinations fell between 30 August 2021 and 17 October 2021 before starting to rise again?
3. Now look at the country names down the left-hand side of the chart and select the UK. Also select another country - it could be where you were born, work, live or have been on holiday. How do its vaccination rates compare to the UK? Can you suggest reasons for this?
4. What percentage of the total vaccinations given across the world are represented by the UK vaccination programme on 19 December

2021? Do you think the vaccination programme was a significant factor in helping a country to recover from the impact of COVID-19? Why?

Step 4: Return to the `Coronavirus Pandemic` home page and select the icon labelled `Cases`.

1. From the list on the left, select `World`. When was the peak in the number of cases of coronavirus?
2. Return to the `Coronavirus Pandemic` home page and select the icon labelled `Deaths`. Are the greatest number of deaths on the same date as the peak number of cases? Can you suggest reasons why they are the same or different?
3. Return to the `Coronavirus Pandemic` home page and select the icon labelled `Cases` again. This time select the `UK` and `China`. What do you notice about the number of cases recorded in China at the start of the pandemic? Is it surprising that the illness was first discovered in China? What does this tell you about data collection and recording?

You can spend as much time as you like exploring the data related to coronavirus.

On the Discussion Board, post the answers to questions 1, 2, 3, 4, 6 and 7, and also record any other findings you noted whilst exploring the data. Read the posts of your peers. Have they drawn any conclusions that you did not? Comment on whether you agree with their thoughts.

This is just a short exercise exploring data. In your working life you will be exposed to multiple sets of data and it is important that you feel comfortable interpreting it.

Unit summary

In this unit you have explored reservoirs of infection and cleaning as a standard precaution in infection prevention and control. You have also briefly looked at data relating to the coronavirus pandemic and started to think about how data is represented and can be interpreted.

Apprenticeship information

For those of you who are studying this module as part of the Enhanced Clinical Practitioner Apprenticeship, completion of this module and the assessment will, as a minimum, support your development of the following knowledge, skills and behaviours (KSBs):

Knowledge: K1, K2, K3, K5

Skills: S1, S2, S3, S4, S5 Behaviours: B1, B2, B3

More information regarding each of these KSBs is available on the Institute for Apprenticeships and Technical Education website (IFATE, 2021).

In preparation for the end point assessment, as you work through the content of this module you are encouraged to reflect on, record and evidence your achievement of these standards in your Personal Journal (or another tool of your choice).

End of unit 4 activity reflecting on cleaning the environment

Aim: To develop understanding of cleaning procedures for health-care environments.

Duration: 20 minutes, excluding cleaning time

Feedback: Peer and tutor feedback via the Discussion Board.

Step 1: Read the guidance issued by the Centre for Disease Control and Prevention (CDC) related to the cleaning of surfaces to prevent healthcare-associated infections (HAIs).

Step 2: Reflect on your own working practices and environmental cleaning procedures. How well do you think they fit with this guidance? Do you think that you might change your own practice considering the recommendations in this guidance?

Step 3: Record your thoughts on the Discussion Board (maximum 100 words). Remember to maintain anonymity and confidentiality.

EPA portfolio opportunities

In this unit there are some opportunities for developing evidence for your EPA portfolio. These are detailed below . You may also think of others.

An observation of you taking part in a professional discussion relating to infection prevention and control procedures, especially maintaining clean working environments.

A witness testimony related to you providing barrier nursing for a patient in your care.

Extended learning opportunities

1. Book onto virtual workshops, for example: referencing independent learning using the `Advanced search` in `Library search` enhancing your academic writing available via the library.
2. Watch the following vide o relating to environmental cleaning in health care. As you watch, consider whether you clean this thoroughly between patients:

Environmental Cleaning in Healthcare Part 7: Clean and Disinfect High-Touch Surfaces (2018) - https://youtu.be/bmR2nglFncQ? si=dlYk1oREY0vjf_CD

Reference list

Bloomfield, S., Exner, M., Flemming, H-C., Goroncy-Bermes, G. et al. (2015) Lesser-known or hidden reservoirs of infection and implications for adequate prevention strategies: Where to look and what to look for, NCBI [Online]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4332272/ (Accessed: 6 July 2023).

British Institute for Cleaning Science (no date) BICS Colour-coding [online] Available at: https://www.bics.org.uk/colour-coding/ (Accessed :15 September 2023)

Centers for Diseases Control and Prevention (2020) Reduce Risk from Surfaces [online] Available at : https://www.cdc.gov/hai/prevent/environment/surfaces.html (Accessed 15 September 2023)

NHS England (2021) National Standards of Healthcare Cleanliness, NHS England [Online]. Available at: https://www.england.nhs.uk/wpcontent/uploads/2021/04/B0271-national-standards-of-healthcare-cleanliness-2021-appendicies-april-2021.pdf (Accessed: 6 July 2023).

Our World in Data (2023) Coronavirus Pandemic (COVID-19), Our World in Data [Online]. Available at: https://ourworldindata.org/coronavirus (Accessed: 6 July 2023).

Weber, D. and Talbot, T. (2021) Mayhall`s hospital epidemiology and infection prevention. 5th edn. Philadelphia, PA: Wolters Kluwer.

World Health Organization (2023) Environmental cleaning and infection prevention and control in health care facilities in low-and middle-income countries. [online] Available at: https://www.who.int/publications/i/item/9789240051041 (Accessed: 15 September 2023)

World Health Organization (2023a) Statement on the update of WHO`s working definitions and tracking system for SAR-CoV-2 variants of concern and variants of interest, World Health Organization [Online]. Available at: https://www.who.int/news/item/16-03-2023-statement-on-theupdate-of-who-s-working-definitions-and-tracking-system-for-sars-cov-2-variants-of-concern-and-variants-of-interest (Accessed: 6 July 2023).

Unit 5 portals of exit

This unit has been developed to give you an understanding of the third link in the chain of infection - portals of exit. In this unit, you will identify the main portals of exit and how periods of communicability affect these. The unit aims to equip you with the knowledge and understanding of the importance of standard precautions, and the appropriate use of infection prevention and control precautions designed to prevent the spread of infection.

Figure 5.1: The chain of infection

Image source: Adapted from Medical Dictionary (2016)

On successful completion of this unit, you will be able to:

identify portals of exit explain the need for infection prevention and control measures in relation to portals of exit recognise the impact and explain the importance of following correct waste disposal procedures

Apprenticeship information

For those of you who are studying this module as part of the Enhanced Clinical Practitioner Apprenticeship, completion of this module and the assessment will, as a minimum, support your development of the following knowledge, skills and behaviours (KSBs):

Knowledge: K1, K2, K3, K5

Skills: S1, S2, S3, S4, S5 Behaviours: B1, B2, B3

More information regarding each of these KSBs is available on the Institute for Apprenticeships and Technical Education website (IFATE, 2021).

In preparation for the end point assessment, as you work through the content of this module you are encouraged to reflect on, record and evidence your achievement of these standards in your Personal Journal (or another tool of your choice).

Portals of exit and periods of communicability

This is the third link in the chain of infection and there are still opportunities to break the chain of infection at this point.

The portal of exit is simply the path in which the microbe leaves the host (remember, the host is the reservoir). The portal of exit is usually where the microorganism is localised and settled.

Portals of exit include:

bodily fluids – e.g. blood, urine or saliva, including needle-stick injuries from injection or venepuncture respiratory tract (or aerosol transmission) – via the nose and mouth sputum

bodily products – vomit, faeces skin – skin lesions, open wounds or wound exudate and operation sites bites – human, insect and animal Incubation and communicability

Microorganisms that multiply quickly and cause local infections have short incubation (the amount of time between exposure to the infection and the first evidence of disease in the host) periods. For example, staphylococcus aureus multiplies so rapidly on unrefrigerated food that symptoms of food poisoning will occur in one to six hours after ingestion. However, disease-causing microorganisms have longer incubation periods. For example, HIV (human immunodeficiency virus) antibodies are detectable one to three months after infection, whereas the host may remain asymptomatic for many years (Weber and Talbot, 2021).

Different infections have different incubation periods. Remember that patients, colleagues and staff may not know they are carrying an infection if they remain asymptomatic.

Knowing the incubation period of a pathogen can help you as a registered practitioner to manage an outbreak. The time to symptom onset is indicative of pathogen growth, replication rates and toxin excretion. Therefore, the incubation period can help to inform you of the likely cause of illness or disease where this is unknown (Weston, 2013).

Communicability is the time in the natural life cycle of the infection during which transmission to other susceptible hosts can occur.

Activity 5.1: incubation periods

Aim: To develop knowledge of the incubation period of specific pathogens.

Duration: 30 minutes Feedback: Instant

Step 1: Use the internet or `Library search` to help you research the incubation period of the illnesses/diseases listed below:

Chicken pox

Chlamydia

COVID-19

Ebola

Flu

Gonorrhoea

Hepatitis B (HBV)

Mpox (formerly monkeypox)

Rabies

Rubella

Tuberculosis

Whooping cough

Step 2: Download and complete the following table:

Incubation periods

Step 3: Once you have completed the table, use the following resource to check your answers:

Incubation periods complete

Infection prevention and control for the portal of exit

Infection prevention and control is a vital part of a health-care practitioner`s duty of care to patients. Respective codes of practice highlight this (including the NMC, 2018 and HCPC, 2016). There are also other codes around the world, and you should ensure that you are familiar with the requirements of the code you are bound by. In relation to breaking the chain of infection at the portal of exit, you will learn about personal protective equipment (PPE) and the management of waste.

Personal protective equipment (ppe)

PPE is fundamental to breaking the chain of infection at the portal of exit. This is because the exit routes for microbes are the GI (gastrointestinal) tract, the GU (genitourinary) tract, the respiratory tract and the skin. Therefore, the aim is to protect uncovered skin, eyes, mucous membranes and any other unprotected aspect of health-care workers (CDC, 2018 ). PPE aims to keep staff safe from potential infectious threats such as HIV, HBV, C. diff (clostridium difficile), COVID-19 and many more infections. It also helps to reduce the transmission of infection to patients from the health-care worker.

Barrier nursing requires the use of PPE, and you should adhere to local policy and procedures for guidance on effective barrier nursing. Barrier nursing occurs when a patient or group of patients are confined to a specific area in a health-care setting. Extra precautions are implemented to reduce the risk of spreading the infection. This will be discussed further in the next unit.

An important consideration in the use of PPE is the correct donning (putting on) and doffing (taking off) of the PPE you are using.

Watch the following video to find out more about the donning and doffing of PPE. Please note that there may be local variations in the donning and doffing of PPE, but this video provides a good starting point:

Donning and Doffing PPE (Personal Protection Equipment) Nursing Skills - https://youtu.be/fp2i3eIBytY?si=-5W11g9wne83O2R4

Health-care workers should pay attention to respiratory etiquette, not least because you now know just how easy it is to inhale a bacteria or virus from aerosol droplets. Wearing of masks is often limited to higher-risk areas such as theatres or intensive care units, but this may vary according to where you work. The use of face masks is certainly more common since the COVID-19 pandemic.

Face masks and respirators provide protection for the service user and the health-care worker in varying degrees. It is vital to use the correct respirator for the disease as each mask has filters in them that vary in the percentage of airborne microbes that they can filter. In addition, you should be aware of the ways in which you should select, fit and dispose of this equipment.

At this point, it is worth noting that a common problem with PPE for health-care workers is adverse skin reactions (Sharma et al., 2021). The itchscratch cycle caused by the adverse skin reactions can make the health-care worker themselves more vulnerable to infection. This is an important consideration when allocating workloads.

Activity 5.2: respirators

Aim: To be able to identify different types of face mask and respirator.

Duration: 20 minutes

Feedback: Tutor feedback via the Discussion Board.

Step 1: Access the US Food and Drug Administration webpage relating to face coverings and read the information about different types of face covering.

Step 2: Make notes in your Personal Journal about the effectiveness of each type of face covering and its uses.

Step 3: Consider the following scenario: you are caring for a patient in intensive care and you do not have the correct respirator available. This compromises both your safety and that of your patient. What would you do in this situation? How might you escalate your concerns?

Step 4: Post your thoughts in relation to your actions regarding the scenario in step 3 on the Discussion Board. Read the posts of your peers - do you agree with their actions? Why/why not? Consider the lines of escalation they have documented. Are any of these available to you?

The use of PPE and other pieces of equipment generates a huge amount of waste in health-care settings. In the next section of the unit you are going to consider waste disposal.

Waste disposal

Climate change and sustainability are dominant on the agenda of many countries across the world. The `Agenda for Sustainable Development` (WHO, 2015 ) was adopted by all member states of the United Nations in 2015. This agenda provides a blueprint for improving health and education and reducing inequality whilst tackling climate change. Waste disposal and the use of appropriate resources are a critical consideration for any health-care provider to ensure sustainability whilst reducing environmental impacts.

You can find out more about the 2030 Agenda for Sustainable Development by watching the following video:

Do you know all 17 SDGs? (2018) - https://www.youtube.com/watch?v=0XTBYMfZyrM

The RCN (2012) defines anybody who works in health care and produces waste as part of their role a `waste producer`. Waste disposal does not just mean the waste put into clinical bags. Waste is anything that has been used in a patient environment that has been disposed of. This includes sharp instruments, contaminated waste, household waste and pharmaceutical waste. Segregation of waste is important, too, as inappropriate disposal costs affect care providers financially.

It is estimated that in the UK, the NHS sends 156,000 tonnes of clinical waste each year for incineration and this is associated with high running costs and carbon emissions. Therefore, the NHS has its own clinical waste strategy to reduce its direct carbon emissions to zero by 2040. Not only is good waste management good for the environment, but it can also have financial savings (NHS England, 2023).

The sorting of waste helps to protect the environment by reducing the amount of waste going to landfill. In the UK, the NHS uses a colour-coding system for the disposal of waste and has issued the following advice to help those working in the NHS to sort waste effectively:

Follow the guidance on bin labels and posters. These will help you sort your waste correctly.

Don`t put general waste or recycling into clinical waste bins.

Use the yellow and black striped bags for non-infectious bandages, masks, and dressings.

Use the orange waste bags for infectious waste that is not chemically and/or medically contaminated, such as bandages and dressings.

Use the yellow waste bags only for infectious clinical waste that is also chemically and/or medically contaminated.

Recycle where possible to protect our environment. It`s also 25% cheaper to use dry mixed recycling bins compared to general waste bins - that`s saving the NHS a lot of money! Speak to your local Facilities Manager if you don`t have recycling bins so we can add them to your site.

(NHS Property Services, 2023)

The following video will help you to understand more about recycling in the NHS:

Royal Berkshire NHS Foundation Trust Waste Watchers - Recycling in Theatres (2020) - https://youtu.be/IIyg2ncBuEA?si=46G-

_MWMrApmXBDt

Each country has its own system of waste disposal and you should refer to your own national and local policies and procedures when disposing of waste.

Unit summary

In this unit you have learned about the portals of exit in the chain of infection, the incubation period of different diseases and the use of PPE to protect the service user and health-care worker from infection. You have also learned why the correct disposal of waste is important in making health-care systems more sustainable and environmentally friendly.

Apprenticeship information

The end of unit activity will help you to consider your role in infection prevention and control and the sustainability of health-care services.

For those of you who are studying this module as part of the Enhanced Clinical Practitioner Apprenticeship, completion of this module and the assessment will, as a minimum, support your development of the following knowledge, skills and behaviours (KSBs):

Knowledge: K1, K2, K3, K5

Skills: S1, S2, S3, S4, S5 Behaviours: B1, B2, B3

More information regarding each of these KSBs is available on the Institute for Apprenticeships and Technical Education website (IFATE, 2021).

In preparation for the end point assessment, as you work through the content of this module you are encouraged to reflect on, record and evidence your achievement of these standards in your Personal Journal (or another tool of your choice).

End of unit 5 activity waste disposal is everyone’s responsibility

Aim: To develop knowledge of your role in infection prevention and control.

Duration: 20 minutes

Feedback: Tutor and peer feedback via the Discussion Board. As you have learned, infection prevention and control procedures and equipment can generate huge amounts of waste for health-care services.

Step 1: In this activity you are required to reflect on your own waste disposal behaviours. During your next shift, make a conscious effort to think about how you dispose of the waste you generate in the course of your work and ask yourself the following questions:

1. Are you using the correct bins?
2. Is it obvious which waste needs to go in which bin?
3. Do you have bins to separate your waste?
4. Based on what you have learned, could you be doing more to reduce the amount of waste going to landfill or for incineration?
5. Think about your coffee/tea/meal breaks – are they as environmentally friendly as they could be? Do you use disposable cutlery or boxes? Do you know the food miles of what you are consuming?
6. Search your infection control policy – is consideration given to the cost of waste disposal or is it only concerned with the health and safety aspect?

Step 2: In no more than 150 words, write your thoughts on the Discussion Board. Read the posts of your peers. Have they provided you with ideas for reducing the amount of waste you produce whilst at work?

EPA portfolio opportunities

In this unit there are some opportunities for developing evidence for your EPA portfolio. These are detailed below. You may also think of others.

Expert witness testimony relating to the correct donning and doffing of PPE

A case-based discussion relating to infection prevention and control, for example a barrier-nurse patient

A case-based discussion relating to a patient with an antibiotic-resistant infection

A teaching guide for junior staff relating to the donning and doffing of PPE

A teaching guide relating to waste disposal and sustainability

Extended learning opportunities

1. Book onto virtual workshops, for example: referencing independent learning

using the `Advanced search` in `Library search` enhancing your academic writing available via the library.

1. Read the following article available on the module reading list relating to adverse skin reactions caused by PPE. As you read, consider whether these adverse reactions make health-care workers more vulnerable to infection:

Sharma, P. et al. (2021) Adverse skin reactions related to PPE among healthcare workers managing COVID-19, Journal of the European Academy of Dermatology and Venereology, 35(8), e481–e483.

When you have read this article, use `Library search` to evaluate the findings. Is this a worldwide problem?

Reference list

Biology Online (2022) Incubation Period, Biology Online [Online]. Available at: https://www.biologyonline.com/dictionary/incubation-period (Accessed: 7 July 2023).

Centers for Disease Control and Prevention (2018) Standard precautions [Online} Available at

https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/standard-precautions.html/#PPE (Accessed: 15

September 2023)

Health & Care Professions Council (2016) Standards of Conduct, Performance and Ethics, Health & Care Professions Council [Online]. Available at: https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics/ (Accessed: 7 July 2023).

Institute for Apprenticeships and Technical Education (2022) Enhanced Clinical Practitioner [online] Available at: https://www.instituteforapprenticeships.org/apprenticeship-standards/enhanced-clinical-practitioner-v1-0 (Accessed 15 September 2023).

NHS England (2023) Clinical Waste Strategy, NHS England [Online]. Available at: https://www.england.nhs.uk/long-read/nhs-clinical-wastestrategy/ (Accessed: 7 July 2023).

NHS Property Services (2023) How to dispose of waste correctly, NHS Property Services [Online]. Available at: https://www.property.nhs.uk/news/blogs/how-to-dispose-of-waste-correctly/ (Accessed: 7 July 2023).

Nursingcomw/Jon Haws RN (2021) Donning and Doffing PPE Nursing Skills [Online] Available at: https://www.youtube.com/watch?v=fp2i3eIBytY (Accessed: 15 September 2023)

Nursing and Midwifery Council (2018) The Code, Nursing and Midwifery Council [Online]. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 7 July 2023).

Royal Berkshire NHS Foundation Trust (2020) Wate Watchers – Recycling in Theatres YouTube [online] Available at https://www.youtube.com/watch?v=IIyg2ncBuEA (Accessed: 15 September 2023)

Royal College of Nursing (2012) Essential Practice for Infection Prevention and Control [Online ] Available at: file:///C:/Users/786340/Downloads/PUB-005940%20(3).pdf (Accessed: 15 September 2023)

Sharma, P., Goel, N., Dogar, K. Bhalla, M et al . (2021) Adverse skin reactions related to PPE among healthcare workers managing COVID-19, Journal of the European Academy of Dermatology and Venereology, 35(8), e481–e483.

United Nations (2018) Do you know all 17 SDGs? YouTube [Online] Available at: https://youtu.be/0XTBYMfZyrM (Accessed: 15 September 2023)

US Food & Drug Administration (2023) N95 Respirators, Surgical Masks, Face Masks, and Barrier Face Coverings [Online] Available at:

https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-face-masks-and-barrierface-coverings (Accessed: 15 September 2023)

Weber, D. and Talbot, T. (2021) Mayhall`s hospital epidemiology and infection prevention. 5th edn. Philadelphia, PA: Wolters Kluwer.

Weston, D. (2013) Fundamentals of infection prevention and control: theory and practice. 2nd edn. Hoboken: Wiley.

World Health Organization (2023) Health topics, World Health Organization [Online]. Available at: https://www.who.int/health-topics/ (Accessed: 7 July 2023).

World Health Organization (2015) Sustainable Development Goals [online] Available at: https://www.who.int/europe/about-us/ourwork/sustainable-development-goals#:~:text=The%20Sustainable%20Development%20Goals%20(SDGs,no%20one%20is%20left%20behind. (Accessed 15 September 2023)

Unit 6 transmission of infection

This unit will examine the fourth link in the chain of infection and will provide insight into the modes of transmission for microbes. You will examine the main modes of transmission. You will also explore standard precautions and barriers in further detail. This unit will help you in developing your assignment by exploring some potential actions for your service improvement plan.

On successful completion of this unit, you will be able to:

describe the main modes of transmission of infection analyse standard precautions for infection prevention and control explain the potential impacts of barrier nursing on patients

Figure 6.1: The chain of infection

Image source: Adapted from Medical Dictionary (2016)

Apprenticeship information

For those of you who are studying this module as part of the Enhanced Clinical Practitioner Apprenticeship, completion of this module and the assessment will, as a minimum, support your development of the following knowledge, skills and behaviours (KSBs):

Knowledge: K1, K2, K3, K4, K5, K6, K26, K30

Skills: S1, S2, S3, S4, S5, S25, S27 Behaviours: B1, B2, B3

More information regarding each of these KSBs is available on the Institute for Apprenticeships and Technical Education website (IFATE, 2021).

In preparation for the end point assessment, as you work through the content of this module you are encouraged to reflect on, record and evidence your achievement of these standards in your Personal Journal (or another tool of your choice).

Direct vs indirect transmission

Transmission of a pathogen refers to the way in which it is spread and acquired (Weston, 2013). Once a pathogen has left the existing host through a portal of exit, it needs a method of transmission to be able to infect its next host. Direct transmission is that which occurs through direct contact or droplet spread. Indirect transmission occurs via airborne, vehicle-borne (food, water, biological waste and fomites) or vector-borne (animal, microbe, human) routes (CDC, 2012).

Direct contact includes contact with infected body fluids, secretions or lesions. Examples of pathogens using direct contact methods of transmission include HIV, sexually transmitted infections and ringworm.

Pathogens which use indirect methods of transmission include the common cold, COVID-19, cholera and C. difficile. Some pathogens such as norovirus can use both airborne and faecal-oral routes (Weston, 2013). Pathogens using indirect methods of transmission may use fomites, for example beds, cutlery or computer keyboards, to aid their transmission to a new host.

Bacteria such as salmonella or listeria may be ingested through the consumption of contaminated food or water. Food safety precautions are an essential part of the health and safety protocols of any health-care setting.

Some blood-borne viruses such as hepatitis B or HIV may also be transmitted through inoculation. This may be through the use of an infected needle. Intravenous drug users, for example, may share needles. Watch the following video to develop your knowledge of the modes of transmission:

Step 1.3 What is an infectious disease? Infection and modes of transmission - https://www.youtube.com/watch?v=u_nExlhyXTQ

Activity 6.1: modes of transmission

Aim: To develop your knowledge of the modes of transmission for different infections/diseases.

Duration: 30 minutes

Feedback: Instant

Step 1: Use the internet to help you identify the different types of infections/diseases for each of the following modes of transmission. Record the details of each of the different modes of transmission and the infections/diseases associated with these. Make notes in your Personal Journal in preparation for step 2.

Modes of transmission

Airborne

Animal borne

Blood borne

Food and water borne

Insect borne

Sexually transmitted Soil borne

Step 2: Check your understanding of the modes of transmission by completing the following quiz.

Select the correct option from the dropdown list to answer the following questions:

1. Infections/diseases including Traveller`s diarrhoea, cholera, cryptosporidiosis, giardiasis, hepatitis A&anp;E, listeriosis, typhoid fever,Pseudomonas use which of the following modes of transmission?

2. Infections/diseases including TB, SARS, mumps, diphtheria, measles use which of the following modes of transmission?

3. Infections/diseases including Malaria, yellow fever, dengue fever, Japanese encephalitis, chikungunya, tick-borne encephalitis use which of thefollowing modes of transmission?

4. Infections/diseases including Rabies, brucellosis, leptospirosis use which of the following modes of transmission?

5. Infections/diseases including Hepatitis B&C, HIV/AIDS, Malaria use which of the following modes of transmission?

6. Infections/diseases including Hepatitis, HIV/AIDS, syphilis use which of the following modes of transmission?

7. Infections/diseases including Anthrax, ascariasis, Trichuris, fungal infections use which of the following modes of transmission?

Check answer

Risk to health care workers

The most common method of indirect transmission is on the hands of health-care workers, which is why hand hygiene is critical to any Infection Prevention and Control (IPC) policy. You will learn more about hand hygiene as a standard precaution later in this unit.

Health-care workers are at risk of accidental blood or fluid exposure as a mode of transmission in a variety of ways, including needle-stick injuries and a splash of blood or body fluids into the mucosa of health-care workers. Contaminated sharps exposure is the most common mode of healthcare occupational exposure to blood-borne viruses in the UK (Health and Safety Executive [HSE], n.d.). The risk of blood-borne transmission of hepatitis B to health-care workers from patients via percutaneous injury is noted to be up to 30%, whilst HIV is only 0.3%. The risk of mucocutaneus transfer is much lower, with the rate of HIV transmission being around 0.1% (H.S.E, n.d.). The WHO (2021) reports that there are approximately 66,000 health-care workers who contract hepatitis B from patients due to sharps injuries each year. This data is based on a report from 2003, so the data may no longer be accurate. However, more up-to-date data could not be located at the time of writing.

Activity 6.2: evaluating the evidence

Aim: To develop your skills in evaluating evidence and your knowledge of exposure to occupation-related blood-borne pathogens.

Duration: 30 minutes, not including reading time.

Feedback: Tutor and peer feedback via the Discussion Board.

Step 1: Read the following article, available in the module reading list:

 Adetoun, A., Olanrewaju, A., Temidayo, O. and Oluwasayo, B. (2021) Exposure to Occupational-related Blood and Fluids Infections, Accidental Injuries and Precaution Practices among Healthcare Workers in a Tertiary Hospital in South-West, Nigeria, African Journal of Health, Nursing and Midwifery, 4(6), pp. 43–59.

Step 2: Critically evaluate the article using a critical crib sheet in the `Evaluating your sources` section of Develop@Derby.

Step 3: Identify what you consider to be the three most important findings from this research, noting any limitations or strengths relating to the findings.

Step 4: Post your findings from step 3 on the Discussion Board. Read the posts of your peers and comment on whether you agree with them about the strengths and limitations of this study.

As you have learned, pathogens are transmitted from person to person in a variety of ways. Therefore, understanding and complying with standard precautions to protect your patients and yourself as a health-care worker is of vital importance. You will learn more about standard precautions in the next section of this unit.

Breaking the chain

As a registered practitioner you have a responsibility as detailed in your code of practice to keep service users safe, as can be seen from the examples below which state:

NMC Code (2018) - `Preserve Safety`

US Code of Ethics for Nurses (2015) - `The nurse promotes, advocates for, and protects the rights, health and safety of the patient`.

HCPC Standards of Conduct, Performance and Ethics (2016) - `You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible`.

The Code of Ethics for Nursing Practitioners in South Africa (n.d.) - `Non-maleficence – This requires a nurse to consciously refrain from doing harm of any nature whatsoever to health-care users, individuals, groups and communities.`

Hence, the reason for developing your understanding of standard precautions becomes clear.

In the UK, NHS England (2023) has issued standard infection prevention and control precautions which should always be used by all staff in all care settings, whether infection is known to be present or not, to ensure the safety of patients, staff and visitors.

The precautions relate to:

patient placement/assessment for infection risk hand hygiene

respiratory and cough hygiene personal protective equipment safe management of care equipment safe management of the care environment safe management of linen safe management of blood and body fluid spillages safe disposal of waste occupational safety prevention of exposure (including sharps injuries)

Isolation

In the UK it is a legal requirement that registered health-care providers who deliver in-patient care can provide or have the ability to secure adequate isolation facilities (Department of Health and Social Care, 2008). In health-care settings, isolation of patients is often seen in the form of barrier nursing.

Patients who are in a hospital and who are known or suspected to be affected by pathogenic organisms which pose a potential risk to other patients or staff should be isolated or barrier nursed to control the spread of infection. The need for isolation should be discussed by the healthcare team and, following risk assessment, appropriate precautions should be put into place. This poses many challenges for health-care staff and can have negative impacts on patients. The purpose of isolating the patient is to prevent cross-infection to health-care staff and other patients (Weston, 2013).

When barrier nursing a patient, standard precautions should be adopted. These may vary from region to region but apply to the following areas:

hand hygiene

the use of PPE as appropriate (determined by the pathogen) the safe handling and disposal of sharps the handling and disposal of human waste the handling, laundering and/or disposal of linen the management of blood and body fluid spillages cleaning procedures following discharge of the patient

(Weston, 2013)

Precautions relating to the prevention of transmission of a pathogen often result in isolation of the patient. To make all those likely to encounter the patient aware of the need for barrier nursing, there should be signage on the doors relating to the precautions required when providing care for the patient on entering the room.

To ensure that patient-centred care remains the focus of provision, it is essential that all staff recognise that it is isolation of the pathogen taking place rather than isolation of the patient. When deciding on the isolation procedures for each patient, staff should take into account the following factors:

the pathogen the mode of transmission the risk of cross-infection to staff and other patients the implications of cross-infection maintaining the safety of the affected patient and other patients at risk of cross-infection the facilities available

(Weston, 2013)

When nursing colonised patients, it is important that they are not moved to another ward unless this is due to clinical need, for example for specialist care or treatment. Consider how those patients who require surgery are managed in relation to operating lists and the necessary recovery and cleaning requirements following the procedure. Ensure that all members of the multi-disciplinary team are aware of the need for barrier nursing and that rehabilitation support such as physiotherapy or occupational therapy is not delayed due to the need for barrier nursing. Ensure that discharge arrangements are made for the patient as soon as they are medically fit. Ensure that family and visitors are provided with information relating to maintaining their own safety in relation to the pathogen.

Stop and think

Think back to the early days of the COVID-19 pandemic. Were there any decisions made in relation to isolation which were unpopular or difficult to manage? Do you think these measures were appropriate at the time? Why? You might want to record your thoughts in your Personal Journal.

Activity 6.3: considering the impact of barrier nursing

Aim: To develop your knowledge of the impact of barrier nursing on patients.

Duration: 20 minutes, not including reading time.

Feedback: Tutor and peer feedback via the Discussion Board.

Step 1: The impact of isolation on patients is well documented and to help you understand these impacts you should now read the following article, available in the module reading list:

 Abad, C., Fearday, A. and Safdar, N. (2010) Adverse effects of isolation in hospitalised patients: a systematic review, The Journal of Hospital Infection, 76(2), pp. 97–102.

Make a note in your Personal Journal of what you think are the main findings of this study.

Step 2: Now read the following article, also available in the module reading list:

 Gaube, S., Daumling, S., Biebel, I. et al. (2023) Patients with multi-drug-resistant organisms feel inadequately informed about their status: adverse effects of contact isolation, The Journal of Hospital Infection, 133, pp. 89-94.

Make a note of what you think are the main findings of this study.

Step 3: Now compare the findings of the two studies. What conclusions are you able to draw?

Record your thoughts (maximum 200 words) on the Discussion Board. Read the posts of your peers. Do you agree with them? Why? Can you offer opposing conclusions although drawn on the same information?

Your tutor will provide feedback on the Discussion Board.

Hand hygiene

Hand hygiene, when performed at critical moments in the care process, is recognised as the most effective way of preventing HAIs (WHO, 2017). Despite this, one in two health-care facilities across the world lack basic hand-hygiene facilities (WHO, 2023a). In addition, 356,000 acute respiratory deaths and 17 million disability-adjusted life years (DALYS) globally are attributable to poor hand hygiene (WHO, 2023a). Hand hygiene is considered so significant in IPC and saving lives that there is a World Hand Hygiene Day each year on or around 5 May (WHO, 2016).

In standardising approaches to hand hygiene, there are `Five moments` for hand hygiene when delivering care, as shown in figure 6.2. The `Five moments` include:

1. before touching a patient
2. before clean/aseptic procedure
3. after body fluid exposure risk
4. after touching a patient
5. after touching patient surroundings

Figure 6.2: Five moments for hand hygiene

Enlarge Image

Image source: WHO (2009) (Accessed on 15.09.2023)

Now you know when to clean your hands, it is important that you use researched methods to hand wash and hand rub. Handwashing (figure 6.3) occurs when using soap and water and should be undertaken when your hands are visibly soiled or after using the toilet, whereas hand rubbing (figure 6.4) is done using hand gel and should be undertaken when hands are not visibly soiled.

The technique you use for hand washing and hand rubbing is vitally important in preventing the spread of infection. The WHO has produced information posters demonstrating these techniques as shown in figures 6.3 and 6.4 below. Figure 6.3: How to hand wash

Enlarge Image

Image source: WHO (2009) (Accessed on 15.09.2023)

Figure 6.4: How to Hand rub

Enlarge Image

Image source: WHO (2009) (Accessed on 15.09.203)

The World Health Organization has many resources available to support you in developing your skills in hand hygiene. You may want to think about introducing World Hand Hygiene Day to your own practice environment if it is not already a feature in your calendar.

The following videos demonstrate the correct technique for hand rubbing and hand washing. As you wash them, reflect on your own hand washing technique. It can be easy to be less attentive to this skill as it becomes more innate.

WHO: How to handrub? With alcohol-based formulation (2015) - https://youtu.be/ZnSjFr6J9HI?si=g13mUO7RPCNP_p8L

WHO: How to handwash? With soap and water (2015) - https://youtu.be/3PmVJQUCm4E?si=LfgpHzHgh9SEBCUu

Sharps safety

In the UK, the Health and Safety (Sharp Instruments in Healthcare) Regulations (Health and Safety Executive, 2013) state the following when the use of sharps is necessary in the workplace:

use of medical sharps at work is avoided so far as is reasonably practicable

when medical sharps are used at work, safer sharps are used so far as is reasonably practicable

needles that are medical sharps are not capped after use at work unless the risk of injury to employees is effectively controlled by use of a suitable appliance, tool or other equipment

in relation to the safe disposal of medical sharps that are not designed for re-use, written instructions are available for employees, and clearly marked and secure containers are located close to areas where medical sharps are used at work

Standard precautions relating to sharps safety may vary between organisations. Therefore, you should ensure that you refer to and adhere to local policies and procedures in relation to sharps safety.

Activity 6.4: sharps safety

Aim: To develop knowledge of sharps safety in relation to IPC.

Duration: 20 minutes, excluding reading time.

Feedback: Tutor and peer feedback via the Discussion Board.

Step 1: Read the sharps safety guidance issued by the Royal College of Nursing.

Step 2: As you can see, there are many laws which cover the management of sharps in the workplace. The term ‘reasonably practicable’ appears in section 2 of the document. In your Personal Journal, write your own definition of what ‘reasonably practicable’ means in relation to sharps management.

Step 3: Post your thoughts (maximum 100 words) on the Discussion Board. Read the posts of your peers. Do you agree with their definitions of ‘reasonably practicable’ in relation to sharps injuries? Comment on at least one other post, discussing differences and commonalities between your definitions and why you agree or disagree with their thoughts.

As you have read, there is a lot of information available to you in relation to sharps injuries. As a health-care worker it is vital that you know what to do if you have mucosal contamination from body fluids or receive a needle-stick injury. We will discuss this in the next section of this unit.

Sharps injuries

In the health-care setting, sharps refers to devices such as needles and blades or any other instrument which could cause injury by pricking or cutting the skin (Health and Safety Executive, 2021). If sharps are contaminated with blood which is infected by pathogens, then the devices pose a threat to the health of the health-care worker. Alfulayw et al. (2021) reported that nurses are the health-care workers most affected by needlestick injuries (NSIs), accounting for 52.5% of all NSIs, with 68% of all NSIs occurring during the morning shift. Perhaps more significant is the occurrence of needle-stick injuries, which were noted to affect 8.4% of all health-care workers.

If you have a sharps injury there is some standard advice that you should follow, although some local policies and procedures may vary. As always, you should adhere to local guidance.

After a sharps injury, you should follow the guidance below:

Immediately wash the puncture or small wound site with soap and water for 15 minutes.

For deep lacerations, apply direct pressure to control the bleeding and seek medical attention.

For injuries to the mouth, rinse with water several times.

For injuries to the eyes, remove contact lenses. If an eye-wash station is available, flush eyes for 15 minutes. If an eye-wash station is not available, ask a colleague to flush the eye with 500ml of normal saline or lactated ringers. If unable to do either of these, then flush the eyes with water for 15 minutes. Keep the eyes open and rotate the eyeballs in all directions to remove contamination from around the eyes.

(Centre for Disease Control and Prevention, 2019)

The Health and Safety Executive (2021) concurs with the above advice but adds the following:

Do not scrub the wound as you wash it, just encourage it to bleed whilst washing under running water.

Do not suck the wound.

Dry the wound and cover with an appropriate dressing.

If your mucosal membranes (eyes and mouth) are contaminated with bodily fluids from a patient, you should follow the same principles that you would for a needle-stick injury. Body fluids may enter your eyes or mouth in a variety of ways, for example performing mouth-to-mouth resuscitation can sometimes induce vomiting in a patient, or a patient may have an arterial bleed resulting in the spray of body fluids to your face.

For body fluid contamination to the mouth, rinse with water several times.

For body fluid contamination to the eyes, remove contact lenses. If an eye-wash station is available, flush eyes for 15 minutes. If an eyewash station is not available, ask a colleague to flush the eye with 500ml of normal saline or lactated ringers. If unable to do either of these then flush the eyes with water for 15 minutes. Keep the eyes open and rotate the eyeballs in all directions to remove contamination from around the eyes.

Following immediate first aid you should report the injury to your workplace for further advice.

Unit summary

In this unit you have learned about standard precautions in relation to modes of transmission. You have learned about different ways to break the chain of infection and the importance of hand hygiene as a primary method for achieving this. You have also explored barrier nursing and its potential impacts on the patients being barrier nursed. The end of unit activity will support you in developing further knowledge in relation to the management of exposure to body fluids or needle-stick injuries and how to communicate this to peers.

Apprenticeship information

For those of you who are studying this module as part of the Enhanced Clinical Practitioner Apprenticeship, completion of this module and the assessment will, as a minimum, support your development of the following knowledge, skills and behaviours (KSBs):

Knowledge: K1, K2, K3, K4, K5, K6, K26, K30

Skills: S1, S2, S3, S4, S5, S25, S27 Behaviours: B1, B2, B3

More information regarding each of these KSBs is available on the Institute for Apprenticeships and Technical Education website (IFATE, 2021).

In preparation for the end point assessment, as you work through the content of this module you are encouraged to reflect on, record and evidence your achievement of these standards in your Personal Journal (or another tool of your choice).

End of unit 6 activity sharps injuries

Aim: To develop knowledge of what to do in relation to exposure to body fluids via mucosal membranes or due to needle-stick injuries, develop skills in designing workplace information and communicate with different audiences.

Duration: 40 minutes

Feedback: Tutor and peer feedback via the Discussion Board.

Your task is to design an information poster for staff in relation to what to do following exposure to body fluids via mucosal membranes or due to needle-stick injuries. There are resources available on Develop@Derby to help you design your poster.

The poster should be A4 in size and inform staff of safe practice in relation to sharps, immediate first aid and what to do following this. You will need to read local policies and procedures as well as information from the internet (ensure that you only refer to reliable sources of information).

You should include references for the sources of your information on the poster.

Post your information poster to the Discussion Board. Review the posters created by your peers and comment on at least one of them. Do you think they have included all the relevant information? Are their sources reliable? Do you think the presentation used would encourage staff to engage with the information?

Extended learning opportunities

1. Book onto virtual workshops, for example: referencing independent learning using the `Advanced search` in `Library search` enhancing your academic writing available via the library.
2. Read the full article relating to needle-stick injuries, available from the module reading list, and evaluate it using a critical crib sheet:  Alfulayw, K.H., Al-Otaibi, S. and Alqahtani, H. (2021) Factors associated with needlestick injuries among healthcare workers: implications for prevention, BMC Health Services Research, 21(1074). http://dx.doi.org.ezproxy.derby.ac.uk/10.1186/s12913-02107110-y

Reference list

Abad, C., Fearday, A. and Safdar, N. (2010) Adverse effects of isolation in hospitalised patients: a systematic review, The Journal of Hospital

Infection, 76(2), pp. 97–102Adetoun, A., Olanrewaju, A., Temidayo, O. and Oluwasayo, B. (2021) Exposure to Occupational-related Blood and Fluids Infections, Accidental Injuries and Precaution Practices among Healthcare Workers in a Tertiary Hospital in South-West, Nigeria, African Journal of Health, Nursing and Midwifery, 4(6), pp. 43–59.

Alfulayw, K.H., Al-Otaibi, S. and Alqahtani, H. (2021) Factors associated with needlestick injuries among healthcare workers: implications for prevention, BMC Health Services Research, 21(1074 ). http://dx.doi.org.ezproxy.derby.ac.uk/10.1186/s12913-021-07110-y

American Nurses Association (2015) Code of Ethics, American Nurses Association [Online]. Available at: https://www.nursingworld.org/practicepolicy/nursing-excellence/ethics/code-of-ethics-for-nurses/ (Accessed: 8 July 2023).

Centre for Disease Control and Prevention (2012) Lesson 1: Introduction to Epidemiology, Centre for Disease Control and Prevention [Online].

Available at: https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section10.html#:~:text=The%20mode%20of%20transmission%20can,the%20mouth%20or%20a% (Accessed: 8 July 2023).

Centre for Disease Control and Prevention (2019) What to do following a sharps injury, Centre for Disease Control and Prevention [Online]. Available at: https://www.cdc.gov/nora/councils/hcsa/stopsticks/whattodo.html (Accessed: 10 July 2023).

Department of Health and Social Care (2008) Health and Social Care Act 2008: code of practice on the prevention and control of infections, GOV.UK [Online]. Available at: https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-theprevention-and-control-of-infections-and-related-guidance/health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-ofinfections-and-related-guidance#guidance-for-compliance (Accessed: 10 July 2023).

Gaube, S., Daumling, S., Biebel, I. et al. (2023) Patients with multi-drug-resistant organisms feel inadequately informed about their status: adverse effects of contact isolation, The Journal of Hospital Infection, 133, pp. 89-94

Health and Care Professions Council (2016) Standards of conduct, performance and ethics [Online] Available at: https://www.hcpcuk.org/standards/standards-of-conduct-performance-and-ethics/ (Accessed: 15 September 2023)

Health and Safety Executive (n.d.) Risk to healthcare workers, Health and Safety Executive [Online]. Available at: https://www.hse.gov.uk/biosafety/blood-borne-viruses/risk-healthcare-workers.htm (Accessed: 8 July 2023).

Health and Safety Executive (2013) Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 Guidance for employers and employees, Health and Safety Executive [Online]. Available at: https://www.hse.gov.uk/pubns/hsis7.htm (Accessed: 8 July 2023).

Health and Safety Executive (2021) Sharps Injuries, Health and Safety Executive [Online]. Available at: https://www.hse.gov.uk/healthservices/needlesticks/#:~:text=Encourage%20the%20wound%20to%20gently,Don`t%20suck%20the%20wound (Accessed: 10 July 2023).

Institute for Apprenticeships and Technical Education (2022) Enhanced Clinical Practitioner [online] Available at: https://www.instituteforapprenticeships.org/apprenticeship-standards/enhanced-clinical-practitioner-v1-0 (Accessed 15 September 2023).

NHS England (2023) National Infection prevention and control manual for England [Online} Available at: https://www.england.nhs.uk/nationalinfection-prevention-and-control-manual-nipcm-for-england/ (Accessed: 15 September 2023)

Nursing and Midwifery Council (2018) The Code, Nursing and Midwifery Council [Online]. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 8 July 2023).

Royal College of Nursing (2023) Sharps Safety [Online] Available at: https://www.rcn.org.uk/Professional-Development/publications/rcn-sharpssafety-uk-pub-010-596 (Accessed 15 September 2023)

S.E.M.S. Vietnam (2015) What is an infectious disease, infection and modes of transmission? YouTube [Online]. Available at: https://youtu.be/0UaOf1XpagE (Accessed: 8 July 2023).

South African Nursing Council (n.d.) The Code of Ethics for Nursing Practitioners in South Africa, South African Nursing Council [Online]. Available at: https://www.sanc.co.za/ (Accessed: 8 July 2023).

Weston, D. (2013) Fundamentals of infection prevention and control: theory and practice. 2nd edn. Hoboken: Wiley.

World Health Organization (2009) Your 5 moments for Hand Hygiene [Online] Available at: https://www.who.int/multi-media/details/your-5moments-for-hand-hygiene-poster (Accessed: 15 September 2023)

World Health Organization (2009) How to hand rub [Online] Available at: https://www.who.int/publications/m/item/how-to-handrub (Accessed: 15

September 2023)

World Health Organization (2009) How to handwash [Online] Available at: https://www.who.int/publications/m/item/how-to-handwash (Accessed:

15 September 2023)

World Health Organization (2016) WHO: How to hand rub? With alcohol-based formulation, YouTube [Online]. Available at: https://www.youtube.com/watch?v=ZnSjFr6J9HI (Accessed: 8 July 2023).

World Health Organization (2016) WHO: How to handwash with soap and water, YouTube [Online]. Available at: https://www.youtube.com/watch? v=3PmVJQUCm4E (Accessed: 8 July 2023).

World Health Organization (2016) Annual 5 May Advocacy Toolkit, World Health Organization [Online]. Available at: https://www.who.int/publications/m/item/annual-5-may-advocacy-toolkit (Accessed: 8 July 2023).

World Health Organization (2017) Evidence of hand hygiene as the building block for infection prevention and control, World Health Organization [Online]. Available at: https://www.who.int/publications/i/item/WHO-HIS-SDS-2017.7 (Accessed: 8 July 2023).

World Health Organization (2021) Sharps Injuries: Global burden of disease from sharps injuries to healthcare workers, World Health Organization [Online]. Available at: https://www.who.int/publications/i/item/9241562463 (Accessed: 8 July 2023).

World Health Organization (2023a) 1-in-2 health care facilities lack basic hand hygiene, World Health Organization [Online]. Available at: https://www.who.int/multi-media/details/1-in-2-health-care-facilities-lack-basic-hand-hygiene (Accessed: 8 July 2023).

World Health Organization (2023b) Improving access to water, sanitation and hygiene can save 1.4 million lives per year, says new WHO report, World Health Organization [Online]. Available at: https://www.who.int/news/item/28-06-2023-improving-access-to-water--sanitation-andhygiene-can-save-1.4-million-lives-per-year--says-new-who-report (Accessed: 8 July 2023).