UNIVERSITY OF THE PHILIPPINES OPEN UNIVERSITY
MASTER OF ARTS IN NURSING
ADRIANA P. COCHANGCO, RN
NURSE CHARACTERISTICS, COMPLIANCE WITH HEALTH PROTOCOLS, AND WELL-BEING OF NURSES DURING COVID-19 PANDEMIC IN A SELECTED
HOSPITAL IN SAUDI ARABIA
Thesis Adviser:
DR. ARACELI O. BALABAGNO
Faculty of Management and Development Studies
July 2023
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NURSE CHARACTERISTICS, COMPLIANCE WITH HEALTH PROTOCOLS, AND WELL-BEING OF NURSES DURING COVID-19 PANDEMIC IN A SELECTED
HOSPITAL IN SAUDI ARABIA
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Adriana P. Cochangco, 27 Aug. 2022 Signature over Student Name and Date
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This Special Project titled: “NURSE CHARACTERISTICS, COMPLIANCE WITH HEALTH PROTOCOLS, AND WELL-BEING OF NURSES DURING COVID- 19 PANDEMIC IN A SELECTED HOSPITAL IN SAUDI ARABIA” is hereby
accepted by the Faculty of Management and Development Studies, U.P. Open University, in partial fulfillment of the requirements for the degree Course.
3 July 2023 ARACELI O. BALABAGNO
Adviser
4 July 2023 LYDIA T. MANAHAN
Critic
19 July 2023 BETTINA EVIO
Panel Member
4 July 2023 FRITZ GERALD JABONETE
Panel Member
10July 2023 PAUL FROILAN GARMA
Panel Member
July 2023 RIA VALERIE D. CABANES
Program Chair
JOANE V. SERRANO Dean
Faculty of Management and Development Studies
Date
25
26 July 2023
Biographical Sketch
Adriana P. Cochangco is a University of the Philippines Open University graduate student under Master of Arts in Nursing program. She received a bachelor’s degree in nursing from Perpetual Help college, Manila. She is currently employed as a nurse in one of the hospitals in Riyadh, Kingdom of Saudi Arabia.
Acknowledgement
First and foremost, I would like to express my deepest gratitude to my thesis advisor, Dr. Araceli Ocampo Balabagno for the constant encouragement, guidance, and remarkable feedback all throughout the process of accomplishing this paper.
Second, my sincere thank you to the thesis critic, Dr. Lydia T. Manahan and to the members of the panel, Prof. Fritz Gerald Jabonete, MAN, RN, Prof. Bettina D. Evio, MAN, RN and Prof. Paul Froilan U. Garma, MAN, RN for their valuable time, constructive comments, direction and expertise in improving this paper.
In addition, my thanks to the University of the Philippines Open University academe, Prof. Queenie Roxas-Ridulme MAN, RN, Prof. Ria Valerie D. Cabanes MAN, RN, for their kind assistance. And to Ms. Maxine R. Ridulme (statistician), Ms. Rachel Anne Joyce Sales (research assistant) and Ms. Jennifer Belen-Bunao (librarian) for sharing their professional specialty.
A special thanks to my nursing director Mr. Mohammed Saed Al Mudhaybiri, MSN, RN for the unending support and advocacy for the continuous education. And to my colleagues and all the respondents of the study great appreciation to all of you.
I would like to mention my thanks to my classmates in the University of the Philippines Open University -MAN program Ms. Zharmaine Celis, Sanchez MAN, RN, and Mr. Arsenic Manlangit, MAN, RN for patiently responding to all my inquiries.
My deepest appreciation to my dear friends in Saudi Arabia, Ms. Rosemeline Cordero, RN, Ms. Cristy S. David, RN, and Ms. Almaida Uddin Alrashid, RRT for their unending help, emotional support and for standing beside me when I feel like wanted to give up.
I would also like to extend my heartfelt thanks to a certain person who took time to help me when I needed it most.
And to my loving mother and auntie who gave their moral support and prayers in
every step of the way of my continuous education. I love you so much.
Finally, but most importantly, giving back my forever gratefulness to God Almighty, for his ultimate provisions.
Dedication
This work is dedicated to my respectful auntie, Magdalena P. Pantoja, whom I considered as my second mother, although she is no longer in this world, her words of wisdom about the value of education and perseverance are still echoing in my heart and mind.
I also dedicate this work to my beloved mother, Marcela P. Pantoja and to my auntie, Severina P. de Padua, they are the pillars of my life.
For the nurses who never gave up and courageously stood up in continuing giving nursing care, spreading hope to their patients, and facing all the challenges that the COVID-19 pandemic has brought to us. Salute to all of you! This work is specially dedicated to all of you nurses!
I offered this gift to our Almighty God. To God be the glory.
TABLE OF CONTENTS
Title Page i
University Permission Page ii
Acceptance Page iii
Biographical Sketch iv
Acknowledgment v
Dedication vi
Table of Contents vii
List of Tables ix
List of Figures x
ABSTRACT xi
CHAPTER I: THE RESEARCH PROBLEM 1
Background of the Study 1
Statement of the Problem 4
Objectives of the Study 5
Significance of the Study 6
Scope and Limitation of the Study 7
CHAPTER II: THEORETICAL BACKGROUND 8
Review of Related Literature 8
COVID-19 8
Nurse Characteristics, Knowledge & Attitude Towards COVID-19 13
Sociodemographic Variables 16
Work-related Factors 19
Compliance 21
Well-Being 23
The Health Promotion Model 26
Conceptual Framework 34
Operational Definition of Terms 35
Hypothesis 37
CHAPTER III: RESEARCH METHODOLOGY 36
Research Design 36
Sampling Technique 38
Study Setting 38
Data Collection Procedures 40
Research Instruments 41
Data Analysis 44
Ethical Considerations 46
CHAPTER IV: RESULTS AND DISCUSSION 47
Results and Discussion 47
CHAPTER V: SUMMARY, CONCLUSION AND RECOMMENDATIONS 69
Summary of Findings 69
Conclusions 71
Recommendations 72
REFERENCES 73
APPENDICES 78
Appendix A: King Fahad Medical City – Institutional Review
Board Papers 79
Appendix B: NIDA Clinical Certificate 84
Appendix C: Permission Letter to Conduct Study 85 Appendix D: Permission Letter to Adopt the Instrument
to the Present Research 89
Appendix E: Informed Consent Form 91
Appendix F: Research Instrument 93
Appendix G: Curriculum Vitae 96
List of Tables
Table 1 Utilized HPM Major Concepts 32
Table 2 Statistical Matrix 44
Table 3 The Variables Mean and Standard Deviation 47 Table 4 Nurse Characteristics and Work-Related Profile
of the Respondents 48
Table 5 Nurse characteristics and compliance to COVID-19
Health protocol 49
Table 6 Work-related factors and compliance to COVID-19
Health protocol 54
Table 7 The cross-tabulation of nurse characteristics and
Nurse well-being 58
Table 8 The cross-tabulation of work-related factors and
Nurse well-being 60
Table 9 The correlation between nurse compliance to COVID-19
Health 62
Table 10 The frequency distribution of the nurse experience in
Time of COVID-19 on well-being 63
List of Figures
Figure 1 Health Promotion Model 28
Figure 2 Conceptual Framework 34
Abstract
The nurse compliance with health protocols and well-being play an important role in better health outcomes for themselves, the patient, and the community. During the height of the COVID-19 pandemic, compliance with COVID-19 health protocols is the best way to combat the rapid virus transmission, to protect oneself, the patient, and the community. However, nurse good compliance cannot be assured as nurses may differ in their perspectives. Noticeably, few of the healthcare workers were fallen ill and died because of the COVID-19 virus. Their state of total well-being was affected because of exhaustion, and this resulted to reduction in the healthcare workforce. The healthcare workers' compliance with COVID-19 preventive measures was limited in the literature. There were contradicting findings and nurse state of well-being included as variables but was not dealt extensively.
This study determined the nurse characteristics, compliance with health protocols, and well-being of nurses during the COVID-19 pandemic in a selected hospital in Saudi Arabia. The study was guided by the notion that nurse characteristics and work-related factors are associated with compliance COVID-19 health protocol and the well-being. This was supported by Pender’s Health Promotion Model to show the relationship of individual characteristics and experiences; behavior-specific cognition and affect and the behavioral outcome. A descriptive-correlation design was utilized. The study was conducted in one of the COVID-19 hospitals in Riyadh, Saudi Arabia. A complete enumeration purposive sampling was applied involving only 117 staff nurses with more than 6 months of working experience at the selected hospital.
An ethics approval was granted by the King Fahad Medical City Ethics Committee.
The study revealed that there is a significant relationship between nurse compliance to COVID-19 health protocol and their state of well-being (ρ = .224, p
=0.01). This indicates that the nurses who have better compliance with the COVID-19
protocol may have a better state of well-being. Sex (p=0.01), nationality (p=0.01);
knowledge (p<.00), attitude (p=0.017) and practices (p=0.001) were associated with their level of compliance with COVID-19 health protocol. In conclusion, the respondents have good knowledge and a positive attitude towards compliance with COVID-19 health protocol and state of well-being. The study supports the proposition that personal factors (Sex, Nationality), prior related behaviors (Practices), perceived competence or self-efficacy (Knowledge) is associated with commitment to a plan of action (Compliance). And the prior related behavior, self- efficacy (Attitude), commitment to a plan of action (Compliance) is associated to the health promoting behavior (Well-being of nurses).
Key words: nurse compliance, nurse well-being, COVID-19, health protocol
Chapter I
THE RESEARCH PROBLEM Background of the Study
Compliance with COVID-19 protocol will help limit the virus transmission from one person to another and ensure everyone's safety and protection. However, there was no assurance that all healthcare workers would comply with the health protocol in COVID-19 precautions.
The health protocol on COVID-19 precautions is an essential measure in preventing the spread of the virus, and it protects the patient, the healthcare workers, and the community. In the first wave of the COVID-19 pandemic, one of the measures to prevent and protect oneself from the COVID-19 virus was the proper implementation of health protocol on COVID-19 precautions. A clear scenario of the rapid transmission of the virus from one person to another has been observed. Patients were going to the emergency department with COVID-19 symptoms, admitted as suspected cases, then shifted to a confirmed- positive COVID-19 ward after a day or so. Some patients are eventually transferred to COVID-19 ICU or referred to a higher center for further continuity of critical care. An increased demand for health care was observed, however the workforce was insufficient. The healthcare workers started to experience exhaustion, their immunity level decreased, and suddenly one after another, they tested positive for COVID-19 infection resulting to a compromised total well-being of the healthcare workers.
The first wave of pandemic was surpassed; however, a COVID-19 variant emerged and was named delta-virus in May 2021. This heightened the transmissibility and mortality rate globally and locally. In the second wave, it was observed that the
healthcare workers did not meticulously comply with the COVID-19 preventive measures. Maybe because at that time, they thought that they had contracted the virus and were immune already, or they considered it not fatal. These observations stimulated the researcher’s interest in dealing with specific individual characteristics and behavior that affects following a particular health protocol. The researcher started searching published studies, but most of it tackled the knowledge, attitude, and perception (K.A.P.) on COVID-19 preventive measures. It is a given fact that healthcare workers were educated about standard preventive guidelines for infectious disease but does it automatically translate to an active compliance. The availability of health protocols does not automatically produce positive behavior towards it.
Compliance with health protocols on COVID-19 is a specific commitment to a plan of action in response to pandemic.
According to the literature, the preventive behaviors against COVID-19 among health care workers were assessed at a relatively desirable level. Based on the P.M.T., threat and coping appraisal were predictors of protection motivation to conduct COVID-19 preventive behaviors (p<0.001). An individual intention was also predictive of COVID-19 preventive behaviors (p<0.001) (Bashirian et al., 2020). In addition, Etafa et al. (2021) assessed Healthcare workers compliance with measures to prevent COVID-19 and its potential determinants in public hospitals in Western Ethiopia. It was reported that overall compliance observed in their study was poor (22%). While Zenbaba et al., (2021) compliance with infection prevention measures among health professionals in public hospitals, Southeast Ethiopia found out that health professionals who have a good knowledge regarding COVID-19 preventive measures were 1.80 more likely to have good compliance regarding COVID-19 preventive measure that their counterparts (AOR=1.80;95% CI 1.14,2.89).In addition, Alhumaid
et al. (2021) study revealed that compliance to hand hygiene and use of P.P.E., has been found to vary widely among Health care workers and is likely influenced by one’s knowledge about infection risk and behaviors. Having good knowledge does not necessarily translate to good practice. For example, Health care workers have demonstrated poor compliance with hand hygiene practices despite well-established guidelines for preventing HAIs. More confounding variables of good I.P.C. practice other than knowledge or experience exist. Unfortunately, good knowledge does not necessarily predict good practice.
These studies show contradictory findings regarding healthcare workers' compliance with COVID-19 preventive measures. It was also noted that attitude knowledge and nurse well-being were not included in their variables. The common factors for the studies mentioned above were the time frame of the data gathering conducted during the first wave of the COVID-19 pandemic, March 2020, August 2020, and October 2020.
The COVID-19 pandemic escalated the demand for healthcare needs; in the end, healthcare workers' health became compromised and patients. The healthcare workers were physically, mentally, environmentally, and spiritually drained. This disruption affects the healthcare workers' total well-being. If this continues, the increased patient health care needs demand exhaustion of healthcare workers will lead to sickness, burnout, and resignation. If this happens, there will be a collapse of the workforce in the healthcare system.
Each person uniquely showed behavioral adaptation to the new life and work changes. Several questions emerged, why is it difficult for some people to follow the COVID-19 health protocols? Do they believe in the fatality of the virus, or maybe there
is a problem in their health protocol practice? Different factors can be associated with one’s behavior. The present study aimed to determine the relationship between compliance to health protocols, nurse characteristics, work-related factors, and the well-being of nurses during the COVID-19 pandemic in a selected hospital in Saudi Arabia.
Statement of the Problem
In the Kingdom of Saudi Arabia, there have been 864 new cases, and from January 3, 2020, to August 11, 2021, a total of 535,176 confirmed cases ended up in 8,357 deaths. The healthcare workers are not immune to the COVID-19 virus. The Pan American Health Organization database revealed that 570,000 healthcare workers have fallen ill due to the COVID-19 virus, and 2,500 died. This is a disturbing state for all healthcare institutions. The healthcare worker's safety must be secured and prioritized in these circumstances. There will be an insufficient healthcare workforce in 2030, with approximately 7.6 million nurses, as reported in the State of the World’s Nursing 2020. This kind of scarcity is a significant threat to every hospital institution. The administration and nurse leader must plan of time. As a result, there is a need to explore and understand the association between compliance to health protocol, nurse characteristics, work-related factors, and nurse well-being during a COVID-19 pandemic. The present study is timely as we are facing a struggle in the healthcare system during this time of the pandemic. The study's findings will provide information that will bring awareness and innovation to the nursing practice field. It will also contribute to the strong foundation for some development in Infection Control guidelines, quality improvement initiatives, and staffing retention programs.
Specifically, the study searched for a guide in answering the following questions:
1. What are the nurse characteristics and work-related factors of the nurse respondents in a selected hospital in Saudi Arabia in time of COVID-19 pandemic?
2. What is the level of nurse compliance to COVID-19 health protocol in time of COVID-19 pandemic?
3. What is the nurse respondents’ well-being in time of COVID-19 pandemic?
4. Is there a relationship between the nurse characteristics and nurse compliance to COVID-19 health protocol in time of COVID-19 pandemic?
5. Is there a relationship between the nurse characteristics and nurse well-being in time of COVID-19 pandemic?
6. Is there a relationship between the work-related factors and nurse well-being in time of COVID-19 pandemic?
7. Is there a relationship between nurse compliance to COVID-19 health protocol and their state of well-being?
8. What are the verbalizations of the respondents regarding their COVID-19 pandemic experience that affect the total well-being?
Objectives of the Research
1. To determine the nurse characteristics and work-related factors of the nurse respondents in a selected hospital in Saudi Arabia in time of COVID-19 pandemic.
2. To determine the level of nurse compliance to COVID-19 health protocol in time of COVID-19 pandemic.
3. To determine the nurse respondents’ well-being in time of COVID-19 pandemic.
4. To determine the relationship between the nurse characteristics and nurse compliance to COVID-19 health protocol in time of COVID-19 pandemic.
5. To determine the relationship between the nurse characteristics and nurse well- being in time of COVID-19 pandemic.
6. To determine the relationship between the work-related factors and nurse well- being in time of COVID-19 pandemic.
7. To determine the relationship between nurse compliance to COVID-19 health protocol and their state of well-being.
8. To determine the nurse respondent’s verbalization regarding their COVID-19 pandemic experience that affects their total well-being.
Significance of the Study
The present study is very significant in this pandemic era. The data gathered from the study regarding the relationship between nurse characteristics, work-related factors, and compliance to COVID-19 protocols during the pandemic serves as a point of reference to the nursing education, nursing service, and infection control department. First, it contributes to nursing education and the infection control department developing a strategy for the novice nurse orientation program. In addition, it will help design a protocol that can effectively enhance the nurse's compliance with health protocol. The novice and staff nurses will benefit from acquiring knowledge and skills on health protocol. It provides hospital institutions preparedness for any emergency of another infectious disease. Moreover, data gathered from the study regarding the relationship between nurse characteristics, work-related factors, compliance to COVID-19 protocols, and nurse well-being in a time of pandemic serves as a foundation for nursing service in formulating programs that promotes a good state
of nurse well-being and strengthening staff retention. The program that promotes well- being will bring job satisfaction and improve working conditions. This benefits the staff nurses and will empower them to engage in work, such as compliance with health protocols that will lead to assurance of quality and safe patient care.
Scope and Limitation of the Study
The research study aimed to determine the relationship between compliance to health protocols, nurse characteristics, work-related factors, and the well-being of nurses during the COVID-19 pandemic. The study's respondents are all staff nurses with more than six months of working experience in a selected Hospital in Riyadh, Saudi Arabia. The primary data source will be web-based self-administered questionnaires designed in Google forms. The questionnaires are readable and answerable in the English language. It was administered from the middle of March 2022 until the middle of April 2022. The study's limitation is the respondents' willingness to complete the research and the target timeline.
Chapter II
THEORETICAL BACKGROUND Review of Related Literature
Using the electronic database, Google Scholar, and UPOU library online resources Elsevier, ScienceDirect, and University Library, the using keywords:
keywords nurse, compliance, well-being, COVID-19 preventive measure. News articles, WHO and CDC latest reports, and books regarding the topic were also tracked. The organization of the review of the literature was arranged according to variables of the study.
COVID-19 Virus
The COVID-19 virus affects every human life. According to (WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus (COVID-19) Dashboard with Vaccination Data, n.d.) of August 12, 2021, globally, there have been 630,656 new cases and 203,944,144 confirmed cases, including 4,312,902 deaths. And a total of 4,428,168,759 vaccine doses were administered as of August 11, 2021. While in the Kingdom of Saudi Arabia, there have been 864 new cases, and from January 3, 2020, to August 11, 2021, a total of 535,176 confirmed cases ended up in 8,357 deaths. And it was reported to WHO that 30,900,685 vaccine doses have been administered in Saudi Arabia (COVID 19 Dashboard: Saudi Arabia, n.d.). The transmission of the COVID-19 virus from human to human was so high-speed that leads to the sudden increase of coronavirus confirmed cases and death. Since the emergence of COVID- 19 in 2019 and the declaration of WHO that it is characterized as a pandemic on March 11, 2020, they summarized four key areas to prevent infection, save lives and minimize the impact. One critical place is reducing transmission (WHO Director-General’s
opening remarks at the Media Briefing on COVID-19 - 11 March 2020, n.d.). Each country's government is trying to achieve HERD immunity; however, different COVID- 19 variants arise that are more highly infectious and have a fast virus transmission.
The CDC calls on everyone to continue wearing the mask and observing preventive measures for COVID-19 (Delta Variant: What We Know About the Science | CDC, n.d.).
According to CDC, the influx of new suspected and confirmed COVID-19 variant cases brought an alarming hospitalization. The health care workers dealing directly with COVID-19 patients are vulnerable to extracting the virus, and they can be a host of the virus. The meticulous practice of COVID-19 preventive measures such as wearing P.P.E.s, hand washing, and social distancing is essential. Among the members of the healthcare teams, the nurses spend more time in direct patient care from admission until recovery, which makes them more susceptible to viral infection.
Their compliance with CDC COVID-19 preventive measures guidelines is imperative.
The CDC posted policies to prevent and control COVID-19 in healthcare settings.
Hospital institutions around the world adopted these guidelines, and full implementation is expected of all healthcare workers. Despite this, full compliance of healthcare workers cannot be assured. Once there is poor compliance with COVID- 19 preventive measures among healthcare workers, they become at risk as well as their families and the patient, and this will cause rapid virus transmission. We value our healthcare workers as they significantly contribute to combating the pandemic and saving people's lives. By ensuring their full compliance with COVID-19 preventive measures, we also showed that we care for their total wellbeing. Nurses are essential to ensuring quality care and patient safety, preventing, and controlling infections, and combating antimicrobial resistance. This is achieved through multiple functions,
including monitoring patients for clinical deterioration, detecting errors and near misses, implementing infection prevention interventions, control monitoring, and mentorship, and ensuring that good practices involving water, sanitation, and hand hygiene are maintained. The nursing workforce faces challenges common to all health occupations, including adequate numbers, equitable distribution and retention, quality education, effective regulation, conducive working conditions, and quality and efficiency within universal health coverage. (World Health Organization, n.d.).
Well-being critically impacts overall health. A healthy nurse is defined as actively focusing on creating and maintaining balance and synergy of physical, intellectual, emotional, social, spiritual, personal, and professional well-being. When high levels of work stress challenge balance and synergy, the result can be depression; lower resilience; job dissatisfaction; and a propensity toward unhealthy lifestyle coping mechanism, such as overeating, alcohol abuse, smoking, and reduced activity. Such behaviors may then lead to chronic health problems that negatively impact work effectiveness. Dr. Maureen Bisognano, keynote speaker at the 2016 Gothenburg International Forum on Quality and Safety in Healthcare, emphasized that burnout, emotional exhaustion, mental depletion, and disengagement are associated with the current state of our global nursing community. Studies reported disengagement rates at 40% and nurse burnout in the U.S. These factors, and their relationship with poor well-being, ultimately harm nurses’ overall health and ability to provide quality patient care (Hume, 2018).
Looking back, the severe acute respiratory syndrome (SARS) outbreak began in Guangdong, China, on November 16, 2002. The first three SARS cases in Singapore were confirmed on March 6, 2003. By May 5, 204 cases, including 27
deaths, had been established. The last case was isolated on May 11, and by July 30, the end of the outbreak, 205 patients had recovered, and 33 had died (Quah & Hin- Peng, 2004). At the same time, Middle East Respiratory (MERS) was initially recognized in 2012. A total of 1621 cases have been reported from 26 countries, with a case fatality rate of 36%. The disease has a wide range of clinical presentation and epidemiology. Three main factors contribute to the transmission of MERS coronavirus (MERS-CoV): the virus, the host, and the environment. Concerning the patterns of communication, there are designs that have been recognized: sporadic transmission, limited intra-familial transmission, and healthcare-associated transmission (Al- Tawfiq&Memish, 2016). Early in the epidemic, hospital outbreaks of SARS occurred in Canada, China, Hongkong, Singapore, Taiwan, and Vietnam. A total of 1706 cases of SARS occurred among Health care workers, and their distribution varied by country (Shaw, 2006). The healthcare workers accounted for 21% of all severe acute respiratory syndrome (SARS) cases during the 2002-2003 outbreak (Koh et al., 2005).
Two-thirds of the nurses who cared for patients with SARS thought that their health and safety had been compromised during the outbreak. There had been a widespread system failure and a lack of preparations against infectious disease, and the public health and emergency infrastructure decayed. These faults, combined with the Ontario government’s lack of understanding of the situation and the failure of hospital administrators to follow occupational health and safety laws for their staff, resulted in the death from SARS of two nurses and the infection of dozens of others.
Finally, a profound lack of awareness of the principle of worker's safety among administrators and government bureaucrats in Ontario led them to resist expert advice on and enforcement of safe practices (Summers, 2009). The cause of SARS was later identified as a coronavirus, which was cultured from specimens provided by a
healthcare worker who subsequently died of SARS (McDonald et al., 2004). On the other hand, MERS-CoV described more than 171 secondary cases in healthcare workers in the 939 cases reported to July 15, with another 174 cases acquired by other patients while in hospital. Another study suggested that infected health care workers were an influential group involved in disease spread (Alsahafi& Cheng, 2016). Current evidence suggests that the virus that causes COVID-19 is transmitted between people through close contact and droplets. People most at risk of acquiring the disease are those who are in contact with or care for patients with COVID-19. This inevitably places health care workers (HCWs) at high risk of infection. Protecting HCWs is of paramount importance to WHO (WHO, 2020). COVID-19 has exposed health workers and their families to unprecedented levels of risk. Although not representative, data from many countries across WHO regions indicate that COVID-19 infections among health workers are far greater than those in general populations (Keep Health Workers Safe to Keep Patients Safe: WHO, n.d.).
Healthcare professionals (H.C.P.s) deliver care and services to the sick and ailing either as physicians, nurses, and respiratory therapists or indirectly as aides, helpers, laboratory technicians, housekeepers, and medical waste handlers. Frontline healthcare professionals are the backbone of effective healthcare systems and face additional burdens and hazards as they respond to the current COVID-19 pandemic.
These burdens include exposure to pathogens, psychological distress, fatigue, long working hours, burnout, and physical and mental violence. All employers need to consider national and international best practices to reduce the transmission of COVID-19 amongst their workforce, maintain business operations, lower the impact in their workplaces and maintain a healthy work environment (COVID-19 Safety Guide for Healthcare Professionals, 2020).
The WHO stated that health workers represent less than 3% of the population in most countries and less than 2 % in all low- and middle-income countries. Around 14% of COVID-19 cases reported to WHO are among health workers. In some countries, the proportion can be as high as 35%. However, data availability and quality are limited, and it is impossible to establish whether health workers were infected in the workplace or community settings. Thousands of health workers infected with COVID-19 have lost their lives worldwide (Keep Health Workers Safe to Keep Patients Safe: WHO, n.d.). Hospital nurses are more at risk than community nurses because they are exposed to direct contact with infected patients. Nurses are the largest group of clinical and care providers for individuals admitted to hospitals because they are responsible for the care and recovery of patients, so they must follow safety and health tips at work (Gheysarzadeh et al., 2020).
Nurse Characteristics, Knowledge, Attitude towards COVID-19
A survey of healthcare workers in South Korea found a poor level of knowledge of the modes of transmission, which was implicated in the rapid spread of the infection in hospitals. Worryingly, more than half of respondents in this survey thought that MERS-CoV could be spread through mosquito bites. Infection control measures are crucial for infectious respiratory cases in healthcare institutes. A high proportion of respondents identified hospital overcrowding, poor hand hygiene and mask use, lack of knowledge about the mode of transmission, a lack of policies and procedures, and insufficient training in infection control procedures also contributed to the spread risk.
Self-reported adherence to infection control measures was surprisingly poor, particularly considering a previous study suggesting that self-reported generally overestimates observed behaviors. This survey indicates insufficient knowledge about
emerging infectious diseases, and self-reported infection control practices were sub- optimal (Alsahafi& Cheng, 2016). In Saudi Arabia, most respondents correctly identified the need for infection prevention measures, patient risk factors, and transmission mode by close contact. It was noted that 45% of the physicians, 53% of nurses, and 61% of other Health care workers in the study perceived their knowledge about MERS-CoV, Ebola, and other emerging diseases to be low. In comparison, 40%
indicated that it was moderate, and ≤7% stated that it was high. As expected, most of the health care workers in the study (≥72.3%) indicated that they need educational courses and training about MERS-CoV, Ebola, and other emerging infectious diseases. Almost two-thirds of respondents were unaware of guidelines or protocols for treating patients with MERS-CoV infection. Only 22.8% reported receiving training about dealing with infectious disease outbreaks, 37.1% said training in infection control policies and procedures, 54.4% reported training in hand hygiene, and 45.6% reported activity in N95 mask-wearing techniques. A high proportion of respondents agreed that emergency department overcrowding, poor hand hygiene, and mask use contributed to the risk of H.C.W. being infected with MERS-CoV. Similarly, a high proportion decided that a lack of knowledge about the mode of transmission, a lack of policies and procedures, and insufficient training in infection control procedures also contributed to the risk. Self-reported compliance with hand hygiene was moderate, with only two-thirds of the health care workers (60.3%) of the physicians, (64.8) of the nurses, and (60.6%) of the other HCEs practicing regular hand washing after patient contact. Less than half of the respondents reported full compliance with surgical masks when required, and a similar proportion reported compliance with N95 respirators when required (Alsahafi& Cheng, 2016).
Alhumaid et al. (2021) study reveal that compliance with I.P.C. practices,
including hand hygiene and use of P.P.E., has been found to vary widely among Health care workers and is likely influenced by one’s knowledge about infection risk and behaviors. However, good knowledge does not necessarily predict good I.P.C.
practice. For example, Health care workers have demonstrated poor compliance with hand hygiene practices despite well-established guidelines for preventing HAIs. More confounding variables of good I.P.C. practice other than knowledge or experience exist. Unfortunately, good knowledge does not necessarily predict good practice.
In general, it is stated in one study that, for Health care workers good knowledge, a positive attitude, and good practice regarding preventive measures such as wearing gloves, protective clothing, goggles, and facemask are imperative to deal with infected patients with minimum risk. The ongoing pandemic nature of the disease made it necessary for Health care workers to adopt increased precautions following the critical situation and to put effort into implementing hygienic conditions and following recommendations. The survey found that the majority of health care workers have good knowledge (93.2%, N=386), a positive attitude (mean 8.43), and good practice (88.7%, N=367) towards COVID-19 (Saqlain et al., 2020). Similarly, (Dalky et al., 2021) study findings show that most hospital H.C.P.s had the proper knowledge about the COVID-19 outbreak: this includes the infection symptoms, the mode of transmission, the diagnosis procedure, and risk factors. Furthermore, in Saudi Arabia (Mohammed Basheerudd in Asdaq et al., 2021) findings indicate that a large percentage of healthcare staff in Riyadh has a sound knowledge of COVID-19, as well as positive attitude and proper practice skills. Developing a positive attitude that leads to proper practice requires knowledge acquisition. Healthcare practitioners' expertise is more valuable because it impacts their own lives and the community’s standard of care. The more knowledge they have, the more they will be able to monitor the spread
of a pandemic like COVID-19. The result of this study showed that healthcare professionals have a clear understanding of a variety of essential items that were assessed. The overall correct answer rate for the questionnaire knowledge domain item was 88 percent. There is a correlation between healthcare professionals’
knowledge of COVID-19 and the use of effective clinical practices. The attitude of healthcare professionals is directly linked to their practice.
In addition, in one study in Jordan regarding factors influencing compliance to infection control precaution among nurses and physicians, the result suggested that clinical experience, knowledge, and attitudes were significant predictors of adherence to I.C.P.s. The Jordanian H.C.P.s showed positive attitudes and high levels of reported compliance with I.C.P.s despite low levels of knowledge. The study affirmed that a positive attitude influences compliance with I.C.P.s (Nofal et al., 2017). Similarly, in the survey by Amanya et al. (2021), knowledge and compliance with COVID-19 prevention and control measures among health workers in Uganda, they found that many of the respondents (69.3%) had sufficient knowledge, with a mean knowledge score of 5.88/8 (SD±1.05). Most of the respondents (68%) had adequate compliance, with a mean score of 27.35/32 (SD±3.3) and varied by item assessed. Adherence was associated with having received training in COVID-19 IPC (p=0.039), having COVID- 19 IPC guidelines at workstations (p=0.036), and sufficient institutional support (p- 0.031).
Sociodemographic Variables
Three demographic characteristics were associated with taking preventive measures against SARS: sex, age, and estimated years of formal education. Women were more inclined (OR 0.770:95%CI 0.689 to 0.861) than men (OR 1.339:95%CI
1.166 to 1.539) to take preventive measures; this finding is consistent with other studies on health behavior in Singapore. People ≥35 years of age were more inclined to take preventative measures (OR 0.872;95%CI 0.806 to 0.943) than their younger counterparts (OR 1.365;95%CI 1.123 to 1.658). The association with education disappeared when controlled for sex. Since SARS appeared unexpectedly, healthcare experts were uncertain about how to handle the epidemic. Consequently, our survey's public opinion of authorities’ crisis management was relevant to Singapore. We also assessed how prevention measures correlated with other factors, including respondents’ demographic characteristics (Quah et al., 2004).
In the determinants of healthcare workers’ compliance with infection control procedures, Yassi et al., 2007) stated that this study demonstrates apparent differences in occupations, gender, and ages regarding compliance. Physicians’
adherence to handwashing was self-reported to be the lowest, consistent with findings in other studies (Berthe et al., 2005; Lipsett and Swoboda, 2001; Salemi et al., 2002).
Men were less compliant with all infection control practices and significantly less likely to clean their hands. This has been previously documented (Sharir et al. 2001). Young workers reported better compliance than older workers, which is consistent with other studies (Gershon et al., 1999). Males across all occupations were less likely to comply with infection control across all questions and were significantly less likely to clean their hands (OR=0.30, p <.001). The following study in I.C. compliance supported these findings. In Northwest Ethiopia, the female healthcare workers were 2.18 times more likely to be consistently compliant with standard precautions than male Health care workers (Haile et al., 2017). Similarly, in that same country during the pandemic (Kassie et al., 2020), compliance toward COVID-19 prevention was significantly affected by sex. Female Health care workers were found to better comply with
prevention recommendations. And Al-Dossary et al. (2020) study pointed out that demographics and work-related issues mattered. Female nurses had better preventive behaviors than male nurses. (Alshammari et al., 2021) found that the preventive practice among females (59.6%) was significantly better than in males (50.1%). In this regard, one study in Ethiopia (Birihane et al., 2020) reported that male Health care workers were 4-times more likely to practice preventive measures than female Health care workers (chi²=4.10 at a p-value of 0.043). Also, a study in Saudi Arabia mentioned that females were more likely to have adequate knowledge and a positive attitude toward COVID-19. Still, males were more likely to comply with appropriate practices regarding COVID-19 (Almohammed et al., 2021).
In addition, few studies in Saudi Arabia reveal that the study participants' average attitude and practice scores were 3.89±0.93 and 3.85±0.81 (mean±SD), respectively. No significant variation was found between the demographic variables and the attitude score of the healthcare professionals. In contrast, an important (P value=0.050) increase in the practice score was noted in unmarried professionals compared to married ones (Mohammed BasheeruddinAsdaq et al., 2021). Also, Al- Dossary et al. (2020) mentioned that marital status significantly impacts the prevention and perception domains on COVID-19. In this study, married nurses, compared to single nurses, scored statistically significantly higher in both the prevention and perception domains on COVID-19. It may be no surprise that nurses with a bachelor’s degree had better prevention and perception of COVID-19 than other educational backgrounds. Finally, non-Saudi nurses self-reported higher perception, prevention, and attitudes towards COVID-19 than Saudi nurses.
Work-related factors
Yassi et al., (2007) sought to study the relationship between the environmental, organizational, and individual factors and self-reported compliance with infection control practices. Our findings that workers' compliance with infection control is significantly affected by the organization and environment they work in but not by their personal beliefs or attitudes are encouraging and telling. In addition, Health care workers with more frequent management support toward safety environment at the institution were 2.23 times more likely to be always compliant than those with less frequent management support (Haile et al., 2017). Generally, there was perceived solid institutional support, with most participants (70.7%) feeling adequately supported by their respective institutions. Moreover, solid institutional support was associated with COVID-19 IPC compliance (p=0.031) (Amanya et al., 2021). Similarly, Alhumaid et al. (2021) mentioned that more confounding variables exist of good I.P.C. practice than knowledge or experience. Nonavailability of resources, high workload, and time limitation have been reported as the main factors influencing HCEs’ compliance with I.P.C. Factors that impact compliance is organized into three overarching domains:
organizational, environmental, and individual characteristics, which allows Health care workers, managers, and policymakers to see clearly where strategies need to be implemented to facilitate compliance and support Health care workers. Also, Alhumaid et al. (2021) also pointed out that three primary factors prompting health care workers to comply with the I.P.C. measures were knowledge, education and training, and experience. The predictors of Health care workers’ noncompliance included high workload and time constraints, more beds and higher patient-to-nurse ratio, and professional category-specific. The reported barriers for Health care workers to adhere to standard precautions included non-availability of equipment (alcohol hand rub,
nearby sink, soap, or paper towels) and intolerable or challenging use of hand hygiene agents. Unfortunately, good knowledge does not necessarily predict good practice.
On the other hand, a descriptive analysis identified the most common barriers to implementing COVID-19 preventive measures. The most frequently barriers perceived by HCWs were inadequate supplies of appropriate PPE (including required standards) (n=336, 83.2%), insufficient supportive medications (n=317, 78.5%), lack of provision of adequate ventilation (n=314, 77.7%), lack of sufficient room/space to isolate patients (n=306, 75.7% and uncooperative community (n=302, 74.7%) (Etafa W. et. al., 2021). Furthermore, most of the responding Health care workers (82.4%) complained of a shortage in P.P.E. supply. Shortage in respirators came in the first place (91.3%), followed by disposable gowns (52.6%) and surgical masks (51.1%).
Also, most of the participants (88.1%) practice the extended use of P.P.E., particularly N95 respirators (91%) (El-Sokkary et al., 2021).
Moreover, only age, years of experience, and unit of expertise were significantly associated when assessing the associations of hand washing compliance with demographic variables. However, gender and title were not found to correlate with hand washing compliance, which contradicts other studies that found significant differences based on participants’ titles (Darawad et al., 2012). An Ethiopian study pointed out that the odds of having good compliance towards COVID-19 preventive measures were two times more likely among health professionals with 3-6 service years than health professionals who have ≤2 service years (A.O.R. = 2.10; 95% CI 1.135,3.21) (Zenbaba et al., 2021). Additionally, work experience affects attitude towards COVID-19, according to this study. Specifically, nurses with 11 to 20 years of experience have a better perspective than those with less than ten years (Al-Dossary
et al., 2020).
On the other hand, H.C.P.s having 6-10 years of experience reported better compliance with COVID-19 prevention recommendations than providers with 11 or more years of experience (Kassie et al., 2020). It was also supported by the study of (El-Sokkary et al., 2021). They found a statistically significant difference between compliant and non-compliant Health care workers regarding gender, work experience, and occupation, where better compliance to proper P.P.E. use was noted between females, physicians with medical specialties, and Health care workers with less than ten years of work experience.
In these circumstances, hospital management is essential since it affects the other factors associated with protecting Health care workers from SARS, including the availability of outbreak standard operation protocols (12%), mandatory body temperature surveillance in hospital (9%), hand washing setups at each checkpoint in hospital (3%) and standardized patient transfer protocol (3%). Hospitals with better management are less likely to have Health care workers acquiring SARS or other nosocomial infections (Yen et al., 2010).
Compliance
Several studies about infection control compliance among healthcare workers were reviewed to understand the topic thoroughly. Yassi et al. (2007) assesses determinants of H.C.W.'s self-reported compliance with infection control procedures.
A cross-sectional, correlation survey approach was used to explore compliance factors in 16 acute care facilities in the province of British Columbia, Canada. Six questions measured compliance (the dependent variable). Several independent variables were examined for possible associations with submission, including demographic,
environmental, and organizational factors. Individual items were chosen before reflecting aspects of the underlying model guiding the study. Overall, 90% of workers reported cleaning their hands after removing gloves > 70% of the time; 91 % said wearing disposable gloves when there was a possibility of exposure to blood or other bodily fluids >70% of the time; 62% reported wearing a disposable garment when there was a possibility of soiling their clothes>70% of the time; 71% said wearing an N95 mask when there is potential exposure to an airborne respiratory communicable disease>70% of the time, and 52% reported wearing protective eyewear whenever there was a possibility of splashes of blood or other bodily fluids>70% of the time.
The nurse's compliance with COVID-19 preventive measures was reviewed, however, there are only limited studies found. Amanya et al. (2021) had findings suggest that most of the health workers in R.R.H.S. in Northern Uganda are knowledgeable and compliant with I.P.C. Good knowledge of COVID-19 IPC has been identified by 69.3% of the respondents. It was also found that most health workers had good compliance (68%) with COVID-19 IPC measures. The health workers reported adequate institutional support (70%). Despite the high scores, fewer health workers reported adequate provision of P.P.E.s.
On the contrary, Etafa et al. (2021) present a cross-sectional study to assess health care workers’ compliance with COVID-19 prevention practice in public hospitals in Western Ethiopia and its potential determinants. Overall reported compliance observed in the study was poor (22%). In addition, reading resources on COVID-19 and obtaining support from the hospital management are other factors requiring emphasis to improve Health care workers’ compliance with COVID-19 prevention.
Moreover, only a few studies were done in Saudi Arabia regarding H.C.W.
compliance with COVID-19 preventive measures. The awareness and practice of COVID-19 precautionary measures among healthcare professionals in Saudi Arabia were conducted by (Binsaleh et al., 2021). A total of 674 healthcare workers participated in this study. Most recruited Health care workers were knowledgeable about COVID-19 transmission routes and hand hygiene (more than 90% of Health care workers answered four questions correctly). Most of the recruited Health care workers exhibited a high practice of personal protective methods (scored >75%). The average total score for wearing protective equipment was highest among pharmacists (4.81/6), followed by general physicians (4.76/6). While Albeladi et al., (2021) measure the level of adherence of health care workers to the COVID-19 prevention measures.
The result showed that Saudi Arabian Health care workers had adhered well to preventive measures against COVID-19. More specifically, the result showed a high level of adherence to mask (96%), gown (85%), gloves (95%), goggles, and face shield (68%) wearing practices, along with adhering to washing hands (80%) and cleaning and disinfection of the patient’s environment (845) courses. In addition, one study focused on fear and threat as motivating factors for COVID-19 preventive behavior compliance (Bashirian et al., 2020). Furthermore, reflection in Southeast Ethiopia concluded that around one-fifth of health professionals in the selected hospital had good observation of COVID-19 preventive measures (Zenbaba et al., 2021). In contrast, Western Ethiopian studies have findings of poor compliance with COVID-19 preventive measures (Etafa et al., 2021).
Well-being
A UK study by Vera San Juan et al. (2021) stated that participants described various struggles at different pandemic stages. Health care workers experienced anxiety and anticipation mainly about a news report of international experiences in
intensive care units (I.C.U.); the possibility of bringing the virus to families and moving into a most excellent good for the most incredible number model of care (where decisions need to be made about the rationing of scarce services between patients), which could have moral and legal implications for clinicians. During the pandemic, staff mentioned experiencing additional cognitive burdens to their everyday work, such as uncertainties around diagnosis without the usual diagnostic technique and feeling overwhelmed by frequent changes in P.P.E. and clinical guidelines. In addition, the most salient form of well-being support mentioned by staff was mutual moral and clinical support between health care workers. This support happened through buddy systems and spontaneously, as a general feeling of motivation, friendship, and empowerment among teams. Also, the health care workers felt appreciated and valued due to community support, citing examples such as rainbow pictures and clapping. Food donated by local restaurants and neighbors was reported to significantly impact keeping morale high and getting staff through long shifts. In general, the team said that anxiety diminished as they became more immersed in their work and, in some cases, once they had contracted and recovered from the virus.
Similarly, Digby et al. (2021) found that the responses reflected a significant amount of anxiety, fear, and uncertainty related to the pandemic, including their perspectives on the impacts on work, home, family, and the community. Many respondents reported feeling confused by what appeared to be conflicting messages received from the government, hospital executives, direct managers, and the media.
Staff had considerable difficulty adjusting to the changing conditions brought about by the pandemic. For some, this meant being redeployed to another hospital department to boost staffing numbers in an area of need. Fast-tracking training was used to upskill nurses to work in higher acuity areas anticipating an influx of seriously ill patients.
Almost all respondents to this survey emphasized the importance of additional staff support to cope with the stress and rapid change required during the pandemic and beyond. Managers were essential in directing the correct process, listening to staff, and addressing issues.
Most global studies about COVID-19 preventive measures focused on knowledge, attitude, awareness, and perception. The results of the studies were contradictory, as one claimed that health care workers have sound knowledge, a positive attitude, and good practice. The perspective of health care workers is associated with their training. However, some study has found that there is a good knowledge among health care workers but had lower prevention practice of COVID- 19. The underlying factors that are associated with good practice must be addressed.
It was also pointed out in compliance to I.C.P. that males are less likely to comply and wash their hands. The organization and environment affect their performance. Only a few studies were made during the early phase of the pandemic, which directly tackled health care workers/nurse compliance to COVID-19 preventive measures, giving contrasting findings.
In Saudi Arabia, they investigate more about K.A.P., knowledge, attitude, perception, and practice of healthcare workers towards COVID-19. There are also limited studies that tackled the healthcare worker's compliance with COVID-19 preventive measures. Ensuring the safety of healthcare workers is crucial in protecting them against the virus and preventing the transmission of the virus. Understanding the behaviors of health care workers, including wearing appropriate personal protective equipment (P.P.E.), is therefore essential in COVID-19 prevention. In this regard, the World Health Organization (WHO) has identified education as one of the critical components of prevention programs (Bashirian et al., 2020). The different published
studies were conducted mainly in the first wave of the pandemic, and the coronaviruses are evolving as discoveries of COVID-19 variants emerge. Compliance with a certain measure is complex to understand. Nurse compliance to COVID-19 health protocols and nurse well-being in a time of pandemic is a critical issue to address in the present time. The possibility of poor compliance and poor state of nurse well-being can significantly impact the safety and protection of one’s life. It will help to understand how individual characteristics and experiences and behavior-specific cognition effect of H.P.M. produce a better behavioral outcome.
The Health Promotion Model
The Health Promotion model is a middle-range nursing theory derived from behavioral approaches. The framework was proposed to integrate nursing and behavioral science perspectives on factors that influence health behaviors. The model is to be used to explore the biopsychosocial processes that motivate individuals to engage in behaviors directed toward health enhancement (Pender et al.,2011). The model has been used extensively for research to predict health-promoting lifestyles and specific behaviors (McEwen & Wills, n.d.).
According to Pender, the Health Promotion Model was designed to be a
“complimentary counterpart to models of health protection.” It defines health as a positive dynamic state rather than simply the absence of disease. Health promotion is directed at increasing a patient’s level of well-being. The health promotion model describes the multidimensional nature of people as they interact within their environment to pursue health. The development of her model was very much influenced by her education, personal experiences, and life events. Her parents were strong supporters of education for women. Her husband and children motivated her to
learn more about optimizing health. Theoretically, her model was influenced by Bandura’s Social Learning Theory which emphasized the importance of cognitive processes in behavior change and by Fishbein’s Theory of Reasoned Action (which is focused on behavior as a function of personal attitudes and social norms (Anonuevo et al., 2000).
Pender’s model focuses on individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes. The theory notes that each person has unique personal features and experiences that affect subsequent actions. The variables for behavior-specific knowledge and effect have important motivational significance. The variable can be modified through nursing actions.
Health-promoting behavior is the desired behavioral outcome, which makes it the endpoint of the Health Promotion Model. These behaviors should result in improved health, enhanced functional ability, and quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing need and preferences, derailing intended actions for promoting health (Pender’s Health Promotion Model - Nursing Theory, n.d.).
Figure 1: Health Promotion Model
(image retrieved from nursekey.com)
(Revised Health Promotion Model. (From Pender, N. J., Murdaugh, C. L., & Parsons, M. A. [2002]. Health promotion in nursing practice [4th ed., p. 60]. Upper Saddle River, NJ: Prentice-Hall. Copyright Pearson Education, Upper Saddle River, NJ.) Prentice-Hall)
The central concepts in the revised health promotion model (Pender et al.,2006) are illustrated in Figure 1. The first area is the individual characteristics and experiences, comprised of prior related behavior that refers to the frequency of the same/similar behavior in the past. This directly and indirectly affects the likelihood of engaging in health-promoting behaviors. Personal factors are categorized as biological, psychological, and sociocultural. These factors predict a given behavior and are shaped by the target behavior being considered. Physical factors include age, gender, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, and balance. Personal psychological factors include variables such as self-esteem, self-motivation, personal competence, perceived health status, and
definition of health. At the same time, factors such as race, ethnicity, acculturation, education, and socioeconomic status are included in sociocultural factors (Alligood, n.d.). The behavioral-specific cognitions and effects are considered major motivational significance; these variables are modifiable through nursing actions (Pender 1996).
The perceived benefits of efforts are anticipated positive outcomes resulting from health behavior. The perceived barriers to activity are expected, imagined, or actual blocks and personal costs of undertaking a given behavior. The perceived self-efficacy is a judgment of individual capability to organize and execute a health-promoting behavior. Perceived self-efficacy influences perceived barriers to action, so higher efficacy results in lowered perceptions of obstacles to the performance of the behavior.
In contrast, the activity-related effect describes subjective positive or negative feelings that occur before, during, and after behavior based on the stimulus properties of the behavior itself. Activity-related affect influences perceived self-efficacy, which means the more positive the subject feels, the greater the feeling of efficacy. In turn, increased feelings of efficacy can generate another positive effect. Interpersonal influences are cognitions concerning behaviors, beliefs, or attitudes of others. It includes norms (expectations of significant others), social support (instrumental and emotional encouragement), and modeling (vicarious learning through observing others engaged in a particular behavior). Family, peers, and health care providers are primary sources of interpersonal influences. In addition, situational influences are personal perceptions and cognitions of any situation or context that can facilitate or impede behavior. They include perceptions of available options, demand characteristics, and aesthetic features of the environment in which given health-promoting behavior is proposed to take place. Situational influences may directly or indirectly influence health behavior (Alligood, n.d.).
The following are immediate antecedents of behavior or behavioral outcomes.
A commitment to action initiates a behavioral event unless a competing demand cannot be avoided or a competing preference cannot be resisted (Pender, personal communication, July 19, 2000). The commitment to a plan of action describes the concept of intention and identification of a planned strategy that leads to implementing health behavior. Moreover, competing demands are alternative behaviors over which individuals have low control because of environmental contingencies such as work or family care responsibilities. Competing preferences are alternative behaviors over which individuals exert relatively high authority, such as the choice of ice cream or an apple for a snack. A health-promoting behavior is an endpoint or action outcome directed toward attaining positive health outcomes such as optimal well-being, personal fulfillment, and productive living (Alligood, n.d.).
The assumptions reflect the behavioral science perspective and emphasize the patient's active role in managing health behaviors by modifying the environment context. In the third edition of Health Promotion in Nursing Practice, Pender (1996) stated the significant assumptions of the health promotion model that address person, environment, and health are as follows: First, person seeks to create conditions of living through which they can express their unique human health potential. Second, people have the capacity for reflective self-awareness, including assessment of their competencies. Third, people value growth in directions viewed as positive and attempt to achieve a personally acceptable balance between change and stability. Individuals seek to regulate their behavior actively. Individuals in all their bio psychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time. Health professionals constitute a part of the interpersonal environment, influencing people throughout their lives. Lastly, self-
initiated reconfiguration of person-environment interactive patterns is essential to behavioral change (pp.54-55) (Alligood, n.d.).
Pender identified health promotion as a goal for the 21st century, just as disease prevention was a task of the 20th century. The model describes the interactions between the nurse and the consumer while considering the role of the environment in health promotion (Pender, Murdaugh, & Parsons, 2010). Pender responded to her time's political, social, and personal environment to clarify nursing’s role in delivering health promotion services to persons of all ages. The model fosters thinking about future opportunities and influences technological advances such as electronic health records to achieve prevention and health promotion (Pender, Murdaugh, & Parsons, 2010) (Alligood, n.d.).
Most research studies used Pender’s work as one component of a conceptual framework for analysis. For example, Wise and Arcamone (2011) used the H.P.M. to study adolescents' food choices during pregnancy, and Maglione and Hayman (2009) used the model to explain how social support, self-efficacy, and a commitment plan influenced physical activity in college students—also focusing on physical activity.
Esposito and Fitzpatrick (2011) examined the relationship between nurses’ beliefs about the benefits of exercise, their exercise behavior, and their recommendation of exercise to their patients (McEwen & Wills, n.d.).
The COVID-19 virus transmission is spreading fast from one person to another;
despite the WHO and C.D.C. recommendation of preventive measures and the goal of HERD immunity, the census of infected people is rising, including healthcare workers. The healthcare workers are responsible for rendering care to the patients and protecting them and themselves from the further transmission of the COVID-19 virus.
