Appendix I: Letter to Respondents

Universidad de Sta. Isabel

Elias Angeles Street
4400, Naga City, Philippines
Website: www.usi.edu.ph

CHAPTER II

REVIEW OF THE LITERATURE AND STUDIES

This chapter presents the related literature and studies after a thorough

and in-depth search done by the researchers. It also presented the theoretical

framework, conceptual framework, and synthesis of state-of-the-art to fully

understand the research done. Lastly, it includes the definition of terms for

better comprehension of the study.

Related Literature

Compliance of Nurses

The Philippines Charity Sweepstakes Office (2023) stated that 87

government hospitals would receive 9,000,000 USD funds to help purchase

medical supplies, equipment, and tools to combat COVID-19. These funds were

just a portion of a bigger 60 million USD package, the majority of which was

allocated to PhilHealth, the country's healthcare system, and to pay for COVID-

19 patients' medical expenses. Since the outbreak began, the PCSO had already

contributed nearly 3 billion PHP to the fight against the virus through direct

payments to 82 government hospitals, and dividend payments to the Department

of Finance and PhilHealth (the country's national insurance program), patient

hospitalization costs, additional funding for pertinent research organizations, and

other local assistance like food packs, sanitizers, and masks. One of the hospitals
that benefited from the funding was the Vicente Sotto Memorial Medical Center

Sub-National Laboratory (VSMMC SNL). The hospital was later on reported to

have utilized the 30 million PHP in buying additional PPE for their frontline

workers as well as increasing their stock of COVID testing supplies.

According to the article written by Gita-Carlos, R.A. (2022), President

Rodrigo Duterte had signed Republic Act (RA) 11712, which required public and

private health professionals to continue receiving benefits throughout the

COVID-19 pandemic and other future public health emergencies. RA 11712

applied to all healthcare and non-healthcare personnel, regardless of

employment status, from the time the public health emergency was declared to

the time that it was lifted. Individuals who worked at medical institutions and

vaccination sites, as well as those active in Covid-19 response activities,

outsourced staff exposed to Covid-19, and village health workers, are referred to

as healthcare and non-healthcare workers. The law mandated the government to

grant qualified beneficiaries a health emergency allowance (HEA) for every

month of service during a state of public health emergency. The amount was

based on the risk exposure categorization, with those in "low-risk areas"

receiving at least PHP3,000, those in "minimum-risk areas" receiving at least

PHP6,000, and those in "high-risk areas" receiving at least PHP9,000.

According to the article of Hughey, P., (2021), the COVID-19 pandemic

had a significant toll and negative impact on the economic sector and all aspects

of healthcare. Many international hospitals and healthcare facilities are facing

catastrophic economic challenges due to COVID-19. Healthcare workers have

continued to provide the best medical care to COVID-19 patients, despite the

personal risk of infection, exhaustion, fear of death, and loss of many colleagues.

Sadly, they have not been compensated fairly for all their work as they should

have been. Healthcare assistants such as physician assistants, nursing assistants,

and medical technologists have always been underpaid compared to physicians

or even nurses. According to the statistics laid out by Brookings, approximately 7

million US healthcare assistants get meager pay. With no predictable signs of the

devastating effects of the COVID-19 pandemic on the economies, no one can

certainly answer the lost jobs of many individuals. Regarding the healthcare

workers, the Medical Society of the State of New York reported that 80 percent

of the doctors had lost more than half of their income sources and revenues

since the outbreak of COVID-19. Due to all the negative impacts of COVID-19 on

businesses and the economic fronts, the healthcare sector is constantly losing

job opportunities rather than gaining. This is due to the drastic decrease in

patient volume in hospitals.

According to Corrales, N., (2023), Teodoro Herbosa, the secretary of

health, stated on Tuesday that the Department of Health (DOH) was dedicated

to accelerating the provision of the COVID-19 benefits for healthcare workers,

particularly nurses, that had been postponed. He emphasized that state

healthcare institutions and private hospitals follow different workflows and that

all perks for government employees have already been provided to them.
Herbosa claimed that incomplete documentation was one of the reasons for the

holdup but reassured the medical staff that "as long as the documentation is

there, they should be paid."

As stated by the World Health Organization, (2020), personal protective

equipment is used by healthcare professionals to keep both themselves and their

patients safe from infection and the spread of disease. Due to a lack of access to

materials including gloves, medical masks, respirators, goggles, face shields,

gowns, and aprons, doctors, nurses, and other frontline workers are severely

underprepared to care for COVID-19 patients.

Hand Hygiene Compliance

According to an article written by Mareckova, M. (2022), hand hygiene

requirements must be followed to reduce hospital-acquired illnesses and prevent

pathogen transmission in healthcare settings. High levels of hand cleanliness had

been identified as an important technique for avoiding the transmission of

COVID-19 in hospitals. Therefore, the maintenance of high-level hand hygiene

compliance (HHC) among healthcare workers (HCWs) becomes a concern. In the

American Journal of Infection Control, Sandbl et al. (2022) evaluated how HCWs'

HHC evolved before and during the COVID-19 pandemic. An automated hand

hygiene monitoring system, manufactured by Sani Nudge (a Danish Healthcare

Technology Company), was used to measure the HHC of around 140 HCWs who

worked in three medical departments at the Danish Regional Hospital of West

Jutland from April 2019 to August 2020. The data revealed that HHC did not rise
as predicted during the COVID-19 epidemic. In fact, the findings found that hand

hygiene standards were greater in two of the three departments prior to the

COVID-19 epidemic. These findings are consistent with a previous study by

Stangerup et al. (2021), which discovered that, despite the pandemic, the HHC

of front-line HCWs declined over time once their data-driven feedback meetings

were discontinued.

As stated in the article of The Australian Guidelines for the Prevention and

Control of Infection in Healthcare by Wolfaardt, B., et al. (2019), all persons may

carry infectious diseases. Standard precautions are workplace policies that

guarantee a minimal degree of infection prevention and control and are applied

to everyone, regardless of their actual or suspected infectious status. Even in

high-risk scenarios, the danger of transmission of infectious agents from person

to person was minimized by using basic precautions as the first line of defense

for infection prevention and control in the healthcare environment.

Factors that Contribute to the Quality of Work of Nurses

According to an article written by Santos, A.P. (2021), motivation is one of

the factors that contributed to the quality of work one performs. With the high

recorded cases of patients with COVID-19, a huge percentage of the nurses in

the Philippines threatened to resign due to the lack of salary and support

received from the government. Nurses were overworked and not given any

benefits by the government. No hazard pays and funds for accommodation and

transport of clients were provided. Hence the motivation of the nurses to

perform their job diminished without their proper and rightful compensation.

Despite the Philippines being the lead supplier of nurses abroad, many hospitals

in the country are severely understaffed due to underpayment.

A journal written by Anastacio, A.L. (2020) tackled the most overlooked

issue by the government in the earlier days of the pandemic. The journal focused

on hospitals that catered to COVID-19 patients. It was found out that nurses

were having trouble regarding PPEs, specifically the lack of it. There was also the

worry about being incapable of providing timely care because of the increase in

workload. Nurses also experienced anxiety regarding their own safety in their

jobs as well. However, the results were not all negative. It was shown that the

nurses had improved compassion, confidence, resilience, resourcefulness,

altruism, belief in God, leadership skills, and of course, experience. The study

expounded on the need of support for nurses at the forefront and suggests an

improvement in the use of technology.

Personal Protective Equipment

In the article written by Livingston, E., MD, et al. (2020), The Global

Healthcare systems are overburdened with potentially contagious individuals

seeking testing and care as the COVID-19 pandemic intensified. Gloves, face

masks, air-purifying respirators, goggles, face shields, respirators, and gowns are

examples of Personal Protective equipment that were advised to be worn to

prevent the spread of infection to and from patients and Health Care Workers. In

places with strong demand, a severe scarcity of all of these was expected to
arise if not already occurring. PPEs, which were once a commonplace and

disposable necessity in the hospital setting, were rare and valuable resources,

especially in the places where highly contagious patients are located. To meet

the growing demand for PPE, there would be a need to be a significant increase

in the supply of PPE production.

It was recommended to follow precautions such as mask-wearing,

distancing, and increased ventilation. According to the article written by Curtis, J.

(2020), along with vaccination, important measures to help protect unvaccinated

and other at-risk workers included separating them from all infected individuals,

all individuals exhibiting COVID symptoms, and any individuals who are not fully

vaccinated who have had close contact with someone who has COVID-19 and

has not tested negative for COVID-19 at least five days after the contact (in

which case they may return 7 days after contact). Close contacts between fully

immunized individuals should be monitored for COVID-19 3-5 days after

exposure, and until they test negative, they must use face masks to cover their

nose and mouth for 14 days. Maintaining ventilation systems, implementing

physical separation, appropriately using face masks (or other Personal Protective

Equipment (PPE) and respiratory protection such as N95 respirators when

appropriate), and proper cleaning are additional fundamental controls that

safeguard unvaccinated and other at-risk workers. Fully immunized individuals

should still wear face masks (or other suitable PPE and respiratory protection)

indoors and in locations with substantial or high levels of transmission. Should an

employee have a disability that prevents them from following safety regulations,

said employee may ask for reasonable accommodations that allow them to

adjust properly with their disability.

MacNeil, A., et. al. (2019) from the Centers for Disease Control and

Prevention, had presented guidelines for isolation precautions to prevent

transmission of infectious agents in healthcare settings. It included the standard

precautions which were proper hand hygiene, personal protective equipment,

respiratory hygiene, and patient placement. In areas of patient placement, they

stated that placing COVID-19 patients in separate rooms can prevent infectious

agent transmission. Hospitals were advised to isolate COVID-19 patients to

reduce staff exposure and preserve high-level personal protective equipment that

has been in short supply.

Routine Infection Control Methods

There were few high-quality primary studies made explicitly to investigate

the best quality PPE for healthcare professionals caring for patients who had

COVID-19 infections and patients that are suspected to have COVID-19

infections. Since SARS-COV2 can spread through aerosol, droplet, and fomite,

supplemental routine infection control methods with the proper PPE, particularly

during surgical emergencies and aerosol-generating operations, was crucial. The

article written by Tan L., et al. (2020) further stated that every piece of biological

material needed to be considered potentially infected with SARS-COV2. Staff

members should have proper training in donning and be under the supervision of
a colleague while wearing and doffing PPE. For the patients suspected or verified

infected with COVID-19, surgical masks should be worn during their transfer to

and from the different rooms and wards.

Michaels, D. (n.d.) stated that employers were required to determine the

hazards to which their employees may be exposed, determine how likely that

exposure was to occur, and then select, develop, and plan measures to decrease

those hazards and likelihoods. In lieu of this, the Occupational Safety and Health

Association suggested combining common precautions such as contact

precautions, and airborne precautions which were goggles and face shields to

protect healthcare workers who had been exposed to the virus. Additionally, the

Centers for Disease Control and Prevention offered healthcare personnel the

most recent infection prevention and control recommendations for handling

suspected or verified COVID-19 infections. This entailed training healthcare

personnel in proper PPE usage. And as part of a comprehensive respiratory

protection program that complied with the requirements of OSHA's Respiratory

Protection standard, they advised healthcare workers exposed to suspected or

confirmed COVID-19 patients to utilize respiratory protection such as the use of

gowns, gloves, disposable N95 filters certified by NIOSH, and eye/face

protection. These strategies were aimed at all workers and employers to

decrease the risk of occupational exposure.

Related Studies

Infection Prevention and Control Guidance

“Healthcare employees, particularly physicians and nurses, form the

backbone of every country's healthcare system,” mentions Salwa, M. et al

(2022). Failure to safeguard them from infection while caring for their patients

has a detrimental influence on overall patient care and puts their own health at

risk. Despite the WHO's interim guideline on Infection Prevention and Control

(IPC) methods given last March 2020, a significant number of HCWs were still

being infected by the virus since the start of the COVID-19 pandemic.

Furthermore, multiple studies have provided the usefulness of using personal

protective equipment (PPE) appropriately in avoiding infection while treating

patients. As a result, HCWs' compliance with IPC recommendations must be

enforced to protect a functional health system by lowering infection rates among

front-line employees. Compliance, defined as the degree to which a person

follows instructions, is critical to infection control but has been found to be

suboptimal among HCWs prior to the pandemic. Even after the pandemic, HCWs'

IPC behavior had been found to be unsatisfactory in several countries. Several

factors had been identified as contributing to HCWs' low adherence to IPC

practices, including a lack of protective resources, insufficient guidelines on how

to use them, increased workload, fatigue, and so on.

According to the study by Mohammad, A., et al. 2022, to minimize the

transmission of the virus, billions of people all over the world stayed at home for

sustained periods. Several countries adopted preventive measures, such as

working from home, restrictions on international travel, lockdowns, social

distancing, and the replacement of face-to-face interactions with online services.

Factors that heighten the risk of COVID-19 infection include unprotected or

unsafe healthcare settings, poor handwashing facilities, lack of personal

protective equipment (PPE), and poor infection-prevention training. To decrease

the spread of COVID-19 and keep nurses and midwives safe, protective actions

need to be practiced in hospitals. Appropriate protective measures include using

PPE, regular hand washing, cleaning and disinfecting used materials and

equipment, effective bio-medical waste management, social distancing, personal

hygiene, and frequent screening for COVID-19 symptoms.

Based on the study of Park, S.H., MD, Ph.D., MPH (2020), the Division of

Infectious Diseases, Department of Internal Medicine, Daejeon St. Mary's

Hospital Healthcare workers (HCWs) were at significant risk of exposure because

of the coronavirus disease (COVID-19) pandemic, which had presented a

problem for healthcare systems. To ensure consistent patient care and keep

healthcare systems running, protecting HCWs is of utmost significance. Personal

protective equipment (PPE), used in conjunction with administrative and

engineering control measures, is the final line of defense and the main element

of security. According to recent statistics, respiratory droplets and close contact

were the major ways that the SARS-CoV-2 virus (severe acute respiratory

syndrome) is spread. While performing aerosol-generating processes, airborne

transmission might happen. The modes of transmission, particularly the potential

for airborne transmission when aerosol-generating processes were not carried

out, were yet unknown. As a result, there were considerable discrepancies in the

respiratory protection equipment that international and national organizations

advise using. HCWs in Korea were frequently unclear about what to wear and

when to wear it because of the numerous adjustments to PPE recommendations

that had been made, allowing alternatives in choosing PPE for respiratory and

physical protection. The danger of exposure and potential transmission

mechanisms are taken into consideration while choosing PPE. PPE offers varying

levels of protection depending on the standards and testing procedures used.

Therefore, choosing the right PPE requires an understanding of them. In this

article, the manner of SARS-COV-2 transmission is examined, the World Health

Organization's current PPE guidelines are contrasted with those in Korea, and

standard requirements and the appropriate PPE selection are covered.

In the study written by Bekele, T., et al., (2020) worded that illnesses

acquired while getting health treatment are referred to as Healthcare-Associated

Infections (HCAIs). HCAIs have become a major public health concern across the

world. Every year, hundreds of millions of patients and around three million

healthcare workers worldwide are affected by HCAIs, regardless of their

country's economic status. According to the European Center for Disease

Prevention and Control (CDC), the prevalence of HCAIs in European countries

ranges between 4.6% and 9.3%, it was also reported that five million patients

developed infections still despite the quality of healthcare, contributing to

135,000 deaths per year in Europe. The compliance with standard safety
precautions was critical to the quality of care and the protection of HCWs,

patients, and communities. Ethiopia, a third-world country, was said to have had

an incidence of dangerous infectious illnesses such as Hepatitis B, C, and Human

Immunodeficiency Virus (HIV) was that has spread endemically. The limited

preventative therapies available for these diseases did not help them in their

situation. Many of the microorganisms that caused HCAIs were hypothesized to

be found on the health care equipment used, septic hands, and the environment

that the patients and HCWs utilize. These pathogens were easily spread from

patient to patient, from HCW to patient, and vice-versa, resulting in increased

inpatient days, larger economic expenditures, and even the sad loss of life.

Compliance Obstacle

In a study made by Elshaer, N. et al. (2022), health teams in healthcare

facilities in regions with high community transmission were more likely to

encounter patients infected with COVID-19. Although HCWs play an important

role in lowering nosocomial transmission, they may also be a source of viral

transmission to their families and communities. COVID-19 poses a risk to

healthcare workers due to high occupational exposure, reliance on vaccination,

and not adhering to infection prevention and control (IPC) measures such as

personal protective equipment (PPE) use and hand cleanliness. The type of PPE

utilized in patient care varies depending on the environment, target staff or

patients, and activity. HCW-related variables (such as gender, age, profession,

knowledge, and perception) and organizational-related factors may influence

HCWs' compliance with IPC measures (such as availability of PPE, IPC guidelines,

training, workload, and hospital policy). Identification of compliance obstacles

and facilitators inside a healthcare institution would be critical to reducing

infection transmission by HCWs.

Nurses working in a chosen hospital in South-South Nigeria were assessed

for their knowledge, and compliance with preventive measures, and determine

the relationship between knowledge and practice of preventive strategies for

COVID-19 as stated by the study written by Odikpo, L., et al. (2022). The study

was conducted using a cross-sectional descriptive approach. The Census method

was used to recruit 378 nurses at the hospital who met the inclusion criteria for

the study. Based on the results, there were 360 nurses who had good knowledge

of the preventive measures for COVID-19, and 311 of the nurses adhered strictly

to the practice of the preventive strategies for COVID-19. Knowledge of COVID-

19 prevention measures is determined by education level and years of

experience, whereas compliance with COVID-19 prevention measures among

nurses is determined by their knowledge, sex, level of education, years of

experience, and unit of practice. Female nurses, nurses with RN/RM credentials,

nurses with more than five years of experience, and nurses working in the

maternity complex and children's ward considerably adhere to the COVID-19

prevention measures more than other nurses. In conclusion, health professionals

should continue to adopt more COVID-19 prevention measures. To reduce the

dangerous impact of the pandemic on healthcare professionals, particularly

nurses, it is necessary to put this information into adequate practice.

The study by Gozo, H.A. (2018) determined if nurses at a Level Three

Private Hospital in Naga City complied with infection control procedures. To

identify the staff nurses' personal and professional characteristics in terms of

age, sex, length of employment at the hospital, attendance at training and

seminars, and area of assignment, the study used the descriptive technique,

frequency, and percentage. Six head nurses and one hundred thirty-one regular

staff nurses were the responders who provided the data. To determine the

respondents' ratings of the degree of compliance with infection control

procedures, weighted mean and ranking were used. In addition to the

comparative method, One-way ANOVA was used to compare the staff nurses'

extent of compliance with infection control as rated by the head nurses and staff

nurses themselves. According to the findings, out of the 131 staff nurses from

the different areas of the hospital, majority of them are under the age ranging

21 to 35 years old, are female, and are single. The extent of compliance with

infection control practices had an overall GAWM of 4.67 (always). This indicates

that the staff nurses strictly adhere to infection control procedures. Also, there is

no significant difference between the ratings of head nurses and staff nurses in

the extent of compliance to infection control practices such as personal

protective barriers, cleaning and disinfecting, use of instruments and equipment,

and infection control instructions. This shows that the given components have no
difference from each other. Based on the study's findings, the researcher has

also recommended a skills-enhancement program that included basic

knowledge/concepts about infection control procedures in the form of

brochures/pamphlets to be distributed and discussed to staff nurses during their

regularly scheduled monthly meetings.

Management of Exposure of Healthcare Workers

As stated by Mohamad, N., et. al (2022), for infection prevention and

control, it is essential for healthcare workers to use safe procedures when

interacting with patients who have COVID-19. The purpose of this study was to

evaluate HCWs' adherence to infection prevention control and explore its

relationships with organizational and sociodemographic factors. A cross-sectional

study was conducted at public healthcare facilities in Malaysia. HCWs who

worked on COVID-19 cases were invited to take the online survey. The World

Health Organization's (WHO) Interim Guidance: WHO Risk Assessment and

Management of Exposure of Healthcare Workers in the Context of COVID-19

served as the basis for the development of the questionnaire. A total of 600

HCWs involved in COVID-19-related works participated in the survey and were

categorized as compliant or non-compliant to IPC. Most of them were compliant

with IPC as they responded to all items as “always, as recommended” during

interaction with patients with COVID-19. The results of the multivariate analysis

indicated that non-compliance was significantly correlated with working in the

emergency room, working as laboratory staff, working as a health attendant, and

other occupations, as well as having more than ten years of work experience.

The likelihood of non-compliance was higher among respondents who had

insufficient training in the new norms and personal protective equipment than

among those who had sufficient training. Even though most respondents

followed IPC rules, compliance levels varied by department, occupational

category, and years of service. To avoid IPC breaches and subsequently reduce

the risk of COVID-19 exposure and transmission in healthcare facilities, it is

essential to provide sufficient training that, ideally, results in behavioral change.

As mentioned by Zenbaba, D., et al. (2021), the healthcare systems of

various nations around the world were rocked and disturbed due to the COVID-

19 epidemic. The COVID-19 epidemic is undoubtedly spreading throughout

Africa, and efforts to combat it have been hampered by a lack of personnel,

personal protective equipment (PPE), infrastructure, and systems for prevention

as well as frail healthcare systems. Until December 26, 2020, there had been

more than 1.8 million recorded deaths and more than 80,3 million confirmed

cases worldwide. Health professionals (HPs) were on the front line of the battle

against the spread of the COVID-19 coronavirus. In every phase of the

pandemic, maintaining a safe working environment for health professionals and

an operational plan is essential. Realizing a thorough set of infection prevention

measures in all healthcare settings is a collective responsibility and essential to

safeguarding the well-being and lives of our valuable healthcare workforce as

well as essential to reducing the spread of the virus in both healthcare settings
and the community. The government of Ethiopia declared a state of emergency

and established a COVID-19 task force at the national level, which was in charge

of planning disease prevention strategies, providing regular situational updates,

and planning massive awareness-building campaigns using various social and

mass media platforms. The COVID-19 crisis provides a clear message to resilient

health systems that this message can only be achieved with dedicated health

personnel.

As stated in the study of Al-Faouri, I., et al. (2021), knowledge and

compliance with standard precautions were essential for healthcare workers to

prevent hospitals associated infections and protect their patients from exposure

to infectious agents. The purpose of this study was to evaluate the degree of

knowledge, compliance, and contributing variables for standard precautions

among registered nurses in the northern part of Jordan. A cross-sectional study

was conducted at two public hospitals and one at a university-affiliated hospital

in the North of Jordan. A questionnaire was distributed among 300 registered

nurses, and 266 of them completed the questionnaire. The survey suggests a

moderately positive relationship between the level of knowledge, years of

experience, and compliance with standard precautions. In conclusion, the

participants may have adequate levels of compliance and knowledge; however,

they need to improve their knowledge and compliance with infection-control

standard precautions. Educational institutes must focus on standard precautions

through training programs.

Lack of Sufficient Awareness

According to the study by Zeb, A. et al. (2019), Nurses' good compliance

with standard precautions can help prevent occupational exposure to infections.

The purpose of the study was to determine nurses’ knowledge, compliance, and

factors affecting their compliance with standard precautions in resource-scarce

settings. A cross-sectional study was conducted in three tertiary care public

sector hospitals in Peshawar to determine nurses’ knowledge, compliance, and

factors affecting their compliance with standard protocols. Through stratified

random sampling, a total of 199 registered nurses were recruited for the study.

Based on the result, both gender and infection control training were found to

have a significant relationship with compliance. Lack of resources, workload, and

a lack of infection control procedures were all recognized as contributing factors

to noncompliance with standard precautions. In conclusion, this study shows that

nurses in Peshawar's tertiary care hospitals lack sufficient awareness of and

compliance with standard precautions. The study recommends that the relevant

steps be taken by health authorities to create and implement infection control

practices in these facilities.