Effect of an Infection Prevention and Control Training Program on Hemodialysis Nurses’ Performance in Governmental Hospitals in the Gaza Strip: A True Experimental Study

Effect of an Infection Prevention and Control Training Program on Hemodialysis Nurses’ Performance in Governmental Hospitals in the Gaza Strip: A True Experimental Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of an Infection Prevention and Control Training Program on Hemodialysis Nurses’ Performance in Governmental Hospitals in the Gaza Strip: A True Experimental Study Mohamed Kuhail, Suliman Odeh Aladini, Mohammed Nimer, Susan Ali Zroog, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6714584/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Infection prevention and control (IPC) measures are essential in hemodialysis (HD) units because of the increased risk of healthcare-associated infections (HAIs). Nurses play a central role in the implementation of IPC protocols; however, adherence to these guidelines remains inconsistent. Objective: This study aimed to evaluate the effects of a structured IPC training program on the knowledge and practices of HD nurses working in governmental hospitals within the Gaza Strip (GS). Methods: A true experimental design was adopted, utilizing a census sampling technique to include all 112 HD nurses, who were randomly assigned to the intervention and control groups. The data collection tools included a self-structured questionnaire and an observational checklist, both of which were developed in accordance with the 2024 Centers for Disease Control and Prevention (CDC) guidelines. Statistical analysis was performed via SPSS version 26. Results: Compared with those in the control group, nurses in the intervention group exhibited statistically significant improvements in both IPC knowledge and practice. The mean knowledge score increased from 49.41 to 79.91 (P=0.001), representing a 61.73% improvement. Similarly, practical adherence rose from 47.6% to 68.9% (P=0.001), indicating a 44.59% improvement in IPC compliance. Conclusion: The IPC training program proved to be highly effective in enhancing the performance of HD nurses regarding infection control measures. These findings underscore the critical need for ongoing, structured IPC training, especially in resource-constrained healthcare settings, to ensure sustained improvements in infection prevention practices. Infection Prevention and Control Hemodialysis Nurses Healthcare-Associated Infections Nursing Performance Training Program 1. Background and justifications of the study Chronic kidney disease (CKD) is an increasing global health concern, with a prevalence of approximately 9.5%, on the basis of a comprehensive analysis involving 161 countries. The highest prevalence rates, reaching 12.8%, have been reported in Eastern and Central Europe ( 1 ). CKD rose from being the 25th leading cause of death in 1990 to the 16th leading cause in 2017, and it is projected to become the 5th leading cause of death by 2040 due to its increasing global burden ( 2 , 3 ). When kidney function declines, waste removal, fluid balance, and hormone regulation are impaired, leading to issues such as heart disease and hypertension ( 4 ). Hemodialysis (HD) units provide vital services for CKD patients but also pose a high risk for healthcare-associated infections (HAIs) because of their environment ( 5 ). HAIs significantly affect patient outcomes and are the second leading cause of death in CKD patients ( 6 ). Infection prevention and control (IPC) is essential in HD units, where frequent vascular access and weakened immunity increase infection risk ( 4 ). Nurses are central to HD care and must be well trained to provide safe and effective services ( 7 ). In the Gaza Strip (GS), limited resources, heavy workloads, and political instability hinder IPC practices, increasing the vulnerability of HD patients ( 8 ). Studies have shown that training improves nurses' IPC knowledge and practices. In the GS, most nurses are knowledgeable about vascular access, but ongoing training is still needed ( 9 ). Gaps in IPC compliance remain a concern ( 10 ). Regular training, management support, and supervision are key to increasing knowledge and reducing HAIs and antimicrobial resistance ( 11 , 12 ). The number of patients undergoing HD continues to rise, accompanied by high mortality rates compared with those of other diseases. Infection remains the second leading cause of death among HD patients ( 13 , 14 ). However, adherence to IPC practices among HD nurses is often inadequate. Ensuring patient safety is a key nursing goal, necessitating regular educational interventions to enhance nurses' knowledge and practice in IPC ( 15 ). However, compliance with IPC guidelines in the GS remains low due to resource limitations, insufficient training, and high nurse-to-patient ratios. These challenges are further compounded in GS by strained healthcare resources and geopolitical instability. Despite existing IPC protocols, high HAI rates persist, highlighting the urgent need for structured training programs to improve compliance. Studies indicate significant gaps in HD nurses' knowledge and adherence to IPC measures, emphasizing the necessity of sustainable educational initiatives to enhance nursing performance and patient care quality in resource-limited settings. Therefore, this study aims to assess the effect of the IPC training program on the performance of HD nurses in governmental hospitals in GS. 2. Methods and Materials Study design This study used a true experimental design with a census technique to assess the effect of a training program related to IPC guidelines on the performance of HD nurses at governmental hospitals in GS. Context of the study By mid-2024, the global Palestinian population was approximately 14.8 million, with 5.61 million in the State of Palestine. GS, with 2.1 million people, has experienced a 6% population decrease due to conflict-related casualties (16). Ongoing conflicts and blockades have devastated the healthcare system of GS, causing severe shortages and service disruptions and prompting urgent international intervention (17). Study Setting The study was conducted at governmental hospitals in the GS, specifically at HD units. These hospitals are Noor Al Kabee, Al-Rantisi Hospital, Al Shifa Medical Complex, Al Aqsa Martyr's Hospital, Hind Aldaghma Center, and Al Najjar Hospital, which face challenges such as limited resources, high patient loads, and geopolitical instability, which affect IPC practices. Study period The study lasted from November 2022 to December 2024 and began immediately after approval from the Ministry of Health (MoH) and Helsinki Ethics Committee (Institutional Review Board) in Gaza Strip. Study population The study population comprised all registered nurses (n=112) employed in HD units within governmental hospitals in the GS. Eligible participants were those currently working in HD units, who were available to attend the full duration of the IPC training program, and who provided informed consent to participate in the study. Nurses who were on official leave during the study period were excluded. Sample and sampling: A census sampling technique was employed, including all 112 HD nurses who met the inclusion criteria and agreed to participate. The participants were randomly allocated into two equal groups according to their serial numbers: those with odd numbers were assigned to the control group, whereas those with even numbers were placed in the intervention group. Data collection t ool The researcher used a self-structured questionnaire and observational checklist, which was based on the Palestinian HD IPC guidelines (18), and the Centers for Disease Control and Prevention checklist (4), to assess HD nurses' knowledge and practices before and after training. An English version of both the questionnaire and the observational checklist has been uploaded as Supplementary File 1 and is cited accordingly in the manuscript. Structured Questionnaire of Knowledge on IPC in Hemodialysis Procedures: The structured questionnaire, which was administered in English, had two parts: the first included HD nurses' personal details (gender, age, education, and experience), and the second included 21 multiple-choice questions on IPC guidelines related to HD procedures. Observational checklist on IPC skills related to hemodialysis: The tool assessed HD nurses' perceived IPC skill confidence via a 73-step checklist. The responses were rated on a three-point Likert scale (0 = not done, 1 = done, needs remediation, 2 = done successfully), with the average score calculated by dividing the total score by the number of items. PC training program and data collection technique To fulfill the study objectives, data were collected in two phases. Before the initiation of data collection, preparatory arrangements were made for the IPC training program in coordination with hospital management. A convenient schedule was established to ensure the availability of participants. The researcher provided a clear explanation of the study's objectives, significance, procedures, and eligibility criteria to the nurses. Those who met the inclusion criteria and consented to participate were invited to complete the baseline questionnaire. Phase 1: Preintervention data collection In the initial phase, the researcher administered a self-structured questionnaire alongside an observational checklist to gather baseline data on participants’ sociodemographic characteristics, knowledge, practices, and self-perceived confidence in infection prevention and control (IPC) skills. This data collection occurred before the implementation of the training intervention. Phase 2: Intervention phase The intervention involved a one-month infection prevention and control (IPC) training program comprising both educational and practical components. To ensure the continuity of hospital operations, the intervention group was divided into smaller subgroups for training. An IPC expert researcher conducted all the sessions, which included interactive lectures, group discussions, and printed handouts aligned with IPC guidelines specific to hemodialysis (HD) units. During the practical component, nurses engaged in hands-on training with real clinical scenarios, where they were required to demonstrate IPC skills individually and repeatedly until each step was performed accurately. Phase 3: Data collection (immediately posttest ): After training, the researcher reassessed IPC knowledge and practices via the same pretest questionnaire and compared the results with those of the control group to evaluate the training's impact. Pilot study The data collection tools were developed by the researcher on the basis of a comprehensive review of the relevant literature. The tools included (1) a structured questionnaire designed to assess hemodialysis (HD) nurses' knowledge of infection prevention and control (IPC), incorporating demographic data and 21 multiple-choice questions based on IPC guidelines, and (2) a CDC-based observational checklist including 73 steps to evaluate nurses’ IPC practices. Content validity was established through expert review by 11 professionals, including HD unit nurses, academic researchers, and IPC specialists. A pilot study was then conducted on 10% of the target sample (12 HD nurses) to evaluate the feasibility, clarity, and applicability of the tools, resulting in minor modifications. Reliability testing via Cronbach’s alpha revealed strong internal consistency for both tools: (r=0.899) for the knowledge questionnaire and (r=0.921) for the observational checklist. 3. Results and Discussion The study included a total of 112 HD nurses, who were evenly divided into control and intervention groups (n=56 each). The highest proportion of participants were from Al Shifa Hospital (29.5%), followed by Nasser Al Ka'bey and Helal Al Daghma Hospitals (19.6% each). The mean age of the participants was 35.76 ± 7.31 years, with the majority (54.5%) aged between 31 and 40 years. Male nurses comprised 71.4% of the sample, and 78.6% held a bachelor's degree. Most participants (91%) were working in adult HD units, and the average duration of work experience was 5.79 ± 5.12 years. More than half of the nurses (50.9%) reported never having received IPC training, whereas among those who had, 77.7% had received training more than five years prior, highlighting the critical need for updated and regular IPC refresher courses (see Table 1 ). The findings presented in Table 2 demonstrate a statistically significant improvement in IPC knowledge and practices among nurses in the intervention group following the training program compared with those in the control group. Post-training, the mean knowledge score in the intervention group increased to 79.91 compared with 49.41 in the control group (P=0.001), representing an overall knowledge gain of 61.73%. Likewise, IPC practice scores improved markedly in the intervention group (mean: 68.9 vs. 47.6, P=0.001), indicating a 44.59% increase in adherence to IPC protocols. Practical skills in the intervention group also improved significantly (mean score: 1.378 vs. 0.953, P=0.001), with most IPC domains showing statistically significant enhancements (P=0.001). Despite these gains, certain practices, such as routine disinfection, showed only marginal improvement (P=0.078), likely reflecting persistent challenges such as limited resources and high patient-to-nurse ratios. These findings are consistent with prior research by Tabash, Kashkash (19) and Eljedi and Dalo (10), who reported similar post-training improvements in IPC adherence among Palestinian HD nurses. Additionally, the results align with those of Singh, Kaur (20), who reported a 50% increase in IPC compliance following training interventions in northern India. Noteworthy improvements were observed in specific clinical procedures, including arteriovenous fistula/graft cannulation (P=0.001) and catheter disconnection care (P=0.001), supporting the results of Tannous, El-Saed (21) and Kadium (22). However, other domains, such as medication administration (P=0.393) and linen management (P=0.234), showed minimal gains, suggesting the need for supplementary strategies beyond training, such as workflow optimization and strict policy enforcement, to achieve sustained IPC compliance. This is supported by Tu, Elling (23), who emphasized that nurses in high-pressure environments may prioritize task efficiency over protocol adherence, despite adequate training. Overall, the study confirms that while hands-on IPC training is effective in enhancing both knowledge and practical skills, achieving long-term compliance requires addressing systemic barriers through continuous education, simulated practice, and structured feedback mechanisms to reinforce behavioral change. The results in Table 3 reveal significant variations in IPC knowledge and practices across different hospitals, HD units, age groups, genders, education levels, professional experience, and prior training. Among hospitals, Al Najjar Hospital’s control group presented lower IPC practice scores, whereas nurses from Al Rantesy Hospital in the intervention group presented significantly greater IPC knowledge and practices (P=0.001). Pediatric HD nurses consistently outperformed adult HD nurses in both knowledge and practice post-intervention (P=0.022, P=0.001), which is a trend that is consistent with the findings of Mohamed and Fashafsheh (24) and the World Health Organization (25), who attributed this to the high acuity of care in pediatric units. While no significant age-related differences were found in IPC knowledge (P=0.091, P=0.181) or practice (P=0.112, P= 0.657), younger nurses scored higher in IPC practice (≤30 years: 1.003 vs. >40 years: 0.812), which aligns with findings by Trifunovic-Koenig, Bushuven (26) on adaptability to evolving protocols. Gender differences in IPC adherence were statistically insignificant, although female nurses slightly outperformed male nurses in practice (P=0.253), which is consistent with the findings of Trifunovic-Koenig, Bushuven (26) but contradicts the findings of Alsulami, Sacgaca (27), suggesting that external factors such as workload distribution play a role. Education level was a significant determinant of IPC knowledge, with master’s degree holders scoring higher than diploma or bachelor-level nurses (P=0.047, P=0.015), yet practice scores did not show a corresponding increase (P=0.112), underscoring the persistent "know-do gap" (28). Professional experience did not significantly impact IPC knowledge (P=0.941, P=0.391) or practice (P=0.211, P=0.603), reinforcing findings from Savul, Ikram (29) that structured training, rather than experience, determines compliance. Similarly, prior training had no significant influence on IPC knowledge (P=0.142, p = 0.381) or practice (P=0.312, P=0.076), suggesting that one-time training is insufficient for sustained adherence and emphasizing the need for continuous, structured IPC programs (25, 29). The observed disparities across hospitals, unit types, and demographics underscore the importance of targeted IPC training tailored to specific institutional and workforce needs. Despite significant knowledge improvements post-intervention, the persistent knowledge‒practice gap suggests that systemic barriers such as resource limitations, high workload, and institutional policies may hinder IPC adherence. These findings highlight the need for sustained mentorship programs, periodic refresher training, and stronger policy enforcement to bridge the gap between theoretical knowledge and practical application, ensuring long-term improvements in IPC compliance across all HD settings. Conclusion and recommendations The findings of this study confirm that the IPC training program had a significant positive effect on nurses’ knowledge and practices within HD units in governmental hospitals in the Gaza Strip. Notably, significant associations were identified between knowledge scores and factors such as workplace, HD unit type, and educational level. Conversely, no significant relationships were found with age, gender, years of experience, or prior IPC training. These results emphasize the importance of sustained and structured IPC training programs to increase the quality and safety of care, particularly in resource-limited healthcare settings. In light of these findings, the study recommends the following actions: (1) Implement regular and mandatory IPC training for HD nurses in Gaza hospitals. (2) Integrate IPC principles into nursing education curricula to ensure foundational infection control competencies. (3) Conduct periodic assessments of IPC training effectiveness to support continuous professional development. (4) Allocate adequate resources to facilitate the proper implementation of IPC measures. (5) Promotion of multidisciplinary collaboration by involving all healthcare professionals in IPC activities to foster a culture of safety. (6) Expand IPC training to other hospital departments and support further research to enhance infection control practices. (7) Enforce IPC guidelines through continuous supervision, routine updates, and clear accountability measures. Abbreviations APIC, Association for Professionals in Infection Control and Epidemiology; CDC, Centers for Disease Control and Prevention; CKD, Chronic Kidney Disease; GS, Gaza Strip; HAI, Healthcare-Associated Infection; HD, Hemodialysis; IPC, Infection Prevention and Control; MoH, Ministry of Health; P, P-value (statistical significance); PCBS, Palestinian Central Bureau of Statistics; SD, Standard Deviation; SPSS, Statistical Package for the Social Sciences. Declarations Ethics approval and consent to participate The study was approved by the Ministry of Health (MoH) and Helsinki Ethics Committee (Institutional Review Board) in Gaza Strip (Correspondence Number: 1242842). Written informed consent was obtained from all participants prior to their inclusion in the study. Participation was entirely voluntary, and strict measures were taken to ensure confidentiality and anonymity. All procedures were conducted in accordance with the ethical standards of the institutional and national research committees and with the principles of the Declaration of Helsinki. Consent for publication The authors take full responsibility for ensuring that all participants provided informed written consent for the use and publication of non-identifiable data. No personal identifiers are disclosed in this manuscript. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests Author SOA developed the questionnaire used in this study. However, no financial gain or conflict of interest is associated with its use. The other authors declare no competing interests . Funding This research received no external funding. It was self-supported by the authors and conducted with administrative and logistical support from governmental hospitals in the Gaza Strip. Authors' contributions M.K. conceptualized the study, developed the methodology, collected data, performed statistical analysis, and prepared the original draft. S.O.A. conducted the literature review, implemented the training, validated instruments, and interpreted data. M.J.A.N. supervised the project, provided critical revisions, and validated the research process. S.A.Z. coordinated data verification and reviewed the manuscript. Y.F.F. contributed to data analysis, visualization, and technical support. O.M.O.K. assisted with training implementation, instrument validation, and institutional coordination. All authors reviewed and approved the final manuscript. Acknowledgements The authors would like to thank the Ministry of Health in the Gaza Strip and the administrative leaders of the participating hospitals for their support. Special appreciation goes to the hemodialysis nurses who committed their time and effort to the study. The authors also acknowledge the valuable contributions of IPC experts who assisted with tool validation and training execution. References Bello AK, Okpechi IG, Levin A, Ye F, Damster S, Arruebo S, et al. An update on the global disparities in kidney disease burden and care across world countries and regions. Lancet Global Health. 2024;12(3):e382–95. Kaur KP, Chaudry MS, Fosbøl EL, Østergaard L, Torp-Pedersen C, Bruun NE. Temporal changes in cardiovascular disease and infections in dialysis across a 22-year period: a nationwide study. BMC Nephrol. 2021;22:1–11. Bikbov B, Purcell CA, Levey AS, Smith M, Abdoli A, Abebe M, et al. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. lancet. 2020;395(10225):709–33. Centers for Disease Control and Prevention. CDC National Healthcare Safety Network (NHSN). Dialysis prevention process measures (PPM) 2022. Available from: https://www.cdc.gov/nhsn/dialysis/process-measures/index.html Vijayan A, Boyce JM. 100% use of infection control procedures in hemodialysis facilities: call to action. Clin J Am Soc Nephrol. 2018;13(4):671–3. Abbasi SH, Aftab RA, Lai PSM, Lim SK, Zainol Abidin RN. Impact of healthcare associated infections on survival and treatment outcomes among end stage renal disease patients on renal replacement therapy. Front Pharmacol. 2021;12:707511. Aldowha AM, Ahmed HM, Mukhtar HME. Nurses’ Knowledge regarding Safety Measures toward Blood Borne Diseases in Hemodialysis Units, At Khartoum State-Sudan (2021–2022). 2022. Lubbad M, Aloul E, Botcher B. Adherence to US Center for Disease Control and Prevention infection control guidelines in the haemodialysis care unit at Dar Al-Shifa Hospital in the Gaza Strip: a clinical audit. Lancet. 2022;399:S39. Abu E-K, Sd, Ahmed N, Kannan T, Abu Shediq N, El Dirani E. Nurses’ knowledge toward hemodialysis vascular access devices: A cross-sectional study in Palestine. SAGE Open Med. 2024;12:20503121241264444. Eljedi A, Dalo S. Compliance with the national palestinian infection prevention and control protocol at governmental paediatric hospitals in gaza governorates. Sultan Qaboos Univ Med J. 2014;14(3):e375. APIC AfPiICaE. What are healthcare-associated infections? 2022. Available from: https://apic.org/monthly_alerts/what-are-healthcare-associated-infections/ Centers for Disease Control and Prevention. CDC Training: Infection prevention in dialysis settings 2023. Available from: https://www.cdc.gov/dialysis-safety/hcp/training/index.html Palmer SC, De Berardis G, Craig JC, Tong A, Tonelli M, Pellegrini F, et al. Patient satisfaction with in-centre haemodialysis care: an international survey. BMJ open. 2014;4(5):e005020. Moursy A, Sharaf A. Vascular access care at hemodialysis unit; nurses compliance to infection prevention and control practices. IORS J Nurs Health Sci. 2017;6(2):6–10. Karkar A. Infection control guidelines in hemodialysis facilities. Kidney Res Clin Pract. 2018;37(1):1. Palestinian Central Bureau of Statistics. PCBS Population and demographic characteristics of the Gaza Strip. 2024. Palestinian Ministry of Health. MOH Annual Report of Hospitals in Gaza. Gaza: The Palestinian Health Information System Centre. 2025. Alabadla R. Infection Control and Prevention Policies and Procedures Guide for Hemodialysis Units. Gaza Strip: Ministry of Health; 2018. Tabash M, Kashkash R, Eljedi A. Compliance of health-care staff toward infection control precautions in hemodialysis units–Gaza governorates. Innovare J Health Sci. 2018;6(1):34–40. Singh S, Kaur K, Saini RS, Singh S, Aggarwal HK, Chandra H. Impact of structured training program about Hospital Infection Control practices on Knowledge and Perception of nursing students at public and private nursing teaching institute of Northern India-An interventional study. J Educ health promotion. 2023;12(1):168. Tannous E, El-Saed A, Ameer K, Khalaf A, Mohammad S, Molaeb B, et al. Infection prevention and control staffing and programs in Middle Eastern Countries. J Infect Developing Ctries. 2022;16(05):889–96. Kadium MJ. Improving nurses' knowledge to reduce catheter-related bloodstream infection in hemodialysis unit. Walden University; 2015. Tu R, Elling H, Behnke N, Tseka JM, Kafanikhale H, Mofolo I, et al. A qualitative study of barriers and facilitators to adequate environmental health conditions and infection control for healthcare workers in Malawi. H2Open J. 2022;5(1):11–25. Mohamed SA, Fashafsheh IH. The effect of simulation-based training on nursing students’ communication skill, self-efficacy and clinical competence for nursing practice. Open J Nurs. 2019;9(08):855. World Health Organization. WHO multimodal improvement strategy summary 2021. Available from: https://www.who.int/publications/m/item/who-multimodal-improvement-strategy-summary Trifunovic-Koenig M, Bushuven S, Gerber B, Otto B, Dettenkofer M, Salm F, et al. Correlation between overconfidence and learning motivation in postgraduate infection prevention and control training. Int J Environ Res Public Health. 2022;19(9):5763. Alsulami A, Sacgaca L, Pangket P, Pasay-An E, Al Amoudi FA, Alreshidi MS, et al. editors. Exploring the Relationship Between Knowledge, Attitudes, Self-Efficacy, and Infection Control Practices Among Saudi Arabian Nurses: A Multi-Center Study. Healthcare: MDPI; 2025. World Health Organization. Global report on infection prevention and control. Geneva: World Health Organization 2022. Available from: https://www.who.int/publications/i/item/9789240051164 Savul S, Ikram A, Khan MA, Khan MA. Evaluation of infection prevention and control training workshops using kirkpatrick's model. Int J Infect Dis. 2021;112:76–80. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Englishversionofthefinaltools.pdf Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6714584","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477507282,"identity":"c607c6a8-1246-446b-a3c5-024511849769","order_by":0,"name":"Mohamed Kuhail","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIie3QMWvCQBTA8XcELsuTrE8i7SconAhBEfwuR8Cp0EKhi2JPAm/UtV+jizhGDpIlH0Dp5N7FpdSl1LhKom5F7j/ccPDj3j0Al+tfJsEDoFYAngFhjlfqIoJNI64jgCq9lDwYOQyfx13s5Kvpbr8cPIGfLEgsJ5UkSmUWvmeEUaETahZxz2D2SqKwNcTnEOWBpNpQmz0F9BiR4PQM+SXszLfJj+Y3BfdfJTkzWIMJFWmmFdvDK1gSr5pYGfcbM0Jab7k35VxJHL50dd1fcm5/4vfkLpjHdrPnkQp8+7He1WwMTgaQ5aFNtahIXE9cLpfrdvsD/M1LFtURBdEAAAAASUVORK5CYII=","orcid":"","institution":"Al-Azhar University","correspondingAuthor":true,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Kuhail","suffix":""},{"id":477507283,"identity":"55c33877-685f-43c9-98aa-d18da0db1c10","order_by":1,"name":"Suliman Odeh Aladini","email":"","orcid":"","institution":"Al Shifa Medical Complex","correspondingAuthor":false,"prefix":"","firstName":"Suliman","middleName":"Odeh","lastName":"Aladini","suffix":""},{"id":477507284,"identity":"b7b08b05-a47c-4fab-9bdd-45bf4f53fcdf","order_by":2,"name":"Mohammed Nimer","email":"","orcid":"","institution":"International University of Africa","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Nimer","suffix":""},{"id":477507285,"identity":"064917c0-d807-44fb-a44a-e2203d396e73","order_by":3,"name":"Susan Ali Zroog","email":"","orcid":"","institution":"Omar Al-Mukhtar University","correspondingAuthor":false,"prefix":"","firstName":"Susan","middleName":"Ali","lastName":"Zroog","suffix":""},{"id":477507286,"identity":"7cd55b54-9faa-44f6-b762-53cc35616bff","order_by":4,"name":"Yousef F. Fahajan","email":"","orcid":"","institution":"University College of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Yousef","middleName":"F.","lastName":"Fahajan","suffix":""},{"id":477507287,"identity":"e2e4db48-5293-41b1-838d-5d2c185be875","order_by":5,"name":"Omar Khattab","email":"","orcid":"","institution":"University College of Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Khattab","suffix":""}],"badges":[],"createdAt":"2025-05-21 08:53:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6714584/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6714584/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96274948,"identity":"198b0f22-637c-4f67-8cb4-4008734a0118","added_by":"auto","created_at":"2025-11-19 09:54:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":669865,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6714584/v1/27774ba6-48ee-44f2-a47f-bc7b00c3e893.pdf"},{"id":85646761,"identity":"03a883fe-0932-4b60-8a51-ba9579df2f6e","added_by":"auto","created_at":"2025-06-30 08:43:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":695388,"visible":true,"origin":"","legend":"","description":"","filename":"Englishversionofthefinaltools.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6714584/v1/69a4b91f45af6e29c3ec4b2b.pdf"},{"id":85646756,"identity":"af14c5cf-8cb7-419c-b1eb-7bc2c86f58dc","added_by":"auto","created_at":"2025-06-30 08:43:40","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25486,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6714584/v1/7ada1bfca72bd1d03ba30174.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of an Infection Prevention and Control Training Program on Hemodialysis Nurses’ Performance in Governmental Hospitals in the Gaza Strip: A True Experimental Study","fulltext":[{"header":"1. Background and justifications of the study","content":"\u003cp\u003eChronic kidney disease (CKD) is an increasing global health concern, with a prevalence of approximately 9.5%, on the basis of a comprehensive analysis involving 161 countries. The highest prevalence rates, reaching 12.8%, have been reported in Eastern and Central Europe (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). CKD rose from being the 25th leading cause of death in 1990 to the 16th leading cause in 2017, and it is projected to become the 5th leading cause of death by 2040 due to its increasing global burden (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). When kidney function declines, waste removal, fluid balance, and hormone regulation are impaired, leading to issues such as heart disease and hypertension (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Hemodialysis (HD) units provide vital services for CKD patients but also pose a high risk for healthcare-associated infections (HAIs) because of their environment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). HAIs significantly affect patient outcomes and are the second leading cause of death in CKD patients (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Infection prevention and control (IPC) is essential in HD units, where frequent vascular access and weakened immunity increase infection risk (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNurses are central to HD care and must be well trained to provide safe and effective services (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In the Gaza Strip (GS), limited resources, heavy workloads, and political instability hinder IPC practices, increasing the vulnerability of HD patients (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Studies have shown that training improves nurses' IPC knowledge and practices. In the GS, most nurses are knowledgeable about vascular access, but ongoing training is still needed (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Gaps in IPC compliance remain a concern (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Regular training, management support, and supervision are key to increasing knowledge and reducing HAIs and antimicrobial resistance (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe number of patients undergoing HD continues to rise, accompanied by high mortality rates compared with those of other diseases. Infection remains the second leading cause of death among HD patients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, adherence to IPC practices among HD nurses is often inadequate. Ensuring patient safety is a key nursing goal, necessitating regular educational interventions to enhance nurses' knowledge and practice in IPC (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, compliance with IPC guidelines in the GS remains low due to resource limitations, insufficient training, and high nurse-to-patient ratios. These challenges are further compounded in GS by strained healthcare resources and geopolitical instability. Despite existing IPC protocols, high HAI rates persist, highlighting the urgent need for structured training programs to improve compliance. Studies indicate significant gaps in HD nurses' knowledge and adherence to IPC measures, emphasizing the necessity of sustainable educational initiatives to enhance nursing performance and patient care quality in resource-limited settings. Therefore, this study aims to assess the effect of the IPC training program on the performance of HD nurses in governmental hospitals in GS.\u003c/p\u003e"},{"header":"2. Methods and Materials","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study used a true experimental design with a census technique to assess the effect of a training program related to IPC guidelines on the performance of HD nurses at governmental hospitals in GS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContext of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy mid-2024, the global Palestinian population was approximately 14.8 million, with 5.61 million in the State of Palestine. GS, with 2.1 million people, has experienced a 6% population decrease due to conflict-related casualties (16). Ongoing conflicts and blockades have devastated the healthcare system of GS, causing severe shortages and service disruptions and prompting urgent international intervention (17).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at governmental hospitals in the GS, specifically at HD units. These hospitals are Noor Al Kabee, Al-Rantisi Hospital, Al Shifa Medical Complex, Al Aqsa Martyr's Hospital, Hind Aldaghma Center, and Al Najjar Hospital, which face challenges such as limited resources, high patient loads, and geopolitical instability, which affect IPC practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy period\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study lasted from November 2022 to December 2024 and began immediately after approval from the Ministry of Health (MoH) and Helsinki Ethics Committee (Institutional Review Board) in Gaza Strip.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population comprised all registered nurses (n=112) employed in HD units within governmental hospitals in the GS. Eligible participants were those currently working in HD units, who were available to attend the full duration of the IPC training program, and who provided informed consent to participate in the study. Nurses who were on official leave during the study period were excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample and sampling:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA census sampling technique was employed, including all 112 HD nurses who met the inclusion criteria and agreed to participate. The participants were randomly allocated into two equal groups according to their serial numbers: those with odd numbers were assigned to the control group, whereas those with even numbers were placed in the intervention group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection t\u003c/strong\u003e\u003cstrong\u003eool\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researcher used a self-structured questionnaire and observational checklist, which was based on the Palestinian HD IPC guidelines (18), and the Centers for Disease Control and Prevention checklist (4), to assess HD nurses' knowledge and practices before and after training. An English version of both the questionnaire and the observational checklist has been uploaded as \u003cstrong\u003eSupplementary File 1\u003c/strong\u003e and is cited accordingly in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructured Questionnaire of \u003c/strong\u003e\u003cstrong\u003eKnowledge\u003c/strong\u003e\u003cstrong\u003e on IPC in \u003c/strong\u003e\u003cstrong\u003eHemodialysis Procedures:\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc191655719\"\u003eThe structured questionnaire, which was administered in English, had two parts: the first included HD nurses' personal details (gender, age, education, and experience), and the second included 21 multiple-choice questions on IPC guidelines related to HD procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObservational checklist on IPC skills related to \u003c/strong\u003e\u003cstrong\u003ehemodialysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc193282967\"\u003eThe tool assessed HD nurses' perceived IPC skill confidence via a 73-step checklist. The responses were rated on a three-point Likert scale (0 = not done, 1 = done, needs remediation, 2 = done successfully), with the average score calculated by dividing the total score by the number of items.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePC \u003c/strong\u003e\u003cstrong\u003etraining\u003c/strong\u003e\u003cstrong\u003e program and data collection technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo fulfill the study objectives, data were collected in two phases. Before the initiation of data collection, preparatory arrangements were made for the IPC training program in coordination with hospital management. A convenient schedule was established to ensure the availability of participants. The researcher provided a clear explanation of the study's objectives, significance, procedures, and eligibility criteria to the nurses. Those who met the inclusion criteria and consented to participate were invited to complete the baseline questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 1: \u003c/strong\u003e\u003cstrong\u003ePreintervention\u003c/strong\u003e\u003cstrong\u003e data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the initial phase, the researcher administered a self-structured questionnaire alongside an observational checklist to gather baseline data on participants’ sociodemographic characteristics, knowledge, practices, and self-perceived confidence in infection prevention and control (IPC) skills. This data collection occurred before the implementation of the training intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 2: \u003c/strong\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003cstrong\u003e phase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention involved a one-month infection prevention and control (IPC) training program comprising both educational and practical components. To ensure the continuity of hospital operations, the intervention group was divided into smaller subgroups for training. An IPC expert researcher conducted all the sessions, which included interactive lectures, group discussions, and printed handouts aligned with IPC guidelines specific to hemodialysis (HD) units. During the practical component, nurses engaged in hands-on training with real clinical scenarios, where they were required to demonstrate IPC skills individually and repeatedly until each step was performed accurately.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhase 3: \u003c/strong\u003e\u003cstrong\u003eData\u003c/strong\u003e\u003cstrong\u003e collection (immediately \u003c/strong\u003e\u003cstrong\u003eposttest\u003c/strong\u003e\u003cstrong\u003e):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter training, the researcher reassessed IPC knowledge and practices via the same pretest questionnaire and compared the results with those of the control group to evaluate the training's impact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePilot study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collection tools were developed by the researcher on the basis of a comprehensive review of the relevant literature. The tools included (1) a structured questionnaire designed to assess hemodialysis (HD) nurses' knowledge of infection prevention and control (IPC), incorporating demographic data and 21 multiple-choice questions based on IPC guidelines, and (2) a CDC-based observational checklist including 73 steps to evaluate nurses’ IPC practices. Content validity was established through expert review by 11 professionals, including HD unit nurses, academic researchers, and IPC specialists. A pilot study was then conducted on 10% of the target sample (12 HD nurses) to evaluate the feasibility, clarity, and applicability of the tools, resulting in minor modifications. Reliability testing via Cronbach’s alpha revealed strong internal consistency for both tools: (r=0.899) for the knowledge questionnaire and (r=0.921) for the observational checklist.\u003c/p\u003e"},{"header":"3. Results and Discussion","content":"\u003cp\u003eThe study included a total of 112 HD nurses, who were evenly divided into control and intervention groups (n=56 each). The highest proportion of participants were from Al Shifa Hospital (29.5%), followed by Nasser Al Ka'bey and Helal Al Daghma Hospitals (19.6% each). The mean age of the participants was 35.76 ± 7.31 years, with the majority (54.5%) aged between 31 and 40 years. Male nurses comprised 71.4% of the sample, and 78.6% held a bachelor's degree. Most participants (91%) were working in adult HD units, and the average duration of work experience was 5.79 ± 5.12 years. More than half of the nurses (50.9%) reported never having received IPC training, whereas among those who had, 77.7% had received training more than five years prior, highlighting the critical need for updated and regular IPC refresher courses (see \u003cstrong\u003eTable 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe findings presented in Table 2 demonstrate a statistically significant improvement in IPC knowledge and practices among nurses in the intervention group following the training program compared with those in the control group. Post-training, the mean knowledge score in the intervention group increased to 79.91 compared with 49.41 in the control group (P=0.001), representing an overall knowledge gain of 61.73%. Likewise, IPC practice scores improved markedly in the intervention group (mean: 68.9 vs. 47.6, P=0.001), indicating a 44.59% increase in adherence to IPC protocols. Practical skills in the intervention group also improved significantly (mean score: 1.378 vs. 0.953, P=0.001), with most IPC domains showing statistically significant enhancements (P=0.001).\u003c/p\u003e\n\u003cp\u003eDespite these gains, certain practices, such as routine disinfection, showed only marginal improvement (P=0.078), likely reflecting persistent challenges such as limited resources and high patient-to-nurse ratios. These findings are consistent with prior research by Tabash, Kashkash (19) and Eljedi and Dalo (10), who reported similar post-training improvements in IPC adherence among Palestinian HD nurses. Additionally, the results align with those of Singh, Kaur (20), who reported a 50% increase in IPC compliance following training interventions in northern India.\u003c/p\u003e\n\u003cp\u003eNoteworthy improvements were observed in specific clinical procedures, including arteriovenous fistula/graft cannulation (P=0.001) and catheter disconnection care (P=0.001), supporting the results of Tannous, El-Saed (21) and Kadium (22). However, other domains, such as medication administration (P=0.393) and linen management (P=0.234), showed minimal gains, suggesting the need for supplementary strategies beyond training, such as workflow optimization and strict policy enforcement, to achieve sustained IPC compliance. This is supported by Tu, Elling (23), who emphasized that nurses in high-pressure environments may prioritize task efficiency over protocol adherence, despite adequate training.\u003c/p\u003e\n\u003cp\u003eOverall, the study confirms that while hands-on IPC training is effective in enhancing both knowledge and practical skills, achieving long-term compliance requires addressing systemic barriers through continuous education, simulated practice, and structured feedback mechanisms to reinforce behavioral change.\u003c/p\u003e\n\u003cp\u003eThe results in Table 3 reveal significant variations in IPC knowledge and practices across different hospitals, HD units, age groups, genders, education levels, professional experience, and prior training. Among hospitals, Al Najjar Hospital’s control group presented lower IPC practice scores, whereas nurses from Al Rantesy Hospital in the intervention group presented significantly greater IPC knowledge and practices (P=0.001). Pediatric HD nurses consistently outperformed adult HD nurses in both knowledge and practice post-intervention (P=0.022, P=0.001), which is a trend that is consistent with the findings of Mohamed and Fashafsheh (24) and the World Health Organization (25), who attributed this to the high acuity of care in pediatric units. While no significant age-related differences were found in IPC knowledge (P=0.091, P=0.181) or practice (P=0.112, P= 0.657), younger nurses scored higher in IPC practice (≤30 years: 1.003 vs. \u0026gt;40 years: 0.812), which aligns with findings by Trifunovic-Koenig, Bushuven (26) on adaptability to evolving protocols. Gender differences in IPC adherence were statistically insignificant, although female nurses slightly outperformed male nurses in practice (P=0.253), which is consistent with the findings of Trifunovic-Koenig, Bushuven (26) but contradicts the findings of Alsulami, Sacgaca (27), suggesting that external factors such as workload distribution play a role. Education level was a significant determinant of IPC knowledge, with master’s degree holders scoring higher than diploma or bachelor-level nurses (P=0.047, P=0.015), yet practice scores did not show a corresponding increase (P=0.112), underscoring the persistent \"know-do gap\" (28). Professional experience did not significantly impact IPC knowledge (P=0.941, P=0.391) or practice (P=0.211, P=0.603), reinforcing findings from Savul, Ikram (29) that structured training, rather than experience, determines compliance. Similarly, prior training had no significant influence on IPC knowledge (P=0.142, p = 0.381) or practice (P=0.312, P=0.076), suggesting that one-time training is insufficient for sustained adherence and emphasizing the need for continuous, structured IPC programs (25, 29). The observed disparities across hospitals, unit types, and demographics underscore the importance of targeted IPC training tailored to specific institutional and workforce needs. Despite significant knowledge improvements post-intervention, the persistent knowledge‒practice gap suggests that systemic barriers such as resource limitations, high workload, and institutional policies may hinder IPC adherence. These findings highlight the need for sustained mentorship programs, periodic refresher training, and stronger policy enforcement to bridge the gap between theoretical knowledge and practical application, ensuring long-term improvements in IPC compliance across all HD settings.\u003c/p\u003e"},{"header":"Conclusion and recommendations","content":"\u003cp\u003eThe findings of this study confirm that the IPC training program had a significant positive effect on nurses\u0026rsquo; knowledge and practices within HD units in governmental hospitals in the Gaza Strip. Notably, significant associations were identified between knowledge scores and factors such as workplace, HD unit type, and educational level. Conversely, no significant relationships were found with age, gender, years of experience, or prior IPC training. These results emphasize the importance of sustained and structured IPC training programs to increase the quality and safety of care, particularly in resource-limited healthcare settings. In light of these findings, the study recommends the following actions: (1) Implement regular and mandatory IPC training for HD nurses in Gaza hospitals. (2) Integrate IPC principles into nursing education curricula to ensure foundational infection control competencies. (3) Conduct periodic assessments of IPC training effectiveness to support continuous professional development. (4) Allocate adequate resources to facilitate the proper implementation of IPC measures. (5) Promotion of multidisciplinary collaboration by involving all healthcare professionals in IPC activities to foster a culture of safety. (6) Expand IPC training to other hospital departments and support further research to enhance infection control practices. (7) Enforce IPC guidelines through continuous supervision, routine updates, and clear accountability measures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAPIC, Association for Professionals in Infection Control and Epidemiology; CDC, Centers for Disease Control and Prevention; CKD, Chronic Kidney Disease; GS, Gaza Strip; HAI, Healthcare-Associated Infection; HD, Hemodialysis; IPC, Infection Prevention and Control; MoH, Ministry of Health; P, P-value (statistical significance); PCBS, Palestinian Central Bureau of Statistics; SD, Standard Deviation; SPSS, Statistical Package for the Social Sciences.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ministry of Health (MoH) and Helsinki Ethics Committee (Institutional Review Board) in Gaza Strip (Correspondence Number: 1242842). Written informed consent was obtained from all participants prior to their inclusion in the study. Participation was entirely voluntary, and strict measures were taken to ensure confidentiality and anonymity. All procedures were conducted in accordance with the ethical standards of the institutional and national research committees and with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors take full responsibility for ensuring that all participants provided informed written consent for the use and publication of non-identifiable data. No personal identifiers are disclosed in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor SOA developed the questionnaire used in this study. However, no financial gain or conflict of interest is associated with its use. The other authors declare no competing interests\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding. It was self-supported by the authors and conducted with administrative and logistical support from governmental hospitals in the Gaza Strip.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.K. conceptualized the study, developed the methodology, collected data, performed statistical analysis, and prepared the original draft. S.O.A. conducted the literature review, implemented the training, validated instruments, and interpreted data. M.J.A.N. supervised the project, provided critical revisions, and validated the research process. S.A.Z. coordinated data verification and reviewed the manuscript. Y.F.F. contributed to data analysis, visualization, and technical support. O.M.O.K. assisted with training implementation, instrument validation, and institutional coordination. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Ministry of Health in the Gaza Strip and the administrative leaders of the participating hospitals for their support. Special appreciation goes to the hemodialysis nurses who committed their time and effort to the study. The authors also acknowledge the valuable contributions of IPC experts who assisted with tool validation and training execution.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBello AK, Okpechi IG, Levin A, Ye F, Damster S, Arruebo S, et al. An update on the global disparities in kidney disease burden and care across world countries and regions. Lancet Global Health. 2024;12(3):e382\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur KP, Chaudry MS, Fosb\u0026oslash;l EL, \u0026Oslash;stergaard L, Torp-Pedersen C, Bruun NE. Temporal changes in cardiovascular disease and infections in dialysis across a 22-year period: a nationwide study. BMC Nephrol. 2021;22:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBikbov B, Purcell CA, Levey AS, Smith M, Abdoli A, Abebe M, et al. Global, regional, and national burden of chronic kidney disease, 1990\u0026ndash;2017: a systematic analysis for the Global Burden of Disease Study 2017. lancet. 2020;395(10225):709\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. CDC National Healthcare Safety Network (NHSN). Dialysis prevention process measures (PPM) 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/nhsn/dialysis/process-measures/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/nhsn/dialysis/process-measures/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVijayan A, Boyce JM. 100% use of infection control procedures in hemodialysis facilities: call to action. Clin J Am Soc Nephrol. 2018;13(4):671\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbbasi SH, Aftab RA, Lai PSM, Lim SK, Zainol Abidin RN. Impact of healthcare associated infections on survival and treatment outcomes among end stage renal disease patients on renal replacement therapy. Front Pharmacol. 2021;12:707511.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldowha AM, Ahmed HM, Mukhtar HME. Nurses\u0026rsquo; Knowledge regarding Safety Measures toward Blood Borne Diseases in Hemodialysis Units, At Khartoum State-Sudan (2021\u0026ndash;2022). 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLubbad M, Aloul E, Botcher B. Adherence to US Center for Disease Control and Prevention infection control guidelines in the haemodialysis care unit at Dar Al-Shifa Hospital in the Gaza Strip: a clinical audit. Lancet. 2022;399:S39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbu E-K, Sd, Ahmed N, Kannan T, Abu Shediq N, El Dirani E. Nurses\u0026rsquo; knowledge toward hemodialysis vascular access devices: A cross-sectional study in Palestine. SAGE Open Med. 2024;12:20503121241264444.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEljedi A, Dalo S. Compliance with the national palestinian infection prevention and control protocol at governmental paediatric hospitals in gaza governorates. Sultan Qaboos Univ Med J. 2014;14(3):e375.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAPIC AfPiICaE. What are healthcare-associated infections? 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apic.org/monthly_alerts/what-are-healthcare-associated-infections/\u003c/span\u003e\u003cspan address=\"https://apic.org/monthly_alerts/what-are-healthcare-associated-infections/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. CDC Training: Infection prevention in dialysis settings 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/dialysis-safety/hcp/training/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/dialysis-safety/hcp/training/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalmer SC, De Berardis G, Craig JC, Tong A, Tonelli M, Pellegrini F, et al. Patient satisfaction with in-centre haemodialysis care: an international survey. BMJ open. 2014;4(5):e005020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoursy A, Sharaf A. Vascular access care at hemodialysis unit; nurses compliance to infection prevention and control practices. IORS J Nurs Health Sci. 2017;6(2):6\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarkar A. Infection control guidelines in hemodialysis facilities. Kidney Res Clin Pract. 2018;37(1):1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalestinian Central Bureau of Statistics. PCBS Population and demographic characteristics of the Gaza Strip. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalestinian Ministry of Health. MOH Annual Report of Hospitals in Gaza. Gaza: The Palestinian Health Information System Centre. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlabadla R. Infection Control and Prevention Policies and Procedures Guide for Hemodialysis Units. Gaza Strip: Ministry of Health; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTabash M, Kashkash R, Eljedi A. Compliance of health-care staff toward infection control precautions in hemodialysis units\u0026ndash;Gaza governorates. Innovare J Health Sci. 2018;6(1):34\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh S, Kaur K, Saini RS, Singh S, Aggarwal HK, Chandra H. Impact of structured training program about Hospital Infection Control practices on Knowledge and Perception of nursing students at public and private nursing teaching institute of Northern India-An interventional study. J Educ health promotion. 2023;12(1):168.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTannous E, El-Saed A, Ameer K, Khalaf A, Mohammad S, Molaeb B, et al. Infection prevention and control staffing and programs in Middle Eastern Countries. J Infect Developing Ctries. 2022;16(05):889\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKadium MJ. Improving nurses' knowledge to reduce catheter-related bloodstream infection in hemodialysis unit. Walden University; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTu R, Elling H, Behnke N, Tseka JM, Kafanikhale H, Mofolo I, et al. A qualitative study of barriers and facilitators to adequate environmental health conditions and infection control for healthcare workers in Malawi. H2Open J. 2022;5(1):11\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamed SA, Fashafsheh IH. The effect of simulation-based training on nursing students\u0026rsquo; communication skill, self-efficacy and clinical competence for nursing practice. Open J Nurs. 2019;9(08):855.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO multimodal improvement strategy summary 2021. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/m/item/who-multimodal-improvement-strategy-summary\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/m/item/who-multimodal-improvement-strategy-summary\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrifunovic-Koenig M, Bushuven S, Gerber B, Otto B, Dettenkofer M, Salm F, et al. Correlation between overconfidence and learning motivation in postgraduate infection prevention and control training. Int J Environ Res Public Health. 2022;19(9):5763.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsulami A, Sacgaca L, Pangket P, Pasay-An E, Al Amoudi FA, Alreshidi MS, et al. editors. Exploring the Relationship Between Knowledge, Attitudes, Self-Efficacy, and Infection Control Practices Among Saudi Arabian Nurses: A Multi-Center Study. Healthcare: MDPI; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global report on infection prevention and control. Geneva: World Health Organization 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240051164\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240051164\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSavul S, Ikram A, Khan MA, Khan MA. Evaluation of infection prevention and control training workshops using kirkpatrick's model. Int J Infect Dis. 2021;112:76\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Infection Prevention and Control, Hemodialysis Nurses, Healthcare-Associated Infections, Nursing Performance, Training Program","lastPublishedDoi":"10.21203/rs.3.rs-6714584/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6714584/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Infection prevention and control (IPC) measures are essential in hemodialysis (HD) units because of the increased risk of healthcare-associated infections (HAIs). Nurses play a central role in the implementation of IPC protocols; however, adherence to these guidelines remains inconsistent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This study aimed to evaluate the effects of a structured IPC training program on the knowledge and practices of HD nurses working in governmental hospitals within the Gaza Strip (GS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A true experimental design was adopted, utilizing a census sampling technique to include all 112 HD nurses, who were randomly assigned to the intervention and control groups. The data collection tools included a self-structured questionnaire and an observational checklist, both of which were developed in accordance with the 2024 Centers for Disease Control and Prevention (CDC) guidelines. Statistical analysis was performed via SPSS version 26.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eCompared with those in the control group, nurses in the intervention group exhibited statistically significant improvements in both IPC knowledge and practice. The mean knowledge score increased from 49.41 to 79.91 (P=0.001), representing a 61.73% improvement. Similarly, practical adherence rose from 47.6% to 68.9% (P=0.001), indicating a 44.59% improvement in IPC compliance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe IPC training program proved to be highly effective in enhancing the performance of HD nurses regarding infection control measures. These findings underscore the critical need for ongoing, structured IPC training, especially in resource-constrained healthcare settings, to ensure sustained improvements in infection prevention practices.\u003c/p\u003e","manuscriptTitle":"Effect of an Infection Prevention and Control Training Program on Hemodialysis Nurses’ Performance in Governmental Hospitals in the Gaza Strip: A True Experimental Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-30 08:43:35","doi":"10.21203/rs.3.rs-6714584/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7a219f05-e4f1-499b-9ef5-e3ef56d2a269","owner":[],"postedDate":"June 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T09:54:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-30 08:43:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6714584","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6714584","identity":"rs-6714584","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}