Exploration of Themes from the Apllication of Standard Operational
Procedures Control Infection Nosocomial at X General Hospital
Dian Anggri Yanti, Pitriani, Samuel Ginting, Kardina Hayati and Tati Murni Karokaro
Faculty of nursing and physiotherapy Institut Kesehatan Medistra Lubuk Pakam
Keywords: Theme exploration, nosocomial infection, SOP of nosocomial control infection.
Abstract: Nosocomial infections are the most common complications in hospitals. One of the important methods to
prevent the risk of nosocomial infections in hospitals by controlling nosocomial standard.This study aims to
explore of themes from the apllication of standard operational prosedure (SOP) of nosocomial control
infectionat X general hospital Medan. The research design used is descriptive phenomenology. Participants
in this study were 10 nurses selected by purposive sampling technique. The data collected werein-depth
interviews completed with field notes and then made in verbatim and analyzed using Colaizzi's approach.
The results of the study found five themes: seek nurse prevention by strictly implementing SOP, safe
guarding nursing actions, ensuring satisfaction in nursing service, creating cooperation and effective
communication as the key to make patient safe and positive support from related hospital management
infection prevention and control. The results show that the nurse adheres to SOP of nosocomial control
infection to prevent the risk of nosocomial infections. This study can be used by hospitals, especially to
prevent and control infection teams increase support for nurses by conducting regular training about
prevent and control infection, so that increases understanding nurses about infection risk identification that
can occur every nurses workplace.
1 INTRODUCTION
Health risks and clinical risks are recognized as
major challenges in health care, in addition health
risks and clinical risks have created concerns and
challenges for the entire health process
(Farokhzadian et al, 2015). The potential risks
adversely affecting developing countries in
developing countries are far greater than the risk of
developing countries, as clinical risks can never be
completely eliminated (WHO, 2014).
Healthcare providers contribute to clinical
incidents that pose a threat to patient safety,
especially those who are the most healthcare
professionals in the hospital and constantly interact
with patients with various procedures and nursing
actions that are likely to cause errors and threaten
patient safety. In addition, fatigue in the nurse is a
contributing factor to errors (Mattox, 2012).
Characteristics of nurses can affect their daily work
and potentially errors in patient safety (White,
2012).
Nosocomial infection or also known as infection
in the hospital which is the most frequent
complications in health services. Infection is the
most commonly acquired effect of a hospital
affecting about 5 to 10% of inpatients in developed
countries (Kadi & Salati, 2012). According to
Weston that nosocomial infections also affect
patients and families that will result in loss of
income, harm, disability or death, increased length
of care, additional expenses for hospitals and may
reduce hospital image (Weston, 2013).
Standard operating procedure (SOP) is a
standardized step / instruction to complete a certain
routine work process, which provides the right and
best steps based on mutual consensus to carry out
various activities and service functions, the standard
operating procedure also helps to reducing errors in
sub-standard services by providing measures that
have been tested and approved in carrying out
various service activities (KARS, 2012). National
Patient Safety Goals Hospital based on Joint
Commission International explains that the
achievement of patient safety is lowering the risk of
112
Yanti, D., Pitriani, ., Ginting, S., Hayati, K. and Karokaro, T.
Exploration of Themes from the Apllication of Standard Operational Procedures Control Infection Nosocomial at X General Hospital.
DOI: 10.5220/0009466701120119
In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 112-119
ISBN: 978-989-758-460-2
Copyright
c
 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

nosocomial infection, one of the important methods
to prevent the risk of nosocomial infections in
hospitals by applying highly valuable SOP
nosocomial control infections in an effort to prevent
potential infectious diseases not expected (JCI,
2015).
The WHO survey results show that in 55
hospitals in Europe, the Middle East, Southeast Asia
and the Western Pacific, an average of 8.7% of
hospital patients have nosocomial infections and
more than 1.4 million people worldwide suffer from
those complications obtained from hospital (WHO,
2015). The National Health and Medical Research
Council says there are approximately 200,000
nosocomial infections in Australia obtained from
acute care health facilities in each year (NHMRC,
2010).
In Indonesia, based on research conducted at 11
hospitals in DKI Jakarta in 2004 that there were 9.8
percent of inpatients getting infected during
treatment, in RSUD Semarang in 2009 was phlebitis
131 incident, infection of operation area 38 incident,
Urinary tract infection as many as 23 events, sepsis
22 events, pneumonia 7 events and decubitus 6
events (Aisyah & Styabakti, 2013).
Infection prevention and control is the
responsibility of nurses in carrying out nursing
practice in accordance with standard operational
procedures that will result in patient safety. The
existence of standard operational procedures can be
used as a reference for nurses in performing tasks,
can improve the quality of services and avoid
malpractice demands for that research will study in
depth about the various perceptions or experiences
nurses apply SOP control Infection nosocomial.
2 METHOD
This research was conducted at X General
Hospital, with reason based on one mission of X
General Hospital that prioritize patient safety in
health service delivery and in order to increase
hospital accreditation to level of plenary.
The study used a qualitative study with
descriptive phenomenology design. This design was
chosen so that the participants' experience can be
explored to be more exposed so that the nurse's
experiences applying the nosocomial SOP control
infection can be illustrated.
Participants in this study were 10 nurses selected
by purposive sampling technique. Data collection
was conducted in-depth interview, and field notes
were then made in verbatim and analyzed using
Colaizzi's approach. In this study also pay attention
to data reliability and ethical research principles.
3 RESULTS AND DISCUSSION
3.1 Results
Researchers collect data by in-depth interview
method and field note. The results of interviews in
the form of written transcripts carried out content
analysis with the help of software Welf-QDA. Based
on the analysis results found 5 themes are:
1) Seek nurse prevention by strictly
implementing SOP.
The nurse uses SOP every action to the patient to
prevent infection. This is because with the SOP and
follow the rules / guidelines in the SOP will be able
to prevent the occurrence of mistakes made by the
nurse during providing care to the patient. This
corresponds to the participant's statement
"Meaning the standard operational
procedures so the rules are what we
use if the action to the patient so that
the nurse is not wrong so the patient
was not infected his infection during
treatment" [Participant 1].
"The rule for us to use is that the
infection does not occur in this
hospital especially in the patient"
[Participant 4].
Nurses make SOP as work instructions in
implementing nursing actions to patients to prevent
the occurrence of infection. This statement
corresponds to the participant's expression:
"Instructions for nurses let how
infections do not occur the same
patients and the nurse it self"
[Participant 6]
"As a nurse's work instructions to the
patient..so with that there, the nurse
knows what to follow so that the
infection does not happen to the
patient" [Participant 8].
Nurses perform nursing actions by following the
steps in accordance with the SOP that has been
established by the hospital to prevent the occurrence
of infection. This is supported by the participant's
statement as follows
"Yes because there SOP there are
steps of action...what we want to do
the procedure to the patient so that's
the follow let me do it wrong so it
Exploration of Themes from the Apllication of Standard Operational Procedures Control Infection Nosocomial at X General Hospital
113

does not happen infection"
[Participant 1].
"All there is a clear sequence of
action steps to be followed, so to be
wrong it is unlikely to be infected"
[Participant 2].
"The workflow steps in the SOP it's
clear how to make no wrong so yes it
we follow let not infection"
[Participant 5].
2) Safeguarding nursing actions
Hand washing is one of the habits performed by
the nurse before contact with the patient to perform
nursing actions. This statement is in accordance with
the phrase:
"I always apply hand washing,
whatever the circumstance because I
think it's the main thing that we do in
the beginning to prevent infection let
me keep all the time I wash my hands
to keep the infection does not
happen." [Participant 4].
"I think the most important wash hand
is yes..that I do for the patient's safety
and for myself because the hand is the
intermediary most quickly spread the
infection..so yes it must be done as
often as possible yes five moments
that" [Participant 7].
For nurses personal protective equipment (PPE)
is considered something that is necessary in
performing nursing actions to the patient. This is
supported by the participant's statement:
"Always use the PPE every action ..in
addition to prevent infection to the
patient, yes of course for us also let's
just want to install infusion we must
use handscoon is let the action remain
sterile so" [Participant 3].
"If for example in SOP mentioned
using mask, yes we must use"
[Participant 6].
"The action that we usually deal with
the blood of the patient, yes in the
SPO there must be a handwashing
nurse and wear personal protective
devices such as handscoon ..so if it
does we join yes the possibility of
nosocomial infection is very big .. can
from nurse to patient or from patient
to nurse can "[Participant 7].
Nurses pay attention to septic and aseptic
techniques. Septic and aseptic techniques are
necessary to be considered and applied in every
action to the patient to prevent infection. In
accordance with the participant's expression:
"Keeping the environment around the
hospital from infectious causes such
as blood splashes or other body fluids
we have to clean" [Participant 1].
"For example if because of
characteryes we must be careful
sterile..not forget to wash hands, do
not forget disinfection genitalia
area..not sure so yes urinary tract
infection is patient" [Participant 2].
3) Ensuring satisfaction in nursing service.
Emotional satisfaction of nurses with categories:
feel easy, feel safe, independent in nursing action,
and confident. Nurses feel with the existence of
standard operational procedures can facilitate nurses
in performing nursing actions to patients. This is in
accordance with the participant's expression
"We are easy to work because there is
SOP to prevent infection"[Participant
1].
" SOP helps me to take action easily"
[Participant 6].
"Definitely make it easier for the
nurse who is in SOP that there is
already action steps where so we do
not cause infection to the patient"
[Participant 7].
The nurse states that in performing nursing
actions to the patient it is important to create a sense
of security for both the patient and the nurse itself.
In accordance with the participant's expression:
"I certainly feel safe every willing to
action to the patient..because work
according to SOP things that seem
trivial we must follow to be safe"
[Participant 4].
"So if we follow the possibility of
wrong it must be small until there is
no even ..that's why we are safe .. we
are free from complement for
example, we are free from infection"
[Participant 7]
Self-reliance of nurses performing nursing
actions indicates a nurse's ability to meet the
patient's needs. This is supported by the participant's
statement as follows:
"All done alone, do not have to be
assisted by friends ..because we
understand the SOP so we know what
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is done and understand yourself how
not to have infection" [Participant 2].
"Increase our independence, so if the
work to already know how the action
was going to be done with should not
have an infection to the patient or
ourselves" [Participant 5].
"Nurses can work to alone, know
what actions will be done to patients
according to SOP even if the infection
is not there" [Participant 9].
One's beliefs will feel confident and able to
behave according to his or her expectations and
desires. It is like a participant's expression:
"I am sure with my actions..no
hesitations..so I cannot be wrong-
wrong..Unless if not come SOP it was
yes it could be a mistake right trust
infection the patient..That's the point
SOP was made hospital "[Participant
2].
"I do with confidence..I believe my
actions are true to the
patient..because of the time in
education we were taught like that"
[Participant 3].
"I am sure of taking action.I am
confident I am capable of doing such
actions without threatening the
patient's safety, without causing any
infections to the patient"[Participant8]
Provide patient satisfaction with the categories
namely: nurses work properly, not harming the
patient, responsible nurses. Nurses apply
SOPcorrectly in every nursing action to ensure
patient safety in the hospital. This is supported by
the participant's statement:
"We as a nurse must really apply the
SOP because it is related to patient
patient's life safety..we nurse also feel
safe if work free from mistake when
join SOP " [Participant 1].
"The important thing remains the
action to the patient is right, do not
let there’s complement let it safe"
[Participant 2].
"So if there is more SOP directed..we
really be how the actions we must do
so as not to cause infection"
[Participant 4].
No harm is a nurse's effort to ensure patient
satisfaction at the hospital. As for this is related to
the participant's statement:
"we assure the patient's safety by
complying with the SOP to prevent
infection ... we guarantee his recovery
by undergoing the treatment we
provide properly and not making him
material or mental loss" [Participant
4].
"Do not let there is a disadvantage to
the patient, how to be satisfied yes we
must note the service for him because
with so later automatically the patient
will return to our hospital"
[Participant 8].
Each nurse carries out the actions to the patient
with a sense of responsibility to ensure patient
satisfaction with the services provided. This is
supported by the participant's statement:
"No matter what the circumstances
we still do the action with full
responsibility to the patient"
[Participant 3].
"My kick yes positioned the patient
like myself so yes so far yes with full
responsibility" [Participant 6].
"I take responsibility .. I am afraid to
make mistakes, I do not want because
of a little patient complement, can get
my SP ..do not dare, should be wary
is the same so-so" [Participant 8].
4) Creating cooperation and effective
communication as the key to make patient safe.
Patient safety in the hospital can be improved by
creating cooperation between patient and family as
well as all parties in the hospital and effective
communication in service process. It is described in
the sub-themes of: fostering cooperation related to
patient safety, and using effective communication.
Nurses make cooperation as necessary to ensure
patient safety at the hospital. This is supported by
the participant's statement
"All parties must cooperate with each
other..nurse cooperation with patients
and families should also, because
families must have an important role
also to keep the patient's safety.
[Participant 3].
"Same family also we love..we give
education how to prevent the
happening of infection, family help to
help keep patient safety also"
[Participant 5].
"The mutual cooperation of each
party in this hospital in maintaining
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115

patient safety for the common good"
[Participant 4].
"In addition to involving our family
yes each of the officials yes each
other cooperation is in healing the
patient yes with attention to the
patient's own safety how let
infections" [Participant 9].
Effective communication is the most important
thing applied by hospital nurses to prevent infection
and ensure patient safety. This is supported by the
participant's statement as follows:
"Fellow nurses have a good
relationship, same patient and family
so.. good communication, good
relationship with all parties of this
hospital" [Participant 7].
"Effective communication is the
prevention of infection ..fellow nurses,
same doctors, patient families are
also important" [Participant 10].
"Effective communication is..it is
important we apply in the hospital let
me not information about patient
safety let not happen things that are
not want" [Participant 5]
"Here is applied SBAR so if I feel
that effective communication is the
most important ..because if it is wrong
we communicate convey something
related patients yes can risk mistakes
that happen" [Participant 9].
5) Positive support of hospital management on
infection prevention and control.
The implementation of a patient safety program
requires the support of a hospital management
organization such as an additional nurse worker,
given information on infection prevention, and
facilitates nurse needs. This is supported by the
participant's statement:
"Additional nurses want to be not
overwhelmed, all can be achieved ..let
the patient's safety is also guaranteed
because nurses are quite able to work
well" [Participant 1].
"The number of nurses wants to be
added...let the work load decrease"
[Participant 2].
"It's about nosocomial infection was
also often reminded ..given the latest
information about infection
prevention" [Participant 2].
"We are here the average nurse
diploma, yes certainly less is the
science of his theory because we need
to be given the latest information
related to how to relieve infection"
[Participant 4].
Fulfillment of nurse needs such as increased
knowledge of infection prevention and control
facilitated through seminars and training is the
expectation of nurses on hospital management. This
is supported by the participant's statement:
"Nurses are often in the seminars or
training so ..nosocomial infection is a
lot of his knowledge, let me add
knowledge" [Participant 3].
"Improve the nurse's knowledge about
patient's safety..why it is important, in
SOP there is how to prevent
infection..but want training there
also..let's have a refresh so same
nurse" [Participant 6].
3.2 Discussion
The patient's safety in the hospital is a system
where the hospital makes the patients care because
of risk assessment, incident identification and
analysis, the ability to learn from incidents and
follow-up, and the implementation of solutions to
minimize risks and prevent injuries caused by
mistakes caused carrying out an action or not taking
appropriate action. Participants say SOP as a rule to
be followed in performing nursing actions to
patients. This is because with the SOP and follow
the rules / guidelines in the SOP will be able to
prevent the occurrence of mistakes made by the
nurse during providing care to the patient.
Groves, Meisenbach, and Scott-Cawiezell argue
that patient safety aims to improve the quality of
care and avoid malpractice demands, so that
standard operational procedures should be used as a
reference in providing services to patients (Groves,
Meisenbach, & Scott-Cawiezell, 2011). Haile,
Engeda, and Abdo's research showed that most of
the nurses had the same level of compliance as the
prevention standard, that is 60 people (88,2%) while
the nurse who had the unfair compliance level of 8
people (11,8%) (Haile, Engeda, & Abdo, 2017).
Important findings in the study that nurses
consider the SOP as a mandatory rule to obey the
goal of preventing the occurrence of errors causing
the infection while providing care to the patient and
applying it strictly to ensure patient safety in the
hospital. As described in the National Patient Safety
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Goals Hospital based on Joint Commission
International that the achievement of patient safety is
to reduce the risk of nosocomial infections, one tool
to prevent the risk of nosocomial infections in
hospitals by applying highly valued SOP nosocomial
control infection in an effort to prevent potential an
unexpected infection event (JCI, 2015).
A risk-conscious culture of culture should be
embedded in every health care provider and hospital
healthcare provider and increase the motivation for
infection prevention and control as a culture rooted
in the hospital. Participants in this study revealed
that the role of nurses in infection control is to
provide safe nursing services by performing the
correct hand washing technique and performed
within 5 moments and making it a habit to avoid
transmission of infection to patients in the hospital.
In line with Najafi's, Nejhad, and Rafii research
mentioned that the related solution of no safety
culture pressure in maintaining hand hygiene at all
levels is to make it a habit (Najafi, Nejhad, &Rafii,
2013). This is also supported by the theories of Kadi
and Salati which state that the implementation of
nursing care practices for the control of nosocomial
infections is part of the role of nurses in hospitals
that begin with maintaining hand hygiene (Kadi &
Salati, 2012).
The use of personal protective equipment such as
gloves and masks is a key component in minimizing
the spread of the disease and maintaining an
infection-free environment as well as protective
measures by nurses and patients on disease
transmission. Participants in this study revealed that
the use of personal protective equipment such as
gloves and masks is done to minimize the
occurrence of transmission of infections directly or
indirectly from the nurse to the patient or vice versa.
Supported by Kang's research, O'donnell, and
Colaianne states that nurses who use gloves will be
able to provide protection for transmission of
infection directly to patients, while masks are
expected to provide protection against indirect
transmission of infection through air borne (Kang et
al, (2016).
Environmental cleaning is done to remove all
foreign materials such as dirt, body fluids, and
organic matter from the environment surrounding
the hospital. Participants stated that performing
aseptic techniques on each nursing action as in the
medication set and wound care. Medical set up in
accordance with the hospital designated SOP, the
nurse uses disposable gloves, and the nurse also
sterilizes the contaminated apparatus for preparation
at any time to be reused. Participants also always
disinfect the area of infusion by using alcohol.
As research conducted by Mariana and
Baharuddin mentioned that wound care techniques
using Nacl 0.9% and pay attention to aseptic
techniques. Aseptic action is performed to reduce
and prevent the occurrence of inflammation. Based
on the results of this study, it can be concluded that
sterile equipment and personnel concerned with
septic and aseptic techniques such as the sterility of
all instruments used in nursing actions, hand
washing, the use of personal protective equipment
such as gloves and mask usage have an important
role in preventing and control of the occurrence of
nosocomial infections in hospitals.
Application SOP of nosocomial control infection
is necessary to be performed by nurses. Mistakes in
the service process were caused by various causes,
among others, caused by health workers 85% and
caused by equipment 15%. Participants in this study
stated that in performing nursing actions to patients
it is important to create a sense of security for both
the patient and the nurse itself, to reduce the rate of
KTD and KNC in the hospital. This is in line with
the research by Nicklin and McVeety that safe
health services are the right of patients and health
workers to meet patient satisfaction and it becomes
the hospital's obligation to provide safe health
services (Nicklin & McVeety, 2012).
One of the functions of nurses is an independent
function which is an independent function and not
dependent on others, where nurses in performing
their duties are carried out on their own with their
own decisions in taking action in order to meet basic
human needs such as fulfillment of physiological
needs, fulfillment of security and comfort needs,
love of love, self-fulfillment and self-actualization
(Potter & Perry, 2010). It was revealed by the
participants that it is important to have independence
for nurses to improve their skills and knowledge
about nursing actions given to patients.
In line with research conducted by Natasia,
Loekqijana and Kurniawati concluded that the
nurse's compliance with SOPimplementation is also
influenced by the level of knowledge and
independence of nurses in performing nursing
actions, because it will affect the quality of nursing
services provided in preventing errors and ensuring
patient safety at the hospital (Natasia, Loekqijana, &
Kurniawati, 2014). Participants also revealed that
with the belief that a person will feel confident and
able to behave in accordance with expectations and
wishes, a nurse who has the confidence will show a
positive attitude that enables him to develop a good
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117

assessment of himself and the environment /
situation he faces.
Responsibility refers to the execution of tasks
associated with the role of the nurse when providing
a properly performed nursing action and evaluating
his response. In this study, the nurses stated that they
always perform their duties based on service
standards. The responsible nurse will remain
competent in knowledge and ability, and
demonstrate a willingness to act according to the
professional ethical guidelines. This is in line with
Arma's research that the nurse is responsible for
patient safety which aims to improve the quality of
service so that standard operational procedures
should be used as a reference in providing nursing
services to patients (Arma, 2012).
Cosway, Stevens and Panesar say that nurses
prioritize the protection and safety of the patient in
performing his nursing duties, and do not cause any
harm to the patient means that it includes security,
courtesy, able to cultivate the confidence of his
patients and also means that hazards, risks and
hesitations (Cosway, Stevens, &Panesar, 2012). It is
in accordance with the disclosed by the participants
that the aspect of the guarantee does not harm the
patient is promising something for the recovery of
the patient by assigning according to the specified
SOPand it is regarded relatively by the nurse. All
actions of nurse service is done continuously in
order to improve the quality of service in order to
occur patient satisfaction and possible will form
patient loyalty.
Cooperation is an effort with complementary
skills and committed to common goals, performance
goals and approaches that are shared responsibly.
The nurse's relationship with the patient and his
family is more of a mutual relationship. Effective
communication is a key element of patient safety
goals because errors in communication are the first
cause of patient safety problems. Good
communication prevents errors and can improve
patient safety (White, 2012).
Casey & Wallis's research revealed that
inaccuracies of information can have a serious
impact on patients, nearly 70% of events that result
in serious death or injury in hospitals are due to poor
communication (Casey & Wallis, 2011). Participants
stated that good communication should be created to
facilitate the implementation of nursing care to
patients. Improved communications allow nurses to
exchange information about patients as needed
accurately, provide opportunities to visualize
patients and ask questions about something that is
poorly understood, while improving nurse awareness
of the impact of communication on patient safety
and service satisfaction.
Griffiths, Renz, and Rafferty stated that factors
that influence the risk of infection in the hospital one
of which is the workload that is not in accordance
with the staff / nurses are available (Griffiths, Renz,
& Rafferty, 2008). While Armstrong argued that the
workload of nurses is an indicator that resulted in the
occurrence of nosocomial infections in the hospital.
Nursing work load is also affected by the number of
nurses, number of patients, patient condition and
nurse work system (Amstrong, 2009). It is also a
hope for participants that sufficient number of nurses
will be able to improve patient safety in hospital.
Casida and Parker argue that superior
performance and effective organization is a
consistent display of nurse managers leadership style
with transformational behavior (Casida & Parker,
2011). Mulyatiningsih's research revealed that
professional leaders are able to facilitate staff in self-
development through training as it is necessary to
improve nurse's ability to perform nursing actions
with regard to infection prevention and control
aspects. The training should be followed by all
nurses but also need periodic refreshes for nurses so
that the implementation of patient safety can be
carried out in accordance with the development of
science and technology (Mulyatiningsih, 2013).
Based on above, it can be concluded that
participants stated the importance of support from
superiors and management in improving patient
safety and the hope that participants are career
development, because there is no career
development program from the hospital itself.
Expected career development here is also an
increase in education, training, seminars, workshops,
etc. and followed by all nurses.
4 CONCLUSIONS
Based on the results of this study can be
concluded that the experience of nurses apply SOP
nosocomialcontrol infection get the theme that is:
seek nurse prevention by strictly implementing SOP;
safe guarding nursing actions; ensuring satisfaction
in nursing service; creating cooperation and
effective communication as the key to make patient
safe and positive support from related hospital
management infection prevention and control.
The themes that emerged in this study indicate
nurse compliance in apply of SOP nosocomial
control infections to prevent infection. This study
can be used by hospitals, especially to prevent and
ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology
118

control infection teams increase support for nurses
by conducting regular training about prevent and
control infection, so that increases understanding
nurses about infection risk identification that can
occur every nurse workplace.
ACKNOWLEDGMENT
Thanks to:
 Chancellor of the Institut Kesehatan Medistra
Lubuk Pakam who has provided financial
support and facilities so that this research can be
carried out properly and smoothly.
 Director of X General Hospital Medan, who has
given permission to carry out this research.
 All nurses who have agreed to be respondents in
the study.
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