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Compliance of nursing students with infection prevention precautions: Effectiveness of a teaching program
American Journal of Infection Control 41 (2013) 332-6
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Compliance of nursing students with infection prevention precautions: Effectiveness of a teaching program Mahmoud Al-Hussami DSc, PhD *, Muhammad Darawad RN, PhD Faculty of Nursing, University of Jordan, Amman, Jordan
Key Words: Compliance Infection Nursing Students
Background: In Jordan’s nursing schools, infection prevention precautions are not taught in special courses. Instead, most nursing schools include the topic as a 1-hour lecture within the clinical courses, which is believed to be insufficient. This study aimed to test the effectiveness of a nursing infection prevention educational program presented to nursing students before graduation, to promote their knowledge of infection prevention precautions. Methods: A true experimental design was used to examine the effects of the infection prevention educational program on students’ educational knowledge. This study involved a random assignment of subjects to experimental and control groups, and administration of the pretest and the posttest to all subjects in both groups separately. Results: Participants in the experimental group demonstrated significantly better knowledge (t ¼ 19.15; df ¼ 95; P ¼ .000) and attitude scores (t ¼ 2.29; df ¼ 46; P ¼ .04) than participants in the control group after particpating in the infection prevention educational program. However, compliance scores were not significantly differernt between the 2 groups (t ¼ 1.92; df ¼ 95; P ¼ .067); indeed, compliance was found to be significant within the experimental group (t ¼ 10.65; df ¼ 46; P ¼ .000). Conclusions: It is important that nursing students be competent in infection prevention precautions; however, there may be deficits in their education in this area. The nursing curriculum should include additional emphasis on practice as a means to help translate theory into clinical behavior. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Nosocomial infections occur during the process of care and contribute to patient mortality and morbidity.1 Infection rates in developing countries may exceed 25%.2 Poor hand hygiene among health care providers and nonadherence to the infection prevention precautions when providing care are primary causes of nosocomial infections.3 These infections have a significant effect on health care services and patient care in the United Kingdom, with an approximate annual cost of 1 billion pounds.4 Nurses are the group of health care providers with the most direct contact with patients while providing direct patient care.5 Therefore, nurses’ adherence to infection prevention precautions would have a profound effect on reducing nosocomial infection rates.6 However, Chan et al7 reported that nurses’ knowledge of standard precautions was inadequate, in terms of applying
* Address corrrespondence to Mahmoud Al-Hussami, DSc, PhD, Assistant Professor, Community Health Nursing Chairperson, Faculty of Nursing, The University of Jordan, Amman 11942, Jordan. E-mail address: [email protected] (M. Al-Hussami). This research was funded by the University of Jordan. Conflict of interest: None to report.
precautions inappropriately and insufficiently. An analysis of incident reports by nursing students found that 25.4% of these reports were related to infection prevention practices.8 Nurses’ compliance with infection prevention precautions is known to vary9; for example, reported hand hygiene compliance rates are 46.7%-57.4% in US nurses,10 63.8% in Jordanian nurses,11 and 86.6% in nurses in Hong Kong.7 Nursing students’ impact on the prevalence and frequency of nosocomial infections is unavoidable.12 In one survey, the majority of nursing students (52%) reported dissatisfaction with the content of their infection prevention course.13 Many studies have found nursing students’ knowledge of infection prevention precautions to be less than the required level. Wu et al14 examined knowledge, application, and confidence with infection prevention precautions among Taiwanese nursing students, and recommended a comprehensive foundation course in infection prevention for nursing students before entering clinical practice. Gaps have been identified in nursing students’ hand hygiene knowledge,15 and their compliance with hand hygiene measures was insufficient.5 In response, Celik and Koçasli16 recommended revising hand hygiene education measures.
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2012.03.029
M. Al-Hussami, M. Darawad / American Journal of Infection Control 41 (2013) 332-6
This lack of knowledge may be rooted to the deficits in the infection prevention education provided to nursing students in nursing schools, which often leaves students confused and unclear regarding which practices are appropriate.17 Given that approximately 33% of the nosocomial infections are preventable,18 educating nursing students on the standards of infection prevention precautions and the importance of complying with those precautions in clinical practice is considered an important role for nursing schools.19,20 Van de Mortel et al21 recommended increasing the emphasis on hand hygiene in the undergraduate curriculum through frequent hand hygiene education and assessment. Other recommendations have included revising the nurse training curriculum with regard to standard infection prevention precautions11 and keeping students’ knowledge of infection prevention up-to-date during clinical application.16 Despite the fact that such educational programs could enhance nurses’ compliance with hand hygiene practices,22,23 compliance with infection prevention practices,24 and knowledge of infection prevention,25,26 there is a lack of research studies focusing on educating nursing students on infection prevention precautions. In Jordan’s nursing schools, infection prevention precautions are not taught in special courses. Instead, most nursing schools include the topic as a 1-hour lecture within the clinical course, which may be insufficient. To date, no studies have been conducted for this purpose in Jordan. As a developing country, Jordan has limited resources, carrying implications for the control of nosocomial infections.27 Jordan has high hepatitis-B endemicity,28 making infection prevention programs of the utmost importance. Consequently, an experimental approach was used in this study, which is intended to serve as a platform for highlighting the importance of infection prevention. This study aimed to evaluate the effectiveness of a nursing infection prevention program presented to nursing students before graduation to improve their knowledge of infection prevention precautions.
METHODS Research hypotheses 1. Nursing students who complete an infection prevention educational program will demonstrate increased knowledge of infection prevention precautions compared with the control group. 2. Nursing students who complete an infection prevention educational program will demonstrate better attitudes toward infection prevention precautions compared with the control group. 3. Nursing students who complete an infection prevention educational program will demonstrate increased compliance of infection prevention precautions compared with the control group.
STUDY DESIGN A true experimental design was used to examine the effects of the infection prevention educational program on nursing students’ knowledge of, attitudes toward, and compliance with infection prevention precautions. This study involved a random assignment of subjects to the experimental group or a control group. The pretest and the posttest were completed by both groups. Participants in the experimental group attended the infection prevention educational program, whereas those in the control group received no training.
333
ESTIMATED SAMPLE SIZE Based on previous studies examining the effect of educational interventions on nursing students’ infection prevention knowledge, attitudes, and compliance, a conservative effect size of 0.35 was estimated.29,30 Using the statistical software G*Power V.331 at a statistical power of 0.80, effect size 0.35, and statistical significance 0.05, the estimated sample size required to perform 2sample t tests was 70 subjects (35 subjects in the experimental group and 35 in the control group). Study setting and sample The study was conducted among nursing students at a public university in Jordan, who receive their clinical training at hospitals in different health sectors, including governmental, military, private, and teaching. We selected at random 120 students from who were in their final year of study, had a grade point average of >2 out of 4, and voluntarily agreed to participate. Of these 120 students, 104 students consented to participate, for a response rate of 87%. Students were assigned at random to the experimental group or control group (52 participants in each group) by assigning odd numbers for the control group and even numbers for the experimental group. Five students from the experimental group (n ¼ 47) and 2 from the control group (n ¼ 50) withdrew from the study, leaving us with a total sample size of 97. Instrument To assess the effectiveness of infection prevention program in increasing nursing students’ knowledge of infection prevention precautions, we developed an assessment test consisting of 2 sections. The first section elicited demographic data, including age, sex, academic level, educational course, high school background, high school average, and grade point average. The second section contained 30 items and was divided into 2 parts. The first part contained 9 true/false items, and the second part included 21 multiple choice questions, each of which had 4 alternative choices with 1 correct answer. The maximum total grade on the test was 30, with higher grades indicating better knowledge of infection prevention precautions. The nursing students’ attitudes toward infection prevention precautions were assessed using the attitude section of the infection prevention knowledge, attitudes, and practices instrument.32 This section contained 11 items measuring attitudes toward choosing personal protective equipment (PPE), donning PPE, and handling high-risk procedures. Responses used a 5-point Likert scale, ranging from 1, “strongly disagree,” to 5, “strongly agree,” with higher scores indicating stronger agreement with the attitude being assessed. The nursing students’ compliance with the standard infection prevention precautions was evaluated using the scale developed by Chan et al,7 containing 15 items scored on a 4-point Likert scale, ranging from 1, “never,” to 4, “always,” with higher scores indicating better compliance with standard precautions. This scale addressed areas related to the use of PPE, disposal of sharps, disposal of waste, decontamination, and prevention of crossinfection between patients. Ethical considerations The study design was approved by the Scientific and Ethical Research Committees at the Faculty of Nursing and University of Jordan. Each participant signed a written consent form that specified the purpose of the study and the rights of the participants.
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M. Al-Hussami, M. Darawad / American Journal of Infection Control 41 (2013) 332-6
Confidentiality was ensured throughout the study. Data were properly secured, saved in the principal researcher’s password protected computer, with hard copies in a cabinet in a locked office. The demographic data sheets were coded by numbers with no names, to maintain confidentiality, and no one except the principal investigator had access to that data. Respondents were advised that participation in the study was voluntary, and that they could withdraw from the study at any time with no consequences. Data collection A pilot study was carried out to evaluate the clarity and understandability of the survey instrument before introducing it to the study participants, as well as to assess the feasibility of the study in terms of acceptability to the participants, cost, and ease of integration into the clinical setting. Estimated Cronbach a values were 0.91 for the attitude subscale and 0.87 for the students’ compliance with the standard infection prevention precautions subscale. After obtaining permission to conduct the study from the Scientific Research Committee, we posted an advertisement inviting nursing students to participate in the study. Interested students were asked to report to an office specifically designated for this purpose. The participants were assigned at random to an experimental group and a control group. On the day of the educational program, the self-administered questionnaire was distributed directly by the researchers to the participants in both groups both at the beginning of the program and after completion of the program. Data were collected over a 3-month period from May 2011 to July 2011. The 4 infection prevention educational program sessions were held in lecture rooms at the school of nursing. Each session took approximately 4 hours. The sessions were guided by King’s theory of goal attainment,33 integrating the concepts and propositions of interaction, communication, perception, and mutual goal attainment. The educational program comprised 3 parts. The first part, preeducation, introduced the infection prevention education program and the pretest. The second part focused on infection prevention education, covering the concepts and principles of infection prevention. The educational program in this part contained 6 modules, covering introduction to immunology and infection, nosocomial infections, hand hygiene, PPE, isolation precautions, and disinfection and sterilization. The third part, posteducation, introduced the posttest and elicited feedback from the participants. Statistical analysis Statistical analyses were performed using SPSS software (IBM, Armonk, NY), with ά ¼ 0.05 (2-tailed). Inferential statistics were used to examine differences between the experimental and control groups. Tests used included t tests for independent groups, which tested the differences between 2 independent group means, and paired t tests, which tested the differences between 2 related group means. RESULTS The study group comprised a random sample of participants (n ¼ 97) drawn from the population of nursing students. The study group was predominately female (81%) and ranged in age from 19 to 25 years (mean age, 21.3 1.1 years). The participants’ grade point average ranged from 1.75 to 3.98 out of 4, and their high school grade ranged from 69 to 99 out of 100 (mean, 84.4 7.1).
Despite that the majority of students took 2 medical-surgical nursing courses that included some infection prevention training, overall pretest scores were relatively low (mean, 12.41/25 3.27, r ¼ 4-16). Participants in the experimental group demonstrated improvement after the infection prevention educational program (posttest mean of 22.89/25 1.41, r ¼ 20-25 vs pretest mean of 12.62 2.9; r ¼ 5-6), whereas those in the control group did not (Table 1). Hypothesis 1 was tested using an independent-samples t test. As shown in Table 2, the difference in knowledge scores between the experimental and control groups after implementation of the infection prevention educational program was statistically significant (mean, 22.89/25 1.41 vs 12.12/25 3.60; t ¼ 19.15; df ¼ 95; P ¼ .000). These results suggest the usefulness of implementing such programs to improve students’ knowledge of infection prevention. The paired t test was used to confirm the foregoing results. Participants in the experimental group demonstrated higher attitude scores after exposure to the infection prevention educational program (posttest mean, 22.89/25 1.4, r ¼ 20-25 vs pretest mean, 12.62/25 2.9, r ¼ 5-16). These findings confirm a statistically significant difference (t ¼ 24.2; df ¼ 46; P ¼ .000) within the experimental group, suggesting the effectiveness of the program. Hypothesis 2 was also tested using an independent-samples t test. As shown in Table 3, the difference in the total attitude scores between the experimental and control group after implementation of the infection prevention program was statistically significant (mean, 54.36/55 2.29 vs 49.4/55 6.77; t ¼ 1.92; df ¼ 95; P ¼ .04). These results suggest the usefulness of implementing such programs to improve students’ attitudes regarding infection prevention. A paired t test was used to confirm the foregoing results (Table 3). The participants in the experimental group demonstrated higher attitude scores after exposure to the infection prevention educational program (posttest mean, 54.36/55 2.29 vs pretest mean, 51.53/55 3.36). These findings confirm a statistically significant difference in scores (t ¼ 6.78; df ¼ 46; P ¼ .000) in the experimental group, supporting the effectiveness of the educational program. An independent-samples t test was also used to test hypothesis 3. The difference in compliance scores between the experimental and control groups after the infection prevention educational program was not significant (mean, 39.46/45 2.88 vs 34.16/45 4.65; t ¼ 1.92; df ¼ 95; P ¼ .067) (Table 4). These results suggest that such educational programs have little effect on improving nursing students’ compliance with infection prevention precautions. However, paired t test results (Table 4) demonstrated improved compliance scores in the experimental group after exposure to the infection prevention educational program (posttest mean, 39.46/ 45 2.88, r ¼ 34-42 vs pretest mean, 32.44/45 4.10, r ¼ 26-36). These findings represent a statistically significant difference (t ¼ 10.65; df ¼ 46; P ¼ .000) in the experimental group, suggesting the effectiveness of the educational program. DISCUSSION Our data show a generally low level of infection prevention knowledge in nursing students, as expected given the lack of specific courses focusing on infection prevention in Jordanian nursing schools. These results are consistent with studies reporting knowledge deficits regarding infection prevention17 and MRSA13 in nursing students. The educational program was effective in promoting participants’ knowledge of infection prevention, which is consistent with
M. Al-Hussami, M. Darawad / American Journal of Infection Control 41 (2013) 332-6 Table 1 Participants’ pretest and posttest scores of infection prevention knowledge
Pretest scores (overall) Experimental group Control group Posttest scores (overall) Experimental group Control group
Number
Range
97 47 50 97 47 50
4-16 5-16 4-15 5-25 20-25 5-16
Mean SD 12.41/25 12.62/25 12.20/25 17.50/25 22.89/25 12.12/25
3.27 2.90 3.64 2.50 1.41 3.60
Table 2 Posttest knowledge scores in the experimental and control groups and pretest and posttest knowledge scores within the experimental group Group Control group (posttest) Experimental group (posttest) Experimental group (pretest) Experimental group (posttest)
Number 50 47 47 47
Mean SD 12.12/25 22.89/25 12.62/25 22.89/25
t
df
3.60 19.15 95 1.41 2.9 24.2 46 1.4
335
Table 3 Posttest attitude scores in the experimental and control groups and pretest and posttest attitude scores within the experimental group Group Control group (posttest) Experimental group (posttest) Experimental group (pretest) Experimental group (posttest)
Number 50 47 47 47
.000*
*Significant at a ¼ 0.05 (2-tailed) using dependent- and independent-samples t tests.
studies34 reporting that application of such programs are beneficial in promoting nurses’ and nursing students’ knowledge of infection prevention. These findings demonstrate that such programs are efficient, lending further support for the call to include infection prevention in nursing school curricula. Participants’ attitudes toward infection prevention were positive overall, indicating that nursing students care about protecting themselves and their patients. Nursing students have been found to have more positive attitudes toward hand hygiene than medical students.21 In the present study, the nursing students’ attitudes toward infection prevention improved after exposure to the educational program, further demonstrating the benefits of such programs for nursing students. This result is in agreement with Atack and Luke,35 who found that such programs significantly increase nurses’ perception of infection prevention competency. The educational program significantly influenced participants’ behavior in terms of compliance with infection prevention precautions. Students’ clinical experience mandates twice-weekly clinical days and numerous paperwork assignments. This limits the amount of bedside nursing care that requires compliance with infection prevention precautions. Nonetheless, the participants reported some improvement (with an increase in mean score from 34 to 39), considered mild but still statistically significant. This finding differs from the conclusion of Ward,19 who found no evidence that education alone improves compliance with infection prevention precautions. Nevertheless, such educational programs have been found to be efficient in promoting nursing students’ confidence in resolving infection prevention issues14 and complying with standard precautions.36 Participants reported satisfaction with the training program, citing its potential to increase their knowledge of and experience with infection prevention precautions. However, we agree with Reime et al,20 who recommended a degree-level course on infection prevention precautions using different teaching approaches. We also recommend that such a course include theoretical and clinical training. This study has some limitations. The educational program used only a lecture format. Other studies have used different approaches. Reime et al20 used both e-learning and lecturing approaches and reported that participants were comfortable were both education methods. Nursing students asked about their preferred educational method cited small group teaching with integration of practical sessions, frequent follow-up, and interactive lecturing.17 Thus, we
2.29 6.77 3.36 2.29
t
df
P value
2.29
95
.040*
6.78
46
.000*
*Significant at a ¼ 0.05 (2-tailed) using dependent- and independent-samples t tests.
Table 4 Posttest compliance scores in the experimental and control groups and pretest and posttest compliance scores within the experimental group
P value .000*
Mean SD 49.4/55 54.36/55 51.53/55 54.36/55
Group Control group (posttest) Experimental group (posttest) Experimental group (pretest) Experimental group (posttest)
Number 50 47 47 47
Mean SD 34.16/45 39.46/45 32.44/45 39.46/45
t
df
4.65 1.92 95 2.88 4.10 10.65 46 2.88
P value .067* .000*
*Significant at a ¼ 0.05 (2-tailed) using dependent- and independent-samples t tests.
recommend future studies to compare outcomes of educational interventions using various teaching approaches. Our small sample size (97 students) drawn from a single institution might limit the generalizability of our results. In addition, the posttest was administered after only 1 week of the educational program, which seems to be insufficient. Finally, including more than one educational approach and comparing these outcomes could have the potential to identify the appropriate approaches to teaching nursing students infection prevention precautions. Our findings indicate that the educational program used in this study helped enhance the nursing students’ knowledge of and attitudes toward infection prevention. Drawing on these findings, nursing school deans and faculty members can facilitate and implement such an infection prevention educational program within their curricula. Such a program may lead to increased nurse adherence to infection prevention precautions and ultimately have a significant effect on reducing nosocomial infection rates.
Acknowledgment We express our appreciation to all of the nursing students who participated in this study. We thank Professor Teresa O’Neill, Fulbright Scholar at the University of Jordan, Faculty of Nursing for editing the manuscript.
References 1. Nobile C, Montouri P, Diaco E, Villari P. Healthcare personnel and hand decontamination in intensive care units: knowledge, attitudes, and behaviors in Italy. J Hosp Infect 2002;51:226-32. 2. Pittet D, Allegranzi B, Storr J, Donaldson L. Clean Care Is Safer Care: The Global Patient Safety Challenge, 2005-2006. Int J Infect Dis 2006;10:419-24. 3. Centers for Disease Control and Prevention. Guideline for hand hygiene in healthcare settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morb Mortal Recomm Rep 2002;51(RR-16):1-48. 4. Plowman R. The socio-economic burden of hospital-acquired infection. London [UK]: Public Health Laboratory Service; 1999. 5. Cole M. Exploring the hand hygiene competence of student nurses: a case of flawed self-assessment. Nurse Educ Today 2009;29:380-8. 6. French G, Friedman C. Infection control: basic concept and training. 2nd ed. Portadown [North Ireland]: International Federation of Infection Control; 2003. pp. 25e35. 7. Chan R, Alexander M, Chan E, Chan V, Ho B, Lai C, et al. Nurses’ knowledge of and compliance with universal precautions in an acute care hospital. Int J Nurs Stud 2002;39:157-63.
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8. Geller NF, Bakken S, Currie LM, Schnall R, Larson EL. Infection control hazards and near-misses reported by nursing students. Am J Infect Control 2011;38:811-6. 9. Ghabrah TM, Madani TA, Albarrak AM, Alhazmi MA, Alazraqi TA, Alhudaithi MA, et al. Assessment of infection control knowledge, attitude and practice among healthcare workers during the Hajj period of the Islamic year 1423. Scand J Infect Dis 2007;39:1018-24. 10. Shimokura G, Weber D, Miller W, Wurtzel H, Alter M. Factors associated with personal protection equipment use and hand hygiene among hemodialysis staff. Am J Infect Control 2006;34:100-7. 11. Al-Hussami MO, Darawad MW, Almheirat I. Predictors of compliance hand washing practice among healthcare professionals. Healthc Infect 2011;16:79-84. 12. Addis G, Karadag A. An evaluation of nurses’ clinical teaching role in Turkey. Nurse Educ Today 2003;23:27-33. 13. Jennings-Sanders A, Jury L. Assessing methicillin-resistant Staphylococcus aureus knowledge among nursing students. Nurse Educ Today 2010;30:789-93. 14. Wu CJ, Gardner G, Chang AM. Taiwanese nursing students’ knowledge, application and confidence with standard and additional precautions in infection control. J Clin Nurs 2009;18:1105-12. 15. Mann CM, Wood A. How much do medical students know about infection control? J Hosp Infect 2006;64:366-70. 16. Celik S, Koçasli S. Hygienic hand washing among nursing students in Turkey. Appl Nurs Res 2008;21:207-11. 17. Ward DJ. The role of education in the prevention and control of infection: a review of the literature. Nurse Educ Today 2011;31:9-17. 18. Alexander MF, Fawcett JN, Runciman PJ. Nursing practice: hospital and home. The Adult, vol XVII. Edinburgh [UK]: Churchill Livingstone; 2006. 19. Ward DJ. The infection control education needs of nursing students: an interview study with students and mentors. Nurse Educ Today 2011;31: 819-24. 20. Reime MH, Harris A, Asknes J, Mikkelsen J. The most successful method in teaching nursing students infection control, E-learning or lecture? Nurse Educ Today 2008;28:798-806. 21. Van de Mortel TF, Apostolopoulou E, Petrikkos G. A comparison of the hand hygiene knowledge, beliefs, and practices of Greek nursing and medical students. Am J Infect Control 2009;38:75-7. 22. Panhotra BR, Saxena AK, Al-Ghamdi AM, Al-Arabi M. The effect of a continuous educational program on handwashing compliance among healthcare workers in an intensive care unit. Br J Infect Control 2004;5:15-8.
23. Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI, et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2004;25:742-6. 24. Perkins AK, Wayne B, Hopes P, Corn K, Kim A. Improving infection control practices of nurses on a telemetry unit. Crit Care Nurse 2009;29:e13. 25. Lee TC, Moore C, Raboud JM, Muller MP, Green K, Tong A, et al. Impact of a mandatory infection control education program on nosocomial acquisition of methicillin- resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2009;30:249-56. 26. Schlonka RL, Scruggs S, Nichols K, Dimmitt RA, Carlo WA. Sustained reductions in neonatal nosocomial infection rates following a comprehensive infection control intervention. J Perinatol 2006;26:176-9. 27. Huskins WC, O’Rourke EJ, Rhinehart E, Goldmann DA. Infection control in countries with limited resources. In: Mayhall DA, editor. Hospital epidemiology and infection control. Philadelphia [PA]: Lippincott, Williams & Wilkins; 1999. 28. André F. Hepatitis B epidemiology in Asia, the Middle East and Africa. Vaccine 2000;18(Suppl 1):S20-2. 29. Considine J, Brennan D. Effect of an evidence-based pediatric fever education program on emergency RNs’ knowledge. Accid Emerg Nurs 2007;15:10-9. 30. Considine J, Botti M, Thomas S. Effect of a self-directed learning package on emergency RNs’ knowledge of assessment of oxygenation and use of supplemental oxygen. Nurs Health Sci 2005;7:199-208. 31. Faul F, Erdfelder E, Buchner A, Lang A. Statistical power analysis using G*Power 3.1: test for correlation and regression analysis. Behav Res Methods 2009;41: 1149-60. 32. Chan M, Ho A, Day MC. Investigating the knowledge, attitudes and practice patterns of operating room staff towards standard and transmissionbased precautions: results of a cluster analysis. J Clin Nurs 2007;17: 1051-62. 33. King M. King’s theory of goal attainment in practice. Nurs Sci Q 1997;10:180-5. 34. Wu C, Gardner G, Chang A. Nursing students’ knowledge and practice of infection control precautions: an educational intervention. J Adv Nurs 2009;65: 2142-9. 35. Atack L, Luke R. Impact of an online course on infection control and prevention competencies. J Adv Nurs 2008;63:175-80. 36. Kim K, Kim M, Chung Y, Kim N. Knowledge and performance of the universal precautions by nursing and medical students in Korea. Am J Infect Control 2001;29:295-300.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Compliance of nursing students with infection prevention precautions: Effectiveness of a teaching program Mahmoud Al-Hussami DSc, PhD *, Muhammad Darawad RN, PhD Faculty of Nursing, University of Jordan, Amman, Jordan
Key Words: Compliance Infection Nursing Students
Background: In Jordan’s nursing schools, infection prevention precautions are not taught in special courses. Instead, most nursing schools include the topic as a 1-hour lecture within the clinical courses, which is believed to be insufficient. This study aimed to test the effectiveness of a nursing infection prevention educational program presented to nursing students before graduation, to promote their knowledge of infection prevention precautions. Methods: A true experimental design was used to examine the effects of the infection prevention educational program on students’ educational knowledge. This study involved a random assignment of subjects to experimental and control groups, and administration of the pretest and the posttest to all subjects in both groups separately. Results: Participants in the experimental group demonstrated significantly better knowledge (t ¼ 19.15; df ¼ 95; P ¼ .000) and attitude scores (t ¼ 2.29; df ¼ 46; P ¼ .04) than participants in the control group after particpating in the infection prevention educational program. However, compliance scores were not significantly differernt between the 2 groups (t ¼ 1.92; df ¼ 95; P ¼ .067); indeed, compliance was found to be significant within the experimental group (t ¼ 10.65; df ¼ 46; P ¼ .000). Conclusions: It is important that nursing students be competent in infection prevention precautions; however, there may be deficits in their education in this area. The nursing curriculum should include additional emphasis on practice as a means to help translate theory into clinical behavior. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Nosocomial infections occur during the process of care and contribute to patient mortality and morbidity.1 Infection rates in developing countries may exceed 25%.2 Poor hand hygiene among health care providers and nonadherence to the infection prevention precautions when providing care are primary causes of nosocomial infections.3 These infections have a significant effect on health care services and patient care in the United Kingdom, with an approximate annual cost of 1 billion pounds.4 Nurses are the group of health care providers with the most direct contact with patients while providing direct patient care.5 Therefore, nurses’ adherence to infection prevention precautions would have a profound effect on reducing nosocomial infection rates.6 However, Chan et al7 reported that nurses’ knowledge of standard precautions was inadequate, in terms of applying
* Address corrrespondence to Mahmoud Al-Hussami, DSc, PhD, Assistant Professor, Community Health Nursing Chairperson, Faculty of Nursing, The University of Jordan, Amman 11942, Jordan. E-mail address: [email protected] (M. Al-Hussami). This research was funded by the University of Jordan. Conflict of interest: None to report.
precautions inappropriately and insufficiently. An analysis of incident reports by nursing students found that 25.4% of these reports were related to infection prevention practices.8 Nurses’ compliance with infection prevention precautions is known to vary9; for example, reported hand hygiene compliance rates are 46.7%-57.4% in US nurses,10 63.8% in Jordanian nurses,11 and 86.6% in nurses in Hong Kong.7 Nursing students’ impact on the prevalence and frequency of nosocomial infections is unavoidable.12 In one survey, the majority of nursing students (52%) reported dissatisfaction with the content of their infection prevention course.13 Many studies have found nursing students’ knowledge of infection prevention precautions to be less than the required level. Wu et al14 examined knowledge, application, and confidence with infection prevention precautions among Taiwanese nursing students, and recommended a comprehensive foundation course in infection prevention for nursing students before entering clinical practice. Gaps have been identified in nursing students’ hand hygiene knowledge,15 and their compliance with hand hygiene measures was insufficient.5 In response, Celik and Koçasli16 recommended revising hand hygiene education measures.
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2012.03.029
M. Al-Hussami, M. Darawad / American Journal of Infection Control 41 (2013) 332-6
This lack of knowledge may be rooted to the deficits in the infection prevention education provided to nursing students in nursing schools, which often leaves students confused and unclear regarding which practices are appropriate.17 Given that approximately 33% of the nosocomial infections are preventable,18 educating nursing students on the standards of infection prevention precautions and the importance of complying with those precautions in clinical practice is considered an important role for nursing schools.19,20 Van de Mortel et al21 recommended increasing the emphasis on hand hygiene in the undergraduate curriculum through frequent hand hygiene education and assessment. Other recommendations have included revising the nurse training curriculum with regard to standard infection prevention precautions11 and keeping students’ knowledge of infection prevention up-to-date during clinical application.16 Despite the fact that such educational programs could enhance nurses’ compliance with hand hygiene practices,22,23 compliance with infection prevention practices,24 and knowledge of infection prevention,25,26 there is a lack of research studies focusing on educating nursing students on infection prevention precautions. In Jordan’s nursing schools, infection prevention precautions are not taught in special courses. Instead, most nursing schools include the topic as a 1-hour lecture within the clinical course, which may be insufficient. To date, no studies have been conducted for this purpose in Jordan. As a developing country, Jordan has limited resources, carrying implications for the control of nosocomial infections.27 Jordan has high hepatitis-B endemicity,28 making infection prevention programs of the utmost importance. Consequently, an experimental approach was used in this study, which is intended to serve as a platform for highlighting the importance of infection prevention. This study aimed to evaluate the effectiveness of a nursing infection prevention program presented to nursing students before graduation to improve their knowledge of infection prevention precautions.
METHODS Research hypotheses 1. Nursing students who complete an infection prevention educational program will demonstrate increased knowledge of infection prevention precautions compared with the control group. 2. Nursing students who complete an infection prevention educational program will demonstrate better attitudes toward infection prevention precautions compared with the control group. 3. Nursing students who complete an infection prevention educational program will demonstrate increased compliance of infection prevention precautions compared with the control group.
STUDY DESIGN A true experimental design was used to examine the effects of the infection prevention educational program on nursing students’ knowledge of, attitudes toward, and compliance with infection prevention precautions. This study involved a random assignment of subjects to the experimental group or a control group. The pretest and the posttest were completed by both groups. Participants in the experimental group attended the infection prevention educational program, whereas those in the control group received no training.
333
ESTIMATED SAMPLE SIZE Based on previous studies examining the effect of educational interventions on nursing students’ infection prevention knowledge, attitudes, and compliance, a conservative effect size of 0.35 was estimated.29,30 Using the statistical software G*Power V.331 at a statistical power of 0.80, effect size 0.35, and statistical significance 0.05, the estimated sample size required to perform 2sample t tests was 70 subjects (35 subjects in the experimental group and 35 in the control group). Study setting and sample The study was conducted among nursing students at a public university in Jordan, who receive their clinical training at hospitals in different health sectors, including governmental, military, private, and teaching. We selected at random 120 students from who were in their final year of study, had a grade point average of >2 out of 4, and voluntarily agreed to participate. Of these 120 students, 104 students consented to participate, for a response rate of 87%. Students were assigned at random to the experimental group or control group (52 participants in each group) by assigning odd numbers for the control group and even numbers for the experimental group. Five students from the experimental group (n ¼ 47) and 2 from the control group (n ¼ 50) withdrew from the study, leaving us with a total sample size of 97. Instrument To assess the effectiveness of infection prevention program in increasing nursing students’ knowledge of infection prevention precautions, we developed an assessment test consisting of 2 sections. The first section elicited demographic data, including age, sex, academic level, educational course, high school background, high school average, and grade point average. The second section contained 30 items and was divided into 2 parts. The first part contained 9 true/false items, and the second part included 21 multiple choice questions, each of which had 4 alternative choices with 1 correct answer. The maximum total grade on the test was 30, with higher grades indicating better knowledge of infection prevention precautions. The nursing students’ attitudes toward infection prevention precautions were assessed using the attitude section of the infection prevention knowledge, attitudes, and practices instrument.32 This section contained 11 items measuring attitudes toward choosing personal protective equipment (PPE), donning PPE, and handling high-risk procedures. Responses used a 5-point Likert scale, ranging from 1, “strongly disagree,” to 5, “strongly agree,” with higher scores indicating stronger agreement with the attitude being assessed. The nursing students’ compliance with the standard infection prevention precautions was evaluated using the scale developed by Chan et al,7 containing 15 items scored on a 4-point Likert scale, ranging from 1, “never,” to 4, “always,” with higher scores indicating better compliance with standard precautions. This scale addressed areas related to the use of PPE, disposal of sharps, disposal of waste, decontamination, and prevention of crossinfection between patients. Ethical considerations The study design was approved by the Scientific and Ethical Research Committees at the Faculty of Nursing and University of Jordan. Each participant signed a written consent form that specified the purpose of the study and the rights of the participants.
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Confidentiality was ensured throughout the study. Data were properly secured, saved in the principal researcher’s password protected computer, with hard copies in a cabinet in a locked office. The demographic data sheets were coded by numbers with no names, to maintain confidentiality, and no one except the principal investigator had access to that data. Respondents were advised that participation in the study was voluntary, and that they could withdraw from the study at any time with no consequences. Data collection A pilot study was carried out to evaluate the clarity and understandability of the survey instrument before introducing it to the study participants, as well as to assess the feasibility of the study in terms of acceptability to the participants, cost, and ease of integration into the clinical setting. Estimated Cronbach a values were 0.91 for the attitude subscale and 0.87 for the students’ compliance with the standard infection prevention precautions subscale. After obtaining permission to conduct the study from the Scientific Research Committee, we posted an advertisement inviting nursing students to participate in the study. Interested students were asked to report to an office specifically designated for this purpose. The participants were assigned at random to an experimental group and a control group. On the day of the educational program, the self-administered questionnaire was distributed directly by the researchers to the participants in both groups both at the beginning of the program and after completion of the program. Data were collected over a 3-month period from May 2011 to July 2011. The 4 infection prevention educational program sessions were held in lecture rooms at the school of nursing. Each session took approximately 4 hours. The sessions were guided by King’s theory of goal attainment,33 integrating the concepts and propositions of interaction, communication, perception, and mutual goal attainment. The educational program comprised 3 parts. The first part, preeducation, introduced the infection prevention education program and the pretest. The second part focused on infection prevention education, covering the concepts and principles of infection prevention. The educational program in this part contained 6 modules, covering introduction to immunology and infection, nosocomial infections, hand hygiene, PPE, isolation precautions, and disinfection and sterilization. The third part, posteducation, introduced the posttest and elicited feedback from the participants. Statistical analysis Statistical analyses were performed using SPSS software (IBM, Armonk, NY), with ά ¼ 0.05 (2-tailed). Inferential statistics were used to examine differences between the experimental and control groups. Tests used included t tests for independent groups, which tested the differences between 2 independent group means, and paired t tests, which tested the differences between 2 related group means. RESULTS The study group comprised a random sample of participants (n ¼ 97) drawn from the population of nursing students. The study group was predominately female (81%) and ranged in age from 19 to 25 years (mean age, 21.3 1.1 years). The participants’ grade point average ranged from 1.75 to 3.98 out of 4, and their high school grade ranged from 69 to 99 out of 100 (mean, 84.4 7.1).
Despite that the majority of students took 2 medical-surgical nursing courses that included some infection prevention training, overall pretest scores were relatively low (mean, 12.41/25 3.27, r ¼ 4-16). Participants in the experimental group demonstrated improvement after the infection prevention educational program (posttest mean of 22.89/25 1.41, r ¼ 20-25 vs pretest mean of 12.62 2.9; r ¼ 5-6), whereas those in the control group did not (Table 1). Hypothesis 1 was tested using an independent-samples t test. As shown in Table 2, the difference in knowledge scores between the experimental and control groups after implementation of the infection prevention educational program was statistically significant (mean, 22.89/25 1.41 vs 12.12/25 3.60; t ¼ 19.15; df ¼ 95; P ¼ .000). These results suggest the usefulness of implementing such programs to improve students’ knowledge of infection prevention. The paired t test was used to confirm the foregoing results. Participants in the experimental group demonstrated higher attitude scores after exposure to the infection prevention educational program (posttest mean, 22.89/25 1.4, r ¼ 20-25 vs pretest mean, 12.62/25 2.9, r ¼ 5-16). These findings confirm a statistically significant difference (t ¼ 24.2; df ¼ 46; P ¼ .000) within the experimental group, suggesting the effectiveness of the program. Hypothesis 2 was also tested using an independent-samples t test. As shown in Table 3, the difference in the total attitude scores between the experimental and control group after implementation of the infection prevention program was statistically significant (mean, 54.36/55 2.29 vs 49.4/55 6.77; t ¼ 1.92; df ¼ 95; P ¼ .04). These results suggest the usefulness of implementing such programs to improve students’ attitudes regarding infection prevention. A paired t test was used to confirm the foregoing results (Table 3). The participants in the experimental group demonstrated higher attitude scores after exposure to the infection prevention educational program (posttest mean, 54.36/55 2.29 vs pretest mean, 51.53/55 3.36). These findings confirm a statistically significant difference in scores (t ¼ 6.78; df ¼ 46; P ¼ .000) in the experimental group, supporting the effectiveness of the educational program. An independent-samples t test was also used to test hypothesis 3. The difference in compliance scores between the experimental and control groups after the infection prevention educational program was not significant (mean, 39.46/45 2.88 vs 34.16/45 4.65; t ¼ 1.92; df ¼ 95; P ¼ .067) (Table 4). These results suggest that such educational programs have little effect on improving nursing students’ compliance with infection prevention precautions. However, paired t test results (Table 4) demonstrated improved compliance scores in the experimental group after exposure to the infection prevention educational program (posttest mean, 39.46/ 45 2.88, r ¼ 34-42 vs pretest mean, 32.44/45 4.10, r ¼ 26-36). These findings represent a statistically significant difference (t ¼ 10.65; df ¼ 46; P ¼ .000) in the experimental group, suggesting the effectiveness of the educational program. DISCUSSION Our data show a generally low level of infection prevention knowledge in nursing students, as expected given the lack of specific courses focusing on infection prevention in Jordanian nursing schools. These results are consistent with studies reporting knowledge deficits regarding infection prevention17 and MRSA13 in nursing students. The educational program was effective in promoting participants’ knowledge of infection prevention, which is consistent with
M. Al-Hussami, M. Darawad / American Journal of Infection Control 41 (2013) 332-6 Table 1 Participants’ pretest and posttest scores of infection prevention knowledge
Pretest scores (overall) Experimental group Control group Posttest scores (overall) Experimental group Control group
Number
Range
97 47 50 97 47 50
4-16 5-16 4-15 5-25 20-25 5-16
Mean SD 12.41/25 12.62/25 12.20/25 17.50/25 22.89/25 12.12/25
3.27 2.90 3.64 2.50 1.41 3.60
Table 2 Posttest knowledge scores in the experimental and control groups and pretest and posttest knowledge scores within the experimental group Group Control group (posttest) Experimental group (posttest) Experimental group (pretest) Experimental group (posttest)
Number 50 47 47 47
Mean SD 12.12/25 22.89/25 12.62/25 22.89/25
t
df
3.60 19.15 95 1.41 2.9 24.2 46 1.4
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Table 3 Posttest attitude scores in the experimental and control groups and pretest and posttest attitude scores within the experimental group Group Control group (posttest) Experimental group (posttest) Experimental group (pretest) Experimental group (posttest)
Number 50 47 47 47
.000*
*Significant at a ¼ 0.05 (2-tailed) using dependent- and independent-samples t tests.
studies34 reporting that application of such programs are beneficial in promoting nurses’ and nursing students’ knowledge of infection prevention. These findings demonstrate that such programs are efficient, lending further support for the call to include infection prevention in nursing school curricula. Participants’ attitudes toward infection prevention were positive overall, indicating that nursing students care about protecting themselves and their patients. Nursing students have been found to have more positive attitudes toward hand hygiene than medical students.21 In the present study, the nursing students’ attitudes toward infection prevention improved after exposure to the educational program, further demonstrating the benefits of such programs for nursing students. This result is in agreement with Atack and Luke,35 who found that such programs significantly increase nurses’ perception of infection prevention competency. The educational program significantly influenced participants’ behavior in terms of compliance with infection prevention precautions. Students’ clinical experience mandates twice-weekly clinical days and numerous paperwork assignments. This limits the amount of bedside nursing care that requires compliance with infection prevention precautions. Nonetheless, the participants reported some improvement (with an increase in mean score from 34 to 39), considered mild but still statistically significant. This finding differs from the conclusion of Ward,19 who found no evidence that education alone improves compliance with infection prevention precautions. Nevertheless, such educational programs have been found to be efficient in promoting nursing students’ confidence in resolving infection prevention issues14 and complying with standard precautions.36 Participants reported satisfaction with the training program, citing its potential to increase their knowledge of and experience with infection prevention precautions. However, we agree with Reime et al,20 who recommended a degree-level course on infection prevention precautions using different teaching approaches. We also recommend that such a course include theoretical and clinical training. This study has some limitations. The educational program used only a lecture format. Other studies have used different approaches. Reime et al20 used both e-learning and lecturing approaches and reported that participants were comfortable were both education methods. Nursing students asked about their preferred educational method cited small group teaching with integration of practical sessions, frequent follow-up, and interactive lecturing.17 Thus, we
2.29 6.77 3.36 2.29
t
df
P value
2.29
95
.040*
6.78
46
.000*
*Significant at a ¼ 0.05 (2-tailed) using dependent- and independent-samples t tests.
Table 4 Posttest compliance scores in the experimental and control groups and pretest and posttest compliance scores within the experimental group
P value .000*
Mean SD 49.4/55 54.36/55 51.53/55 54.36/55
Group Control group (posttest) Experimental group (posttest) Experimental group (pretest) Experimental group (posttest)
Number 50 47 47 47
Mean SD 34.16/45 39.46/45 32.44/45 39.46/45
t
df
4.65 1.92 95 2.88 4.10 10.65 46 2.88
P value .067* .000*
*Significant at a ¼ 0.05 (2-tailed) using dependent- and independent-samples t tests.
recommend future studies to compare outcomes of educational interventions using various teaching approaches. Our small sample size (97 students) drawn from a single institution might limit the generalizability of our results. In addition, the posttest was administered after only 1 week of the educational program, which seems to be insufficient. Finally, including more than one educational approach and comparing these outcomes could have the potential to identify the appropriate approaches to teaching nursing students infection prevention precautions. Our findings indicate that the educational program used in this study helped enhance the nursing students’ knowledge of and attitudes toward infection prevention. Drawing on these findings, nursing school deans and faculty members can facilitate and implement such an infection prevention educational program within their curricula. Such a program may lead to increased nurse adherence to infection prevention precautions and ultimately have a significant effect on reducing nosocomial infection rates.
Acknowledgment We express our appreciation to all of the nursing students who participated in this study. We thank Professor Teresa O’Neill, Fulbright Scholar at the University of Jordan, Faculty of Nursing for editing the manuscript.
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