- Email: [email protected]
National survey of infection control practitioners' educational needs
National survey of infection control practitioner& educational needs Joan G. Turner, DSN, RNC Wendy C. Booth, MSN, RNC Kathleen C. Brown, PhD, RNC Kenny M. Wllllamson, MSN, RNC Birmingham,
Alabama
The purpose of this study was to conduct a nationwide survey to determine the number of master’s-prepared infection control practitioners (ICPs) and those eligible for admission to graduate programs. Continuing education needs also were assessed to determine whether they might best be met through formal education or in a continuing education format. ICPs at 3765 health care facilities listed by the American Hospital Association as having more than 100 beds were invited to participate, and 2197 usable responses were received. Respondents’ perceived educational needs were categorized into the eight sections outlined by the Educational Committee of the Association for Practitioners in Infection Control (APIC). Whenever possible, demographic characteristics of subjects were compared with the findings of the 1976-1977 Study on the Efficacy of Nosocomial Infection Control; apparent shifts have occurred in age, basic educational preparation, and numbers of practitioners with advanced degrees. The major perceived educational needs of the respondents were in the areas of Management and Communication, followed by Infectious Diseases and Epidemiology and Statistics. Nationwide generalization of the results may be hampered by the skewed regional distribution of responses. ICPs, however, expressed a multiplicity of perceived educational needs in each of APIC’s eight sections, which may indicate that many ICPs believe that their performance and effectiveness are hampered by knowledge deficits. (AM J INFECT CONTROL 1990;18:86-92)
One of the tasks involved in marketing, administering, and evaluating a federally funded program to prepare infection control practitioners (ICPs) at the master’s degree level was to conduct a nationwide survey of ICPs to determine their educational status as of 1987 and to query them for perceived continuing education (CE) needs. Information regarding formal educational preparation was needed for two rea-
From ham, Area
the School of Nursing, University and the Alabama Department Ill.
of Alabama at Birmingof Health, Public Health
Reprint requests: Joan G. Turner, DSN, RNC, School of Nursing, University of Alabama at Birmingham, UAB Station, Birmingham, AL 35294. 1?/46/12486 86
sons. First, after 3 years of funding and student matriculation at this (as well as at other programs in the nation), it was necessary to ascertain whether the existence of master’s level programs had increased the number of ICPs with master’s degrees. The second reason why data were needed relative to formal educational preparation was that a bachelor’s degree was a requisite for admission to all graduate programs with an emphasis in infection control.’ Thus for recruitment purposes it was important to know how many practicing ICPs would actually be eligible for admission to these programs. In addition to educational preparation, perceived CE needs were assessed. It was believed that analysis of CE needs might have specific implications for program development in either
Volume 18 Number April 1990
2
National survey of ICPs' educational needs 87
formal education or for special projects that might be congruent with CE format. The purpose of this descriptive study was to present pertinent demographic data of respondents, including formal education credentials and perceived educational needs. The myriad of perceived educational needs identified by practicing ICPs have not previously been systematically assessed. MATERIAL Conceptual
AND METHODS model
Portions of the conceptual model developed to guide the Study on the Efficacy of Nosocomial Infection Control (SENIC) study were applied to this study. In the SENIC model, external and observable characteristics that influence the overall effectiveness of any infection surveillance and control program include the infection control staff’s use of empiric and behavioral precepts to effect needed change in any given agency. Specifically, SENIC project directors recognized that the effectiveness of the ICP is proportionate to how he or she is viewed by the staff, that is, the ICP’s “apparent expertise in patient care, knowledge of infection control [our italics], helpfulness and demeanor.“l14, P. 610 In terms of this philosophic approach, inferences can be drawn about the relationship between an effective infection control and surveillance program and a knowledgeable ICP. Sampllng
All ICPs practicing in all types of acute health care facilities with more than 100 beds in the United States and its territories were surveyed. Subsequently, in January 1987, 3765 subjects were sent both a letter of invitation to participate and a copy of the data collection tool: subjects were assured of anonymity and were urged to return the completed tool in 30 days in the prestamped envelope provided. A total of 2197 completed questionnaires were returned by the designated cutoff date 30 days later, yielding a response rate of 58.4%. Instrument
A 74-item tain a wide cluding job of practice
questionnaire was developed to obvariety of information on ICPs, intitle, educational credentials, years in infection control, understanding
Table ‘I. Demographic Demographic characteristics
profile
of respondents f
%
205 896 685 354 57
9.3 40.8 31.2 16.1 2.6
101 2091
4.6 95.2
2126 48 9 9 4
96.8 2.2 0.4 0.4 0.2
Age!(~0 21-30 31-40 41-50 51-60 61-70 Sex Male Female Ethnic background White Back Asian Hispanic Native American
of the role, proportion of time spent on various activities, administrative assignment, support personnel, criteria and protocol used to “call” nosocomial infections, surveillance methods, organizational affiliation, job satisfaction, salary range, CE needs, and/or perceived knowledge deficiencies. In all, there were 73 items that required either multiple choice or shortanswer completion and a final question that invited a written response: “What are your educational needs?” Demographic data from the instrument were analyzed with the use of the frequencies procedure on Crunch Interactive Statistical Package (CRISP). Because this was a descriptive study, the investigators were interested primarily in the frequency of occurrence of demographic factors, specifically, educational credentials. Data analysis for the short-answer completion question regarding CE needs and/or perceived knowledge deficits required content analysis. To analyze perceived educational needs, it was necessary to perform content analysis on responses. The responses were then categorized by the eight sections of knowledge developed by the Curriculum Committee members of the Association for Practitioners in Infection Control (APIC). Those eight categories, based on the 1980 APIC Educational Standards for ICPs, are (1) Epidemiology and Statistics, (2) Microbiology, (3) Infectious Diseases, (4) Sterilization, Disinfection, and Sanitation, (5) Patient Care Practices, (6) Education, (7) Management and Communication Skills, and (8) Em-
American INFECTION
SE Turner et al. Table 2. Educational background of respondents Hlghest educational degree Diploma Associate Degree in Nursing Bachelor of Science in Nursing Master of Science in Nursing Doctor of Science in Nursing Master of Public Health BS in other discipline Master’s in other discipline PhD in other discipline Medical technician/other
1976 (SENIC study) %
144 303
30.4 13.8
65 8
589
26.8
23
95
4.3
0.7
2
0.1
-
40
1.8
338
15.4
129
5.9
11
0.5
22
1.0
2197
TOTAL
*Unspecified
1967 (Current study) f %
3.0 -
4
100.00
degree
ployee Health.3 The major study limitation was the degree of consistency of the researcher in content analyzing 2 197 varied responses. RESULTS
Displayed in Table 1 is a demographic profile of respondents. Subjects ranged in age from 21 to 70 years, with a median age of 40.0. Almost 20% of the respondents (n = 439) reported their age as 51 years or older. As might be anticipated, only 4.6% of respondents (n = 101) were men. Minorities appear to be underrepresented in that 95.26% (n = 2092) of subjects were white. Educational levels of respondents are shown in Table 2. Almost 14% of subjects (13.8%, n = 303) reported that the Associate Degree in Nursing (ADN) was their highest degree, whereas 30% (n = 668) had earned diplomas. More than 40% (n = 936) reported preparation at the bachelor’s level, whereas 12% (n = 264) held master’s degrees. There was a relatively weak but statistically significant correlation between preparation of the ICP at the bachelor’s, master’s, and doctoral level and the size of the facility (Y = 0.233, p = 0.0001). That is, as the hospital size in-
Journal of CONTROL
Table 3. U.S. region of employment Region
f
96
New England Mid-Atlantic North Central Southeast South Central Mountain Pacific Pacific U.S. territories
77 185 483 615 472 121 235 9
3.5 8.4 22.0 28.0 21.5 5.5 10.7 0.4
Table 4. Professional membership of respondents Organizational membwshlp Association for Practitioners in Infection Control, Inc. (APIC) American Nurses’ Association (ANA) Society for Hospital Epidemiologists (SHEA) American Medical Association (AMA)
f
%
1714
78.1
310 7
14.1 0.3
4
0.2
creased, so did the educational preparation of the ICP. Regionality of respondents is reported in Table 3. The largest response rate (28%, n = 615 was received from the Southeastern region. The North Central region response rate was 22% (n = 483), and the South Central rate was 21.5% (n = 472). Lowest response frequencies were received from the Mid-Atlantic, Pacific, Mountain Pacific, and New England states, and five responses were received from United States territories. Generalization of study findings to the nation as a whole is limited because the response was skewed by geographic locale. Although the majority of ICPs are registered nurses, very few subjects reported membership in the American Nurses’ Association (ANA) (Table 4). More than 78% of all subjects (n = 1715) reported membership in APIC. There was a weak but statistically significant correlation (n = 0.315, p < 0.0001) between membership in APIC and bed size of the employing agency. That is, the larger the institution, the more likely practitioners were to belong to APIC. Table 5 summarizes the eight sections of
Volume
18 Number
2
National
April 1990
survey of ICPs’ educational
89
needs
Table 5. APIC curriculum APIC motion Title
No.
f
%
Epidemiology and statistics Principles of Epidemiology Presentation of Data Basic Statistical Application in Infection Control Surveillance System Development Outbreak Investigation Literature Critique Hospital/Community Interface in Reporting
613
27.9
II
Microbiology Microorganism Characteristics Clinical Microbiology Epidemiologic Markers Collection/Interpretation of Environmental Microbiologic Specimens
437
19.9
Ill
Infectious Diseases Principles of Pathogenesis Diseases, Syndromes, Implications Pathogens Distinction and Implications Antimicrobial Therapy
664
30.0
IV
Sterilization, Principles Principles
144
6.6
V
Patient Care Practices General Patient Care Strategies for Patient Special Care Units
392
17.8
164
7.5
689
31.4
68
3.1
VI
VII
Disinfection, of Cleaning, of Sanitation
and Cleaning Disinfection, Sterilization
Principles with Alteration
Education Principles of Adult Learning Impact of Physical, Psychological, Institutional Educational Needs Program Planning, Implementation, Management Management Components Organizational Implementation EvahJatiOn
in Body
Intellectual
System
Influences
on Adult
Learning
Evaluation
and Communication Process and Application of Planning Structure/Lines of Authority of a Plan within Formal/Informal
Structure
Of OUtCOmeS
Self-Assessment Skills/Implications Legal Considerations of ICP VIII
Employee Health Components of Program Infec:tion Risks Methods to Prevent, Detect,
IX
Miscellaneous
Control
for Role
Development
Infections
knowledge as outlined by APIC and identifies the components of each major section. In Section I, Epidemiology and Statistics, 27.9% (n = 613) of respondents expressed perceived educational deficits. Whereas 13% (n = 285) cited specific epidemiologic needs such as sur-
0.90
4.1
veillance techniques, outbreak investigation and reporting, and discharge follow-up, the other 114.9% (n = 328) requested education in basic research methods, the use of computers, and information about software packages for analyzing and reporting data.
American
90
Turner et al.
In Section II, Microbiology, needs were divided among applied microbiology, immunology, and virology; 19.9% (n = 437) identified needs in these areas. Respondents expressed knowledge deficits in a variety of concepts in this section, but knowledge of methicillinresistant Staphylococcus aureus (MRSA) infections and human retroviruses were specifically identified with greatest frequency as learning needs. Section III, Infectious Diseases, included the control and management of infectious diseases, as well as antibiotic therapy and antibiotic surveillance. A wide variety of phenomena, including acquired immunodeficiency virus (AIDS), hepatitis, sexually transmitted diseases, and diseases affecting special populations, such as pediatric and gerontologic patients, were cited as areas of knowledge deficit. A need for information on “new antibiotic therapy” was expressed by 30% (n = 660). Additionally, respondents requested basic or introductory level infection control education to include defining nosocomial infections and basic interpretation of laboratory tests. Some respondents suggested that material for home study would be helpful. Section IV, Sterilization, Disinfection, and Sanitation, was a source of concern for 6.6% (n = 144) of respondents. Numerous questions surrounding hazardous waste disposal, chemotherapeutic wastes, and environmental sanitation were raised. The educational needs identified by 17.8% (n = 392) of the respondents in Section V, Patient Care Practices, revolved around several areas. The largest group (n = 214) was interested in the application of infection control practices to such specific populations as those in rural hospitals, nursing homes, extended care facilities, outpatient clinics, obstetric areas, particularly neonatal intensive care units and newborn nurseries, psychiatric units, home care agencies, day-care centers, pediatric units, and institutional departments such as housekeeping, engineering, and construction areas. A second group requested information about patient isolation requirements and current practices. Surgical wound infections, operating room procedures, and invasive procedures and monitoring practices also were cited as areas of
INFECTION
Journal
of
CONTROL
concern to the ICP. Several ICPs wanted information on the reuse of disposable equipment in patient care settings. Section VI, Education, was chosen by 7.5% (n = 164) of ICPs. These requests mainly encompassed new strategies for staff development, ideas for in-service education, and a few questions regarding patient education. A number of practitioners requested ideas for motivating staff members, which was categorized under the management section. The largest number of of educational deficits were identified in Section VII, Management and Communication. There were 689 responses, or 31.4%, in this category. The majority, 10.5% (n = 232), claimed that they lacked expertise in budgeting, cost containment, proving the effectiveness of the ICP role, and in marketing skills. Many specified the need for improved communication with physicians to enhance their compliance, support, and the reporting of infections. The need for ideas and strategies to motivate nursing staff to adhere to standards was expressed. Quality assurance and the criteria of the Joint Commission on Accredition of Healthcare Organizations were an ongoing concern. A group of 45 respondents believed they lacked expertise in the development and updating of policies and procedures. Another 4.7% (n = 125) desired a generalized update on infection control, some specifying “close to home” availability and others meeting the requirements for the APIC certification examination. Sixteen respondents (0.73%) requested assistance with technical writing skills to enhance publication efforts or grant writing. Another 30 ICPs (1.4%) wanted increased networking with other practitioners both on a state and national level. The establishment of support groups and an infection control hotline were suggested particularly by ICPs in rural areas. Requests for educational updates in Section VIII, Employee Health, were the least frequent, representing 3.1% (n = 68). Specific information in this area usually was omitted. A conglomerate of additional comments was categorized into a miscellaneous category that represented 4.1% (n = 90). Reference to advanced educational needs in pharmacology, pathophysiology, hematology, chemistry, nutrition, biology, peer review, review of medical
Volume
18 Number
2
April 1990
literature, and health care economics were expressed by a few respondents. Several ICPs wished to pursue degrees in higher education, ranging from a BS N degree to a master’s degree in infection control nursing, an MSN, an MPH, a nurse practitioner degree, or an MBA. Two respondents aspired to pursue doctoral programs, and one specified a doctorate in infection control. An undercurrent of frustration and dissatisfaction was obvious to the researchers. Many ICPs expressed a feeling of general lack of preparation for their job: inadequate time to do the job well because of diversity of responsibility (“wearing many hats”) or a lack of administrative support or recognition for the ICP role. One respondent’s expressed need was for “open positions in the USA” whereas another wrote, “Want out after 16 years with the same frustrations.” Several ICPs wanted information on how to survive in the political arena. Many desired APIC certification but admitted a need for infection control updates or the Centers for Disease Control’s course, which was not readily available to them. The options of home study or correspondence courses were requested as were educational offerings near respondents’ homes. APIC recertification through CEUs rather than examination also was suggested. DISCUSSION
Although it is not possible to directly compare most facets of the nationwide SENIC study done in 1976- 1977 with findings from this study because of different sampling, analysis, and reporting methods, it is possible to compare the study populations in terms of age distribution, gender, and educational preparation. Although McGuckin and Rose’ mention educational preparation generally, distinction is not made between types and levels of degrees. Emori et a1.2 reported that only 16% of their subjects were more than 50 years of age; whereas nearly 20% of this study’s respondents (n = 439) reported their age as 51 years or older. The fact that subjects in the 1987 survey were somewhat older than participating ICPs in the 1977 study may be attributed to the national demographic trend toward an increase in the age of the population.
National
survey of ZCPs’ educational
needs
91
Most ICPs continue to be women. Only 4.6% of our respondents (n = 101) were men, which is closely consistent with the 3% of ICPs in the 1977 study.2 Ethnic background also seems to have fluctuated very little in that 98% of subjects in the earlier survey were white, and nearly 97% of the 1987 study population was also white. Besides the fact that ICPs are chronologically more mature, the most significant change during the lo-year interval seems to be in educational preparation. In 1977, of all ICPs who were registered nurses (and more than 94% of respondents in 1977 were registered nurses), only 8% were prepared at the ADN level compared with 13.8% in 1987. Another notable change apparently has occurred in the number of RNs prepared at the diploma level. In 1977 Emori et al.* reported that for 65% of ICPs the diploma in nursing was their highest degree, whereas in 1987 only 30% (n = 668) reported the diploma in nursing as their highest educational credential. Certainly the shift from diploma to ADN-prepared RNs functioning as ICPs can be explained partially by the changing national nursing climate in that diploma programs are becoming very scarce whereas ADN programs are becoming more numerous. ICPs also are more frequently prepared at educational levels beyond the ADN or by other associated degrees. The number of ICPs with a baccalaureate preparation has doubled during the lo-year interval (from 23% to 42%), and the percentage of ICPs with a master’s degree has grown from an estimated 1% in 1977* to 12% (n = 163) in the 1987 study results. Furthermore, there were no master’s level programs specializing in infection control in 1976- 1977, but in 1987 there were nine graduate programs and more are in the planning stages. In 1980198 1 McGuckin and Rose’ reported that 36% (n = 3 1) of respondents had a degree whereas 63% (n = 54) had no degree. In the late 1970s at least two infection control educator& ’ discussed the importance of education for the ICP. Nursing educators and hospital and nursing administrators were encouraged to educate and hire nurses with specific credentials to fill the ICP position. These experts claimed that proper education and preparation
American
92
Turner
et ai.
of the ICP ultimately would contribute to the delivery of quality patient care. In 198 1 the University of Pennsylvania began a specific Infection Control Education master’s and doctoral level program that was not under the umbrella of nursing. Unfortunately, respondents to the 1987 survey indicated a preoccupation with justifying their role to management and proving their worth financially, and many were still educationally unprepared for the ICP role. Many claimed they had been placed in the role of ICP without orientation, education, or resource personnel to assist them. The origination of the survey in a southeastern institution may account for the highest number of responses from that area. However, the next highest number from the north central region and responses from all 5 1 states, the District of Columbia, and several territories indicate a national cross section of responses. The fact that 78.1% of ICPs are APIC members is interesting. Although it is not known how many are actually certified by APIC, many expressed the desire to attain certification. Questions concerning the examination content, the proximity of or the least distance to the closest seminars, and recertification procedures were common. There seemed to be considerable interest and allegiance to the APIC organization among these practitioners, thus providing a unique opportunity for APIC to attempt to meet their members’ needs. SUMMARY
In an effort to ascertain the perceived educational needs of the ICP nationwide a wealth of information was uncovered. Although ICPs are more highly educated than they were 10 years ago, they still express a multiplicity of diverse educational deficits. Perceived educational needs most commonly mentioned were in Communication and Management, followed by Infectious Diseases, then Epidemiology and
INFECTION
Journal
of
CONTROL
Statistics. Data collected were collapsed into the eight sections of knowledge outlined by APIC and a miscellaneous category and analyzed qualitatively. The ICP is an integral and essential member of any health care facility. Because the ICP role is expanding in complexity, scope, and importance, educators and administrators would be well advised to seize the opportunity to ensure that the educational needs and results of the ICP are met or to align with physicians and management personnel to redefine the ICP role and needs of the ICP. Increased educational access and a congruent role definition for the ICP will optimize the quality of patient care, reduce costs, and enable the practitioner to assume a more active stance in the dynamic, demanding health care environment. Recommendations for further study might include the following: (1) What do physician epidemiologists or management personnel perceive as ICP needs? (2) How do ICPs and others define the ICP role? and (3) Will education or role redefinition or both enhance and facilitate the practice of the ICP? References programs with emphasis in infection control. 1. Graduate APIC News 1987;6(1):18, 19. control 2. Emori TG, Haley RW, Stanley RC. The infection nurse in US hospitals, 1976-1977. Am J Epidemiol 1980; 111:592-607. for infection control 3. Soule BM, ed. The APIC curriculum practice. Dubuque, Iowa: Kendall/Hunt, 1983. 4. Centers for Disease Control. Conceptual model for an infection control surveillance and control program [Appendix A]. Am J Epidemiol 1980; 111:60812. 5. McGuckin MB, Rose RD. Relationship between demographic variables, nonformal education, and the infection control practitioner’s knowledge of surveillance. AM J INFECT CONTROL 1982; 10:43-50. 6. Turner JG. The nurse epidemiologist: selection and preparation. Superv Nurse 1978;9:33-6, 38,41. 7. Chavigny KH. Hospital epidemiology: a challenge to nursing education. Nurse Educator 1979;4:28-34.
Alabama
The purpose of this study was to conduct a nationwide survey to determine the number of master’s-prepared infection control practitioners (ICPs) and those eligible for admission to graduate programs. Continuing education needs also were assessed to determine whether they might best be met through formal education or in a continuing education format. ICPs at 3765 health care facilities listed by the American Hospital Association as having more than 100 beds were invited to participate, and 2197 usable responses were received. Respondents’ perceived educational needs were categorized into the eight sections outlined by the Educational Committee of the Association for Practitioners in Infection Control (APIC). Whenever possible, demographic characteristics of subjects were compared with the findings of the 1976-1977 Study on the Efficacy of Nosocomial Infection Control; apparent shifts have occurred in age, basic educational preparation, and numbers of practitioners with advanced degrees. The major perceived educational needs of the respondents were in the areas of Management and Communication, followed by Infectious Diseases and Epidemiology and Statistics. Nationwide generalization of the results may be hampered by the skewed regional distribution of responses. ICPs, however, expressed a multiplicity of perceived educational needs in each of APIC’s eight sections, which may indicate that many ICPs believe that their performance and effectiveness are hampered by knowledge deficits. (AM J INFECT CONTROL 1990;18:86-92)
One of the tasks involved in marketing, administering, and evaluating a federally funded program to prepare infection control practitioners (ICPs) at the master’s degree level was to conduct a nationwide survey of ICPs to determine their educational status as of 1987 and to query them for perceived continuing education (CE) needs. Information regarding formal educational preparation was needed for two rea-
From ham, Area
the School of Nursing, University and the Alabama Department Ill.
of Alabama at Birmingof Health, Public Health
Reprint requests: Joan G. Turner, DSN, RNC, School of Nursing, University of Alabama at Birmingham, UAB Station, Birmingham, AL 35294. 1?/46/12486 86
sons. First, after 3 years of funding and student matriculation at this (as well as at other programs in the nation), it was necessary to ascertain whether the existence of master’s level programs had increased the number of ICPs with master’s degrees. The second reason why data were needed relative to formal educational preparation was that a bachelor’s degree was a requisite for admission to all graduate programs with an emphasis in infection control.’ Thus for recruitment purposes it was important to know how many practicing ICPs would actually be eligible for admission to these programs. In addition to educational preparation, perceived CE needs were assessed. It was believed that analysis of CE needs might have specific implications for program development in either
Volume 18 Number April 1990
2
National survey of ICPs' educational needs 87
formal education or for special projects that might be congruent with CE format. The purpose of this descriptive study was to present pertinent demographic data of respondents, including formal education credentials and perceived educational needs. The myriad of perceived educational needs identified by practicing ICPs have not previously been systematically assessed. MATERIAL Conceptual
AND METHODS model
Portions of the conceptual model developed to guide the Study on the Efficacy of Nosocomial Infection Control (SENIC) study were applied to this study. In the SENIC model, external and observable characteristics that influence the overall effectiveness of any infection surveillance and control program include the infection control staff’s use of empiric and behavioral precepts to effect needed change in any given agency. Specifically, SENIC project directors recognized that the effectiveness of the ICP is proportionate to how he or she is viewed by the staff, that is, the ICP’s “apparent expertise in patient care, knowledge of infection control [our italics], helpfulness and demeanor.“l14, P. 610 In terms of this philosophic approach, inferences can be drawn about the relationship between an effective infection control and surveillance program and a knowledgeable ICP. Sampllng
All ICPs practicing in all types of acute health care facilities with more than 100 beds in the United States and its territories were surveyed. Subsequently, in January 1987, 3765 subjects were sent both a letter of invitation to participate and a copy of the data collection tool: subjects were assured of anonymity and were urged to return the completed tool in 30 days in the prestamped envelope provided. A total of 2197 completed questionnaires were returned by the designated cutoff date 30 days later, yielding a response rate of 58.4%. Instrument
A 74-item tain a wide cluding job of practice
questionnaire was developed to obvariety of information on ICPs, intitle, educational credentials, years in infection control, understanding
Table ‘I. Demographic Demographic characteristics
profile
of respondents f
%
205 896 685 354 57
9.3 40.8 31.2 16.1 2.6
101 2091
4.6 95.2
2126 48 9 9 4
96.8 2.2 0.4 0.4 0.2
Age!(~0 21-30 31-40 41-50 51-60 61-70 Sex Male Female Ethnic background White Back Asian Hispanic Native American
of the role, proportion of time spent on various activities, administrative assignment, support personnel, criteria and protocol used to “call” nosocomial infections, surveillance methods, organizational affiliation, job satisfaction, salary range, CE needs, and/or perceived knowledge deficiencies. In all, there were 73 items that required either multiple choice or shortanswer completion and a final question that invited a written response: “What are your educational needs?” Demographic data from the instrument were analyzed with the use of the frequencies procedure on Crunch Interactive Statistical Package (CRISP). Because this was a descriptive study, the investigators were interested primarily in the frequency of occurrence of demographic factors, specifically, educational credentials. Data analysis for the short-answer completion question regarding CE needs and/or perceived knowledge deficits required content analysis. To analyze perceived educational needs, it was necessary to perform content analysis on responses. The responses were then categorized by the eight sections of knowledge developed by the Curriculum Committee members of the Association for Practitioners in Infection Control (APIC). Those eight categories, based on the 1980 APIC Educational Standards for ICPs, are (1) Epidemiology and Statistics, (2) Microbiology, (3) Infectious Diseases, (4) Sterilization, Disinfection, and Sanitation, (5) Patient Care Practices, (6) Education, (7) Management and Communication Skills, and (8) Em-
American INFECTION
SE Turner et al. Table 2. Educational background of respondents Hlghest educational degree Diploma Associate Degree in Nursing Bachelor of Science in Nursing Master of Science in Nursing Doctor of Science in Nursing Master of Public Health BS in other discipline Master’s in other discipline PhD in other discipline Medical technician/other
1976 (SENIC study) %
144 303
30.4 13.8
65 8
589
26.8
23
95
4.3
0.7
2
0.1
-
40
1.8
338
15.4
129
5.9
11
0.5
22
1.0
2197
TOTAL
*Unspecified
1967 (Current study) f %
3.0 -
4
100.00
degree
ployee Health.3 The major study limitation was the degree of consistency of the researcher in content analyzing 2 197 varied responses. RESULTS
Displayed in Table 1 is a demographic profile of respondents. Subjects ranged in age from 21 to 70 years, with a median age of 40.0. Almost 20% of the respondents (n = 439) reported their age as 51 years or older. As might be anticipated, only 4.6% of respondents (n = 101) were men. Minorities appear to be underrepresented in that 95.26% (n = 2092) of subjects were white. Educational levels of respondents are shown in Table 2. Almost 14% of subjects (13.8%, n = 303) reported that the Associate Degree in Nursing (ADN) was their highest degree, whereas 30% (n = 668) had earned diplomas. More than 40% (n = 936) reported preparation at the bachelor’s level, whereas 12% (n = 264) held master’s degrees. There was a relatively weak but statistically significant correlation between preparation of the ICP at the bachelor’s, master’s, and doctoral level and the size of the facility (Y = 0.233, p = 0.0001). That is, as the hospital size in-
Journal of CONTROL
Table 3. U.S. region of employment Region
f
96
New England Mid-Atlantic North Central Southeast South Central Mountain Pacific Pacific U.S. territories
77 185 483 615 472 121 235 9
3.5 8.4 22.0 28.0 21.5 5.5 10.7 0.4
Table 4. Professional membership of respondents Organizational membwshlp Association for Practitioners in Infection Control, Inc. (APIC) American Nurses’ Association (ANA) Society for Hospital Epidemiologists (SHEA) American Medical Association (AMA)
f
%
1714
78.1
310 7
14.1 0.3
4
0.2
creased, so did the educational preparation of the ICP. Regionality of respondents is reported in Table 3. The largest response rate (28%, n = 615 was received from the Southeastern region. The North Central region response rate was 22% (n = 483), and the South Central rate was 21.5% (n = 472). Lowest response frequencies were received from the Mid-Atlantic, Pacific, Mountain Pacific, and New England states, and five responses were received from United States territories. Generalization of study findings to the nation as a whole is limited because the response was skewed by geographic locale. Although the majority of ICPs are registered nurses, very few subjects reported membership in the American Nurses’ Association (ANA) (Table 4). More than 78% of all subjects (n = 1715) reported membership in APIC. There was a weak but statistically significant correlation (n = 0.315, p < 0.0001) between membership in APIC and bed size of the employing agency. That is, the larger the institution, the more likely practitioners were to belong to APIC. Table 5 summarizes the eight sections of
Volume
18 Number
2
National
April 1990
survey of ICPs’ educational
89
needs
Table 5. APIC curriculum APIC motion Title
No.
f
%
Epidemiology and statistics Principles of Epidemiology Presentation of Data Basic Statistical Application in Infection Control Surveillance System Development Outbreak Investigation Literature Critique Hospital/Community Interface in Reporting
613
27.9
II
Microbiology Microorganism Characteristics Clinical Microbiology Epidemiologic Markers Collection/Interpretation of Environmental Microbiologic Specimens
437
19.9
Ill
Infectious Diseases Principles of Pathogenesis Diseases, Syndromes, Implications Pathogens Distinction and Implications Antimicrobial Therapy
664
30.0
IV
Sterilization, Principles Principles
144
6.6
V
Patient Care Practices General Patient Care Strategies for Patient Special Care Units
392
17.8
164
7.5
689
31.4
68
3.1
VI
VII
Disinfection, of Cleaning, of Sanitation
and Cleaning Disinfection, Sterilization
Principles with Alteration
Education Principles of Adult Learning Impact of Physical, Psychological, Institutional Educational Needs Program Planning, Implementation, Management Management Components Organizational Implementation EvahJatiOn
in Body
Intellectual
System
Influences
on Adult
Learning
Evaluation
and Communication Process and Application of Planning Structure/Lines of Authority of a Plan within Formal/Informal
Structure
Of OUtCOmeS
Self-Assessment Skills/Implications Legal Considerations of ICP VIII
Employee Health Components of Program Infec:tion Risks Methods to Prevent, Detect,
IX
Miscellaneous
Control
for Role
Development
Infections
knowledge as outlined by APIC and identifies the components of each major section. In Section I, Epidemiology and Statistics, 27.9% (n = 613) of respondents expressed perceived educational deficits. Whereas 13% (n = 285) cited specific epidemiologic needs such as sur-
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veillance techniques, outbreak investigation and reporting, and discharge follow-up, the other 114.9% (n = 328) requested education in basic research methods, the use of computers, and information about software packages for analyzing and reporting data.
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In Section II, Microbiology, needs were divided among applied microbiology, immunology, and virology; 19.9% (n = 437) identified needs in these areas. Respondents expressed knowledge deficits in a variety of concepts in this section, but knowledge of methicillinresistant Staphylococcus aureus (MRSA) infections and human retroviruses were specifically identified with greatest frequency as learning needs. Section III, Infectious Diseases, included the control and management of infectious diseases, as well as antibiotic therapy and antibiotic surveillance. A wide variety of phenomena, including acquired immunodeficiency virus (AIDS), hepatitis, sexually transmitted diseases, and diseases affecting special populations, such as pediatric and gerontologic patients, were cited as areas of knowledge deficit. A need for information on “new antibiotic therapy” was expressed by 30% (n = 660). Additionally, respondents requested basic or introductory level infection control education to include defining nosocomial infections and basic interpretation of laboratory tests. Some respondents suggested that material for home study would be helpful. Section IV, Sterilization, Disinfection, and Sanitation, was a source of concern for 6.6% (n = 144) of respondents. Numerous questions surrounding hazardous waste disposal, chemotherapeutic wastes, and environmental sanitation were raised. The educational needs identified by 17.8% (n = 392) of the respondents in Section V, Patient Care Practices, revolved around several areas. The largest group (n = 214) was interested in the application of infection control practices to such specific populations as those in rural hospitals, nursing homes, extended care facilities, outpatient clinics, obstetric areas, particularly neonatal intensive care units and newborn nurseries, psychiatric units, home care agencies, day-care centers, pediatric units, and institutional departments such as housekeeping, engineering, and construction areas. A second group requested information about patient isolation requirements and current practices. Surgical wound infections, operating room procedures, and invasive procedures and monitoring practices also were cited as areas of
INFECTION
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concern to the ICP. Several ICPs wanted information on the reuse of disposable equipment in patient care settings. Section VI, Education, was chosen by 7.5% (n = 164) of ICPs. These requests mainly encompassed new strategies for staff development, ideas for in-service education, and a few questions regarding patient education. A number of practitioners requested ideas for motivating staff members, which was categorized under the management section. The largest number of of educational deficits were identified in Section VII, Management and Communication. There were 689 responses, or 31.4%, in this category. The majority, 10.5% (n = 232), claimed that they lacked expertise in budgeting, cost containment, proving the effectiveness of the ICP role, and in marketing skills. Many specified the need for improved communication with physicians to enhance their compliance, support, and the reporting of infections. The need for ideas and strategies to motivate nursing staff to adhere to standards was expressed. Quality assurance and the criteria of the Joint Commission on Accredition of Healthcare Organizations were an ongoing concern. A group of 45 respondents believed they lacked expertise in the development and updating of policies and procedures. Another 4.7% (n = 125) desired a generalized update on infection control, some specifying “close to home” availability and others meeting the requirements for the APIC certification examination. Sixteen respondents (0.73%) requested assistance with technical writing skills to enhance publication efforts or grant writing. Another 30 ICPs (1.4%) wanted increased networking with other practitioners both on a state and national level. The establishment of support groups and an infection control hotline were suggested particularly by ICPs in rural areas. Requests for educational updates in Section VIII, Employee Health, were the least frequent, representing 3.1% (n = 68). Specific information in this area usually was omitted. A conglomerate of additional comments was categorized into a miscellaneous category that represented 4.1% (n = 90). Reference to advanced educational needs in pharmacology, pathophysiology, hematology, chemistry, nutrition, biology, peer review, review of medical
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literature, and health care economics were expressed by a few respondents. Several ICPs wished to pursue degrees in higher education, ranging from a BS N degree to a master’s degree in infection control nursing, an MSN, an MPH, a nurse practitioner degree, or an MBA. Two respondents aspired to pursue doctoral programs, and one specified a doctorate in infection control. An undercurrent of frustration and dissatisfaction was obvious to the researchers. Many ICPs expressed a feeling of general lack of preparation for their job: inadequate time to do the job well because of diversity of responsibility (“wearing many hats”) or a lack of administrative support or recognition for the ICP role. One respondent’s expressed need was for “open positions in the USA” whereas another wrote, “Want out after 16 years with the same frustrations.” Several ICPs wanted information on how to survive in the political arena. Many desired APIC certification but admitted a need for infection control updates or the Centers for Disease Control’s course, which was not readily available to them. The options of home study or correspondence courses were requested as were educational offerings near respondents’ homes. APIC recertification through CEUs rather than examination also was suggested. DISCUSSION
Although it is not possible to directly compare most facets of the nationwide SENIC study done in 1976- 1977 with findings from this study because of different sampling, analysis, and reporting methods, it is possible to compare the study populations in terms of age distribution, gender, and educational preparation. Although McGuckin and Rose’ mention educational preparation generally, distinction is not made between types and levels of degrees. Emori et a1.2 reported that only 16% of their subjects were more than 50 years of age; whereas nearly 20% of this study’s respondents (n = 439) reported their age as 51 years or older. The fact that subjects in the 1987 survey were somewhat older than participating ICPs in the 1977 study may be attributed to the national demographic trend toward an increase in the age of the population.
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Most ICPs continue to be women. Only 4.6% of our respondents (n = 101) were men, which is closely consistent with the 3% of ICPs in the 1977 study.2 Ethnic background also seems to have fluctuated very little in that 98% of subjects in the earlier survey were white, and nearly 97% of the 1987 study population was also white. Besides the fact that ICPs are chronologically more mature, the most significant change during the lo-year interval seems to be in educational preparation. In 1977, of all ICPs who were registered nurses (and more than 94% of respondents in 1977 were registered nurses), only 8% were prepared at the ADN level compared with 13.8% in 1987. Another notable change apparently has occurred in the number of RNs prepared at the diploma level. In 1977 Emori et al.* reported that for 65% of ICPs the diploma in nursing was their highest degree, whereas in 1987 only 30% (n = 668) reported the diploma in nursing as their highest educational credential. Certainly the shift from diploma to ADN-prepared RNs functioning as ICPs can be explained partially by the changing national nursing climate in that diploma programs are becoming very scarce whereas ADN programs are becoming more numerous. ICPs also are more frequently prepared at educational levels beyond the ADN or by other associated degrees. The number of ICPs with a baccalaureate preparation has doubled during the lo-year interval (from 23% to 42%), and the percentage of ICPs with a master’s degree has grown from an estimated 1% in 1977* to 12% (n = 163) in the 1987 study results. Furthermore, there were no master’s level programs specializing in infection control in 1976- 1977, but in 1987 there were nine graduate programs and more are in the planning stages. In 1980198 1 McGuckin and Rose’ reported that 36% (n = 3 1) of respondents had a degree whereas 63% (n = 54) had no degree. In the late 1970s at least two infection control educator& ’ discussed the importance of education for the ICP. Nursing educators and hospital and nursing administrators were encouraged to educate and hire nurses with specific credentials to fill the ICP position. These experts claimed that proper education and preparation
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of the ICP ultimately would contribute to the delivery of quality patient care. In 198 1 the University of Pennsylvania began a specific Infection Control Education master’s and doctoral level program that was not under the umbrella of nursing. Unfortunately, respondents to the 1987 survey indicated a preoccupation with justifying their role to management and proving their worth financially, and many were still educationally unprepared for the ICP role. Many claimed they had been placed in the role of ICP without orientation, education, or resource personnel to assist them. The origination of the survey in a southeastern institution may account for the highest number of responses from that area. However, the next highest number from the north central region and responses from all 5 1 states, the District of Columbia, and several territories indicate a national cross section of responses. The fact that 78.1% of ICPs are APIC members is interesting. Although it is not known how many are actually certified by APIC, many expressed the desire to attain certification. Questions concerning the examination content, the proximity of or the least distance to the closest seminars, and recertification procedures were common. There seemed to be considerable interest and allegiance to the APIC organization among these practitioners, thus providing a unique opportunity for APIC to attempt to meet their members’ needs. SUMMARY
In an effort to ascertain the perceived educational needs of the ICP nationwide a wealth of information was uncovered. Although ICPs are more highly educated than they were 10 years ago, they still express a multiplicity of diverse educational deficits. Perceived educational needs most commonly mentioned were in Communication and Management, followed by Infectious Diseases, then Epidemiology and
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Statistics. Data collected were collapsed into the eight sections of knowledge outlined by APIC and a miscellaneous category and analyzed qualitatively. The ICP is an integral and essential member of any health care facility. Because the ICP role is expanding in complexity, scope, and importance, educators and administrators would be well advised to seize the opportunity to ensure that the educational needs and results of the ICP are met or to align with physicians and management personnel to redefine the ICP role and needs of the ICP. Increased educational access and a congruent role definition for the ICP will optimize the quality of patient care, reduce costs, and enable the practitioner to assume a more active stance in the dynamic, demanding health care environment. Recommendations for further study might include the following: (1) What do physician epidemiologists or management personnel perceive as ICP needs? (2) How do ICPs and others define the ICP role? and (3) Will education or role redefinition or both enhance and facilitate the practice of the ICP? References programs with emphasis in infection control. 1. Graduate APIC News 1987;6(1):18, 19. control 2. Emori TG, Haley RW, Stanley RC. The infection nurse in US hospitals, 1976-1977. Am J Epidemiol 1980; 111:592-607. for infection control 3. Soule BM, ed. The APIC curriculum practice. Dubuque, Iowa: Kendall/Hunt, 1983. 4. Centers for Disease Control. Conceptual model for an infection control surveillance and control program [Appendix A]. Am J Epidemiol 1980; 111:60812. 5. McGuckin MB, Rose RD. Relationship between demographic variables, nonformal education, and the infection control practitioner’s knowledge of surveillance. AM J INFECT CONTROL 1982; 10:43-50. 6. Turner JG. The nurse epidemiologist: selection and preparation. Superv Nurse 1978;9:33-6, 38,41. 7. Chavigny KH. Hospital epidemiology: a challenge to nursing education. Nurse Educator 1979;4:28-34.