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Nursing students' intentions to comply with standard precautions: An exploratory prospective cohort study
American Journal of Infection Control xxx (2014) 1-6
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American Journal of Infection Control
American Journal of Infection Control
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Major article
Nursing students’ intentions to comply with standard precautions: An exploratory prospective cohort study Ilana Livshiz-Riven PhD, RN a, b, *, Ronit Nativ MPH, RN b, Abraham Borer MD b, c, Yaniv Kanat-Maymon PhD d, Ofra Anson PhD c a Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel b Infection Control and Hospital Epidemiology Unit, Soroka University Medical Center, Beer-Sheva, Israel c Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel d School of Psychology, Interdisciplinary Center, Herzliya, Israel
Key Words: Cohort study Infection control and prevention Nursing education Occupational risk perception Safety climate Sense of coherence Standard precautions Transtheoretical model of change (TTMC)
Background: Partial compliance of health care workers with standard precaution (SP) guidelines has been extensively documented. The aim of this study was to describe the development of nursing students’ intentions to comply with SPs. Methods: Prospective cohort study. Two consecutive classes of a 4-year bachelor of nursing program completed questionnaires 3 times. The transtheoretical model of change was used to describe the change in intentions to comply with SPs. Factor analysis displayed 2 behavioral categories: commonly used standard precautions (CUSPs) and less commonly used standard precautions (LUSPs). Knowledge, risk perception, sense of coherence (SOC), safety climate (SC), and emphasis given by educators were evaluated as associated factors. Results: Of the 91 students, 85 (93%) completed the questionnaire during their second year, 57 of 88 students (65%) completed it during the third year, and 70 of 82 students (85%) completed it at the end of the fourth year. Of the 82 students, 45 (55%) completed 3 measurements. CUSPs exhibited a rise from the second to the third year, with a moderate decline from the third to the fourth year, whereas LUSPs continued ascending. CUSPs were positively associated with SC and SOC; LUSPs were commonly associated with risk perception. Conclusion: The different evolution of CUSPs and LUSPs and dissimilar associations may suggest that different strategies might encourage diverse SP behaviors. Improving the SC might be appropriate when aiming to encourage CUSPs, and highlighting risks may be appropriate to encourage LUSPs. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Health careeassociated infections (HAIs) are adverse events occurring because of utilization of health care services.1,2 These unnecessary complications pose needless financial burden and human suffering on patients, families, health care personnel, and health care organizations.3-5 Isolation precaution (IP) guidelines, designed by the Centers for Disease Control and Prevention (CDC), were written to enhance biosafety in health care settings. Within the IPs, standard precautions (SPs) comprise the fundamental tier, which aims to prevent the cross-contamination of unknown and known infectious agents transmittable by contact with blood or
* Address correspondence to Ilana Livshiz-Riven, PhD, RN, Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 8410501, Israel. E-mail address: [email protected] (I. Livshiz-Riven). Conflict of interest: None to report.
body fluids. SPs are designed to be used by all health care workers (HCWs) when caring for all patients.1 The recommendations for application of SPs for the care of all patients in all health care settings includes the following: (1) hand hygiene (HH) after touching blood, body fluids, secretions, excretions, contaminated items, immediately after removing gloves, and between patient contacts; (2) using disposable gloves for touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and nonintact skin; (3) using mask, eye protection (goggles), or face shield during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, or secretions, especially suctioning and endotracheal intubation; (4) using a gown during procedures and patient care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated; (5) handling soiled patient care equipment in a manner that prevents transfer of microorganisms to others and the
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environment; (6) developing procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas as a measure of environmental control; (7) handling textiles in a manner that prevents transfer of microorganisms to others and to the environment; (8) safe disposal of needles and other sharps; (9) patient placement by prioritizing to reduce risk of pathogen transmission; and (10) respiratory hygiene/ cough etiquette instruction to symptomatic persons to cover mouth/ nose when sneezing/coughing.1,6 The partial compliance of HCWs with SPs has been extensively researched during the last several decades, with compliance ranging from <30% in HH to >90% in appropriate sharps disposable.7,8 A substantial proportion of research focusing on HCWs’ compliance with IPs was on proper handling and disposal of sharps and HH.7,9 The focus on HCW compliance with HH guidelines might be explained, in part, by the World Health Organization’s engagement in reducing HAIs through improving HCWs’ HH.5 In the quest for ways to enhance HCWs’ compliance with SPs, studies have found that knowledge and social factors (eg, safety climate, organizational campaigns) have a positive influence on attitudes and behaviors regarding infection control and prevention.10-12 Students of health care professions might also be susceptible to the impact of the same cognitive and social factors as the HCWs while their intentions to comply and their patterns of behavior regarding infection control and prevention are being formed. The current study uses the transtheoretical model of change (TTMC) developed by Prochaska et al,13 which posits that behavior change involves progress through 5 stages: (1) precontemplation, when the behavior is not under any consideration; (2) contemplation, when the behavior is under consideration, and one starts to look at pros and cons of acting; (3) preparation, when intending to take action in the immediate future and may begin taking small steps toward behavior change; (4) action, when making specific overt modifications in behavior; and (5) maintenance, when the behavior is practiced for at least several months. Jeffe et al14 used the TTMC to describe medical students’ stages of intention to comply with SPs. They found that preclinical medical students are at different stages of intention to comply than students who were exposed to clinical rotations. In agreement with those findings, the current study aims to describe the development of nursing students’ intentions to comply with SPs during the years of formal training and to explore potentially associated organizational, cognitive-social factors.5,15-17 METHODS Study design This is a prospective observational cohort study conducted by following the evolution of nursing students’ intentions to comply with SPs as they progress through their formal education. The curriculum in this particular program includes SP guidelines taught in the first year of studies. This part of the program, similar to most nursing bachelor degree programs in Israel, is based on the CDC guidelines1 that were adopted by the Israel Ministry of Health.18 Two consecutive classes of a 4-year bachelor of nursing program (starting their second year during 2004 and 2005 and ending in 2006 and 2007, respectively) were asked to answer selfadministered questionnaires 3 times during their formal training: (1) at the middle of the second year in the program, a preclinical period with a minimal clinical exposure (time 1); (2) at the end of the third year and after major clinical rotations, under the guidance of clinical instructors affiliated with the university (time 2); and (3) at the end of the fourth year after an advanced and prolonged clinical training period conducted under the supervision of clinical
preceptors working mainly at the hospital (time 3). School management and the ethics committee approved the study. Participation in the study was not obligatory. The participating students received a letter explaining the importance of the study and that anonymity would be guaranteed. The last 3 digits of students’ identification numbers were used to match the 3 times they completed the questionnaire to strengthen the internal validity of the study. Questionnaire design The questionnaire included demographic data and the following sections. The first section included intentions to comply with SPs, based on the questionnaire by Jeffe et al14 originally measuring medical students’ intention to comply with SPs, using the stages of behavioral change developed by Prochaska et al.13 The study by Jeffe et al14 was published 5 years prior to the start of our cohort study and fit its theoretical framework. The current study focused on the following 6 behaviors: (1) appropriate use of disposable gloves, (2) proper disposal of sharps, (3) consistent performance of HH before and after each patient contact, (4) consistent performance of HH before and after using disposable gloves, (5) appropriate use of protective goggles, and (6) appropriate use of gowns and aprons (Table 1). Each behavior could be in any of 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance (properties of this section and the statistical approach used for these measurements are subsequently presented). The 5 stages of change were represented on a 5-point Likert scale referring to the students’ intentions to comply with SPs and equivalent to progression across the TTMC model. The second section included knowledge regarding bloodborne pathogens (BBPs) and included 7 questions based on the questionnaire developed by Jeffe et al.14 Cronbach a ranged from .65 to .68 for the 3 times measured (knowledge 1). An additional 12 questions assessed the students’ knowledge regarding the need for using SPs in caring for various patients. Cronbach a was .75, .77, and .79 at times 1, 2, and 3, respectively (knowledge 2). Twenty-one questions assessed students’ knowledge regarding suitable selection of appropriate personal protective equipment and HH measures in various clinical situations. Cronbach a was .77, .76, and .68 at times 1, 2, and 3, respectively (knowledge 3). The third section on perception of professional risk of contracting BBPs was assessed using questions from Jeffe et al,14 ranging from very high to very low on a 4-point Likert scale (3 questions; Cronbach a ¼ .82, .78, and .80 at times 1, 2, and 3, respectively), and estimation of the BBP prevalence in the general population in the region (3 additional questions; Cronbach a ¼ .94, .71, and .82 at times 1, 2, and 3, respectively). The fourth section included the concept of the personality trait sense of coherence (SOC) from Antonovsky,19 which measured coping abilities with various general stressful life situations (13 questions on a 7-point Likert scale; Cronbach a ¼ .65, .77, and .84 at times 1, 2, and 3, respectively). The fifth section included an organizational safety climate (SC) questionnaire built by Gershon et al, 20 published 3 years prior the beginning of our cohort study, and measured HCWs’ perceptions regarding hospital SC with respect to institutional commitment to BBP risk management programs. We used the questionnaire by Gershon et al20 to assess students’ perceptions regarding the SPs SC in clinical settings (20 questions on a 5-point Likert scale; Cronbach a ¼ .90, .88, and .91 at times 1, 2, and 3, respectively). The final section included the emphasis given on SP compliance by formal educators in various areas of nursing education and was also measured on a Likert scale (6 questions on a 6point Likert scale; Cronbach a ¼ .56 and .75 at times 2 and 3, respectively). Time 1 was missing because most of the students were unfamiliar with most of the formal educational leaders in the different clinical areas of nursing.
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Table 1 Factor analysis with varimax orthogonal rotation for items of intentions to comply with SPs at times 1, 2, and 3 Time 1 (n ¼ 71) Item*
Mean SD
Always using disposable gloves as indicated by SPs Always disposing of sharps into a safe container immediately after use Always performing HH before and after each contact with a patient Always performing HH before and after using disposable gloves Always using protective goggles when a splash of blood or body fluids is anticipated Always using apron or gown when a splash of body fluids or discharges is anticipated Eigen value Explained variance (%)
4.18 4.06 4.17 4.15 2.20
0.87 0.87 0.79 0.86 1.27
Factor 1y,z
Time 2 (n ¼ 53) Factor 2y,z
0.85 0.70 0.94 0.85
2.18 1.28 2.94 49.07
Mean SD
0.94
4.57 4.60 4.51 4.55 2.58
0.93
2.96 1.34
1.74 29.07
0.53 0.49 0.72 0.57 1.34
Factor 1y,z
Time 3 (n ¼ 65) Factor 2y,z
0.97 0.93 0.72 0.91
3.18 53.09
Mean SD
0.89
4.63 4.62 4.37 4.32 2.65
0.89
3.58 1.40
1.58 26.46
0.65 0.72 0.97 0.95 1.45
Factor 1y,z
Factor 2y,z
0.97 0.93 0.92 0.73 0.88 0.87 2.46 49.94
1.34 22.35
*The students were asked to mark 1 box that best describes their behavior or their intentions to behave in a clinical setting. The answers range from 1-5: 1 (precontemplation; no plans); 2 (contemplation; may start in 3-6 months); 3 (preparation; may start in 1 month); 4 (action; doing it now); and 5 (maintenance; doing it for >6 months). y Factor loadings < .20 are suppressed. z Factor 1 concerns CUSPs and factor 2 concerns LUSPs.
Table 2 Intention to comply with CUSPs and LUSPs as reported by nursing students 3 times during their formal education*
CUSPsy LUSPsx
Time 1
Time 2
Time 3
n
Mean SD
Mean SD
Mean SD
F
P value
45 41
4.13 0.69 2.20 1.31
4.54 0.51 2.67 1.21
4.47 0.69 3.11 1.20
6.612,88 7.492,80
.002z .001z
*Measured on 5-point Likert scale corresponding with the TTMC stages of change from 1-5: 1 (precontemplation; no plans); 2 (contemplation; may start in 36 months); 3 (preparation; may start in 1 month); 4 (action; doing it now); and 5 (maintenance; doing it for >6 months). y CUSPs included HH, use of gloves, and disposal of sharps. z P < .01. x LUSPs included use of aprons/gowns and goggles.
Statistical analysis Data redaction by Factor Analysis (SPSS Inc, Chicago, IL)21 with varimax orthogonal rotation was performed on questions addressing the intention to comply with SPs (Table 1). Scales converged to a single factor revealed 2 categories of behavioral intentions within SP domains: (1) commonly used standard precautions (CUSPs), including HH, use of gloves, and disposal of sharps, and (2) less commonly used standard precautions (LUSPs), including use of aprons/gowns and goggles. Internal reliabilities, as measured with Cronbach a, were .88, .89, .76 for CUSPs and .85, .72, .49 for LUSPs at times 1, 2, and 3, respectively. Scales of intention to comply with SPs were regarded as quasi-interval. Analysis of variance was performed with repeated measurements to describe the changes in intentions to comply with SPs over the years. Bonferroni post hoc contrast was applied to determine pairwise comparison between the measured intentions to comply with SPs in the second, third, and fourth years of nursing education. Polynomial contrast trend analysis was performed to detect the direction of the trend.22 An exploratory analysis of associations through Pearson correlation tests of the cognitive-social factors, educational emphasis of formal educators, clinical SC, and intention to comply with SPs were performed at times 1, 2, and 3. The same analysis of correlations was performed for the CUSPs and LUSPs at time 3 with all other variables retrieved from earlier stages of the study to detect delayed effect. Linear regression models were used to predict the intention to comply with CUSPs and LUSPs with knowledge, personal, and social factors after extracting the associated variables, including variables with possible delayed effect (eg, perceived SC at time 1, intention to
comply with CUSPs at time 3). Statistical analysis was performed using SPSS version 15 software (SPSS Inc, Chicago, IL). A P value <.05 was considered significant.
RESULTS Of 82 graduating students, 45 fully completed the intention to comply with SP questionnaires 3 times (55% compliance rate). The compliance by class was 25 out of 37 students (68%) and 21 out of 45 students (47%) of the first and second cohort classes, respectively. However, at any given time measured, the compliance rate for completing the questionnaire, with both cohorts combined, was different (85/91, 93% at time 1; 57/88, 65% at time 2; and 70/82, 85% at time 3). The mean overall ages of the two consecutive classes at time 1 were 24.1 2.16 and 24.4 1.83 years. Women comprised 85% and 75.5% of the classes, respectively. No significant difference between classes was detected in age or sex. Furthermore, no difference was found in proportions of native and immigrant students in each class (52.5% and 54.5% native Israelis in classes 1 and 2, respectively). Mean overall scores of CUSPs at times 1, 2, and 3 were 4.13 0.69, 4.54 0.51, and 4.47 0.69, respectively (Table 2). Although it was imbedded in the action stage, the fourth stage of the behavioral change within the TTMC, there was a statistically significant difference in the scores along the 3 years measured. Bonferroni post hoc pairwise comparisons21 revealed that the intentions to comply with CUSPs were significantly higher at time 2 than at time 1 (P ¼ .001). However, intentions to comply with LUSPs started with an overall mean score of 2.20 1.31 at time 1 and then rose to 2.67 1.21 and 3.11 1.20 at times 2 and 3, respectively, moving from the contemplation to preparation stage. In this case, the Bonferroni pairwise comparisons revealed that the significant difference was between times 1 and 3. Polynomial contrast trend analysis (Fig 1) displayed the CUSPs’ significant quadratic slope (mean sum of squares ¼ 1.793, F1,44 ¼ 7.97, P ¼ .007) and the LUSPs’ statistically significant ascending linear slope (mean sum of squares ¼ 17.149, F1,40 ¼ 14.68, P < .001). The exploratory analysis of association between intentions to comply with SPs and social cognitive and personality trait variables discovered that CUSPs were not related to any of the social and cognitive variables examined at time 1. It was positively associated with SOC (r ¼ 0.31, P ¼ .05, n ¼ 57) and perceived SC (r ¼ 0.27, P ¼ .05, n ¼ 57) at time 2; it was positively associated with none of the variables examined at time 3.
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Fig 1. Trend analysis of the intentions to comply with Commonly Used Standard Precautions (CUSPs) (n ¼ 45) and Less Commonly Used Standard Precautions (LUSPs) (n ¼ 41) on the stages of the Transtheoretical Model of Change (TTMC).
Table 3 Linear regression model, compliance with CUSPs at time 3 (n ¼ 42) Predictor variable Overall grade of knowledge, time 2 SC, time 1 Risk perception, time 3 Summary: F3,38 ¼ 3.52, R2 ¼ 0.22, P ¼
B
SE
b
t
P value
2.51 0.39 0.28 .02*
0.98 0.2 0.17
0.37 0.28 0.24
2.57 1.95 1.65
.01* .058 .11
*P < .05.
On the other hand, intentions to comply with LUSPs were negatively associated with 2 domains of knowledge in 2 separate measurements: (1) at time 1, knowledge 2 (r ¼ 0.34, P < .01, n ¼ 85), and (2) at time 2, knowledge 1 (r ¼ 0.29, P < .05, n ¼ 57). At time 3, intentions to comply with LUSPs were positively associated with estimation of BBP prevalence as a form of perceived risk (r ¼ 0.38, P < .01, n ¼ 70) and emphasis of their formal educators on the importance of SPs (r ¼ .29, P < .05, n ¼ 70). By exploring correlations between the intention to comply with SPs during the fourth year and all other variables measured in previous years, we found that CUSPs were positively associated with students’ total knowledge (which was the average grade for the knowledge sections) from the third year (r ¼ 0.40, P ¼ .004, n ¼ 50) and SC perception at time 1, which was after minimal clinical exposure (r ¼ 0.23, P ¼ .07, n ¼ 62). The LUSPs were positively associated with higher evaluation of professional risk at time 2 (r ¼ 0.28, P ¼ .048, n ¼ 49). In the linear regression model for the intention to comply with CUSPs at the end of the educational program (Table 3), we included factors from the knowledge, organizational, and personal domains. We found that level of knowledge at time 2 was a significant predictor. Risk perception of contracting BBPs and SC as perceived by the students in the early stages of their clinical exposure contributed to the model (P ¼ .02), explaining 22% of the variance in CUSPs. The linear regression model that aimed to find the predictors to comply with LUSPs (Table 4) at the end of formal education, on the other hand, included another form of risk perception, prevalence of BBPs in the region’s population (P ¼ .001), and emphasis given on SPs by formal educators at the same time (P ¼ .003). SOC and overall
grade of knowledge (with a negative regression coefficient, b ¼ 1.14) at time 3 explained 29% of the variance in intention to comply with LUSPs. DISCUSSION The current study aimed to describe the natural development of nursing students’ intentions to comply with SP guidelines as they progress through their formal educational training. The behavioral intentions evaluated in this study address behaviors the student has to decide to perform (eg, performing HH, using protective equipment). This study did not include behaviors that are typically not performed by students (eg, environmental cleaning, allocating patient placement). It became evident that intentions to comply with SP guidelines cannot be regarded as a homogeneous set of behaviors. The students classified each SP-related behavior into 1 of the following 2 categories: (1) less commonly used SP behavior, or (2) more commonly used SP behavior. The intentions to comply with CUSPs and LUSPs were located at different stages on the continuum of the TTMC along the study. The 2 sets of behavioral intentions evolved in a diverse manner. The intentions to comply with CUSPs remained in the action stage during the 3 years of the study. However, within this stage, the finding of the significant quadratic slope suggests that the intention to comply with CUSPs increases from the second to the third year, after which the level of intentions moderately declined. This finding, by itself, is not surprising and may be related to the students’ position in the clinical environment. As the students approach the end of the formal educational program, they become more involved in the real world of the clinical practice scene, and they draw away from the controlled educational environment. This moderate decline in the trend of intentions to comply with CUSPs might be explained, at least to some extent, by several factors, including increased workload and increased responsibility. Additional explanations may include a phenomenon called theorypractice gap. This phenomenon in nursing education refers to the conflict and difficulties nursing students experience when they move from the formal educational environment and encounter a
I. Livshiz-Riven et al. / American Journal of Infection Control xxx (2014) 1-6 Table 4 Linear regression model, compliance with LUSPs at time 3 (n ¼ 60) Predictor variable, time 3
B
Estimation of the BBP prevalence 0.05 Emphasis given on SP compliance by 0.75 formal educators Overall grade of knowledge 1.35 SOC 0.01 Summary: F4,55 ¼ 5.55, R2 ¼ 0.29, P ¼ .001
SE
b
t
0.01 0.24
0.43 0.39
3.61 3.13
1.19 0.2
0.14 0.01
1.14 0.09
P value .001* .003* .26 .93
*P < .01.
different reality in clinical settings. At this point, the students usually have to choose sides, and more often than not the students or young graduates decide to drop previously learned knowledge or behavior in favor of new ways in order to facilitate their acceptance by surrounding clinicians in the new clinical setting.23,24 In contrast with CUSPs, the intention to comply with LUSPs, which were in the contemplation stage at the beginning of the study, maintained a positive linear progression from the second to fourth year. The LUSPs trend analysis results imply that students continue to increase their intentions to comply with LUSPs linearly from the second to fourth year. This puzzle might be explained by an external force majeure that forced dramatic changes in the hospital environment. A national outbreak of carbapenem-resistant Klebsiella pneumoniae, a multidrug resistant organism with extremely high epidemiologic significance, affected almost all hospitals in Israel during 2007.25 This outbreak created a new reality in many aspects, one of which was the enhanced utilization of gowns and aprons. Prochaska et al26 identified that different stages of behavior change are influenced by different factors. In their work they found that in the first stages of behavioral change people are more influenced by considering the pros and cons and emotional processes. Advanced stages of behavioral change are influenced more by social processes. In accord with their observations, we found that the intentions to comply with CUSPs, which were located on a high stage of behavioral change, were significantly associated with clear social factors (eg, SC). In addition, risk perception, an emotional process, is significantly associated with the intention to comply with LUSPs that were consistently located at the beginning stages of behavioral change during the 3 measurements. Knowledge is considered an important component of any program to change behaviors.8,15 In our study, knowledge demonstrated a strong predictive capacity for CUSPs during the final year in the nursing program, but its effect is subject to a long delay. Therefore, it may be that previously learned knowledge can serve as reinforcement of behaviors encountered frequently in the clinical setting. SOC was found to be significantly and positively associated with intentions to comply with CUSPs during the third year of formal education (time 2). This finding coincides with the claim that SOC is positively related to health19,27 and probably to health-related choices. In conclusion, the intentions to comply with CUSPs are positively associated with high levels of knowledge, strong SOC, and supportive SC. The intention to comply with LUSPs was associated positively with high-risk perception of contracting BBPs and by emphasis of formal educators on the subject. Moreover, the different location of CUSPs and LUSPs on the stages of the TTMC may further suggest that different strategies may be needed to increase the distinct SP behaviors. Educators and infection preventionists may consider SC improvement and personalprofessional empowerment when aiming to encourage HH or the use of disposable gloves as part of CUSPs. Then, it might be appropriate to highlight risks to encourage wearing goggles and masks as part of LUSPs, which is located on a much lower level on the stages of change.
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The current findings support the idea that cognitive-social, organizational, and personality factors together with perceived risk may be valuable elements to incorporate and consider when preparing programs to promote the desired behavior of learners in infection control. It is important to be aware of the varied roles of each element at different stages of behavioral evolution during the vulnerable period of formal education of health care professionals. The main limitation of the current study is that it was conducted in a natural cohort environment. In such circumstances, it is not unusual to meet major unexpected changes in the research background settings. Additionally, 45% of the population did not complete all 3 questionnaires. There may be some characteristics of those persons that differ in some way from those who did complete all data sets. An additional limitation is the fact that the relationship between intentions and actual behaviors of the students is unknown, and predictive validity of the intentions to comply with SPs is yet to be explored. Further investigation of methods to improve intentions to comply with SPs in light of the associated factors may clarify the utilization potential of the current findings. References 1. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(10 Suppl 2):S65-164. 2. Mayhall CG. Hospital epidemiology and infection control. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004. 3. Eber MR, Laxminarayan R, Perencevich EN, Malani A. Clinical and economic outcomes attributable to health careeassociated sepsis and pneumonia. Arch Intern Med 2010;170:347-53. 4. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Washington, DC: Centers for Disease Control; 2009. 5. World Health Organization. WHO guidelines on hand hygiene in health care. Geneva: World Health Organization Press; 2009. 6. Tarrac SE. Application of the updated CDC isolation guidelines for health care facilities. AORN J 2008;87:534-46. 7. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand Hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283-94. 8. Gammon J, Morgan-Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. J Clin Nurs 2008;17:157-67. 9. Perry J, Jagger J, Parker G, Phillips EK, Gomaa A. Disposal of sharps medical waste in the United States: impact of recommendations and regulations, 19872007. Am J Infect Control 2012;40:354-8. 10. Stringer B, Haines AT, Goldsmith CH, Berguer R, Blythe J. Is use of the handsfree technique during surgery, a safe work practice, associated with safety climate? Am J Infect Control 2009;37:766-72. 11. Sax H, Uçkay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol 2007;28:1267-74. 12. Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford SM. Compliance with universal/standard precautions among health care workers in rural north India. Am J Infect Control 2005;33:27-33. 13. Prochaska JO, Redding CA, Harlow LL, Rossi JS, Velicer WF. The transtheoretical model of change and HIV prevention: a review. Health Educ Behav 1994;21: 471-86. 14. Jeffe DB, Mutha S, Kim LE, Evanoff BA, L’Ecuyer PB, Fraser VJ. Does clinical experience affect medical students’ knowledge, attitudes, and compliance with universal precautions? Infect Control Hosp Epidemiol 1998;19:767-71. 15. Chan MF, Ho A, Day MC. Investigating the knowledge, attitudes and practice patterns of operating room staff towards standard and transmission-based precautions: results of a cluster analysis. J Clin Nurs 2008;17:1051-62. 16. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307-12. 17. Huis A, van Achterberg T, de Bruin M, Grol R, Schoonhoven L, Hulscher M. A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 2012;7:92. 18. Israel Ministry of Health. Standard precautions in hospitals [in Hebrew]. Jerusalem: Ministry of Health; 2010. 19. Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass; 1987. 20. Gershon RR, Karkashian CD, Grosch JW, Murphy LR, Escamilla-Cejudo A, Flanagan PA, et al. Hospital safety climate and its relationship with safe work
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21. 22. 23. 24.
I. Livshiz-Riven et al. / American Journal of Infection Control xxx (2014) 1-6 practices and workplace exposure incidents. Am J Infect Control 2000;28: 211-21. Hairs JF, Anderson RE, Tatham RL, Black WC. Multivariate data analysis: with readings: Prentice Hall; 1995. Tabachnick BG, Fidell LS. Using multivariate statistics: international edition. Pearson; 2012. Swain J, Pufahl E, Williamson GR. Do they practise what we teach? A survey of manual handling practice amongst student nurses. J Clin Nurs 2003;12:297-306. Maben J, Latter S, Clark JM. The theory-practice gap: impact of professionalbureaucratic work conflict on newly-qualified nurses. J Adv Nurs 2006;55:465-77.
25. Schwaber MJ, Lev B, Israeli A, Solter E, Smollan G, Rubinovitch B, et al. Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention. Clin Infect Dis 2011;52:848-55. 26. Prochaska JM, Paiva AL, Padula JA, Prochaska JO, Montgomery JE, Hageman L, et al. Assessing emotional readiness for adoption using the transtheoretical model. Child Youth Serv Rev 2005;27:135-52. 27. Eriksson M, Lindström B. Antonovsky’s sense of coherence scale and the relation with health: a systematic review. J Epidemiol Community Health 2006;60:376-81.
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American Journal of Infection Control
American Journal of Infection Control
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Major article
Nursing students’ intentions to comply with standard precautions: An exploratory prospective cohort study Ilana Livshiz-Riven PhD, RN a, b, *, Ronit Nativ MPH, RN b, Abraham Borer MD b, c, Yaniv Kanat-Maymon PhD d, Ofra Anson PhD c a Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel b Infection Control and Hospital Epidemiology Unit, Soroka University Medical Center, Beer-Sheva, Israel c Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel d School of Psychology, Interdisciplinary Center, Herzliya, Israel
Key Words: Cohort study Infection control and prevention Nursing education Occupational risk perception Safety climate Sense of coherence Standard precautions Transtheoretical model of change (TTMC)
Background: Partial compliance of health care workers with standard precaution (SP) guidelines has been extensively documented. The aim of this study was to describe the development of nursing students’ intentions to comply with SPs. Methods: Prospective cohort study. Two consecutive classes of a 4-year bachelor of nursing program completed questionnaires 3 times. The transtheoretical model of change was used to describe the change in intentions to comply with SPs. Factor analysis displayed 2 behavioral categories: commonly used standard precautions (CUSPs) and less commonly used standard precautions (LUSPs). Knowledge, risk perception, sense of coherence (SOC), safety climate (SC), and emphasis given by educators were evaluated as associated factors. Results: Of the 91 students, 85 (93%) completed the questionnaire during their second year, 57 of 88 students (65%) completed it during the third year, and 70 of 82 students (85%) completed it at the end of the fourth year. Of the 82 students, 45 (55%) completed 3 measurements. CUSPs exhibited a rise from the second to the third year, with a moderate decline from the third to the fourth year, whereas LUSPs continued ascending. CUSPs were positively associated with SC and SOC; LUSPs were commonly associated with risk perception. Conclusion: The different evolution of CUSPs and LUSPs and dissimilar associations may suggest that different strategies might encourage diverse SP behaviors. Improving the SC might be appropriate when aiming to encourage CUSPs, and highlighting risks may be appropriate to encourage LUSPs. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Health careeassociated infections (HAIs) are adverse events occurring because of utilization of health care services.1,2 These unnecessary complications pose needless financial burden and human suffering on patients, families, health care personnel, and health care organizations.3-5 Isolation precaution (IP) guidelines, designed by the Centers for Disease Control and Prevention (CDC), were written to enhance biosafety in health care settings. Within the IPs, standard precautions (SPs) comprise the fundamental tier, which aims to prevent the cross-contamination of unknown and known infectious agents transmittable by contact with blood or
* Address correspondence to Ilana Livshiz-Riven, PhD, RN, Department of Nursing, Recanati School of Community Health Professions, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 8410501, Israel. E-mail address: [email protected] (I. Livshiz-Riven). Conflict of interest: None to report.
body fluids. SPs are designed to be used by all health care workers (HCWs) when caring for all patients.1 The recommendations for application of SPs for the care of all patients in all health care settings includes the following: (1) hand hygiene (HH) after touching blood, body fluids, secretions, excretions, contaminated items, immediately after removing gloves, and between patient contacts; (2) using disposable gloves for touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and nonintact skin; (3) using mask, eye protection (goggles), or face shield during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids, or secretions, especially suctioning and endotracheal intubation; (4) using a gown during procedures and patient care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated; (5) handling soiled patient care equipment in a manner that prevents transfer of microorganisms to others and the
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environment; (6) developing procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas as a measure of environmental control; (7) handling textiles in a manner that prevents transfer of microorganisms to others and to the environment; (8) safe disposal of needles and other sharps; (9) patient placement by prioritizing to reduce risk of pathogen transmission; and (10) respiratory hygiene/ cough etiquette instruction to symptomatic persons to cover mouth/ nose when sneezing/coughing.1,6 The partial compliance of HCWs with SPs has been extensively researched during the last several decades, with compliance ranging from <30% in HH to >90% in appropriate sharps disposable.7,8 A substantial proportion of research focusing on HCWs’ compliance with IPs was on proper handling and disposal of sharps and HH.7,9 The focus on HCW compliance with HH guidelines might be explained, in part, by the World Health Organization’s engagement in reducing HAIs through improving HCWs’ HH.5 In the quest for ways to enhance HCWs’ compliance with SPs, studies have found that knowledge and social factors (eg, safety climate, organizational campaigns) have a positive influence on attitudes and behaviors regarding infection control and prevention.10-12 Students of health care professions might also be susceptible to the impact of the same cognitive and social factors as the HCWs while their intentions to comply and their patterns of behavior regarding infection control and prevention are being formed. The current study uses the transtheoretical model of change (TTMC) developed by Prochaska et al,13 which posits that behavior change involves progress through 5 stages: (1) precontemplation, when the behavior is not under any consideration; (2) contemplation, when the behavior is under consideration, and one starts to look at pros and cons of acting; (3) preparation, when intending to take action in the immediate future and may begin taking small steps toward behavior change; (4) action, when making specific overt modifications in behavior; and (5) maintenance, when the behavior is practiced for at least several months. Jeffe et al14 used the TTMC to describe medical students’ stages of intention to comply with SPs. They found that preclinical medical students are at different stages of intention to comply than students who were exposed to clinical rotations. In agreement with those findings, the current study aims to describe the development of nursing students’ intentions to comply with SPs during the years of formal training and to explore potentially associated organizational, cognitive-social factors.5,15-17 METHODS Study design This is a prospective observational cohort study conducted by following the evolution of nursing students’ intentions to comply with SPs as they progress through their formal education. The curriculum in this particular program includes SP guidelines taught in the first year of studies. This part of the program, similar to most nursing bachelor degree programs in Israel, is based on the CDC guidelines1 that were adopted by the Israel Ministry of Health.18 Two consecutive classes of a 4-year bachelor of nursing program (starting their second year during 2004 and 2005 and ending in 2006 and 2007, respectively) were asked to answer selfadministered questionnaires 3 times during their formal training: (1) at the middle of the second year in the program, a preclinical period with a minimal clinical exposure (time 1); (2) at the end of the third year and after major clinical rotations, under the guidance of clinical instructors affiliated with the university (time 2); and (3) at the end of the fourth year after an advanced and prolonged clinical training period conducted under the supervision of clinical
preceptors working mainly at the hospital (time 3). School management and the ethics committee approved the study. Participation in the study was not obligatory. The participating students received a letter explaining the importance of the study and that anonymity would be guaranteed. The last 3 digits of students’ identification numbers were used to match the 3 times they completed the questionnaire to strengthen the internal validity of the study. Questionnaire design The questionnaire included demographic data and the following sections. The first section included intentions to comply with SPs, based on the questionnaire by Jeffe et al14 originally measuring medical students’ intention to comply with SPs, using the stages of behavioral change developed by Prochaska et al.13 The study by Jeffe et al14 was published 5 years prior to the start of our cohort study and fit its theoretical framework. The current study focused on the following 6 behaviors: (1) appropriate use of disposable gloves, (2) proper disposal of sharps, (3) consistent performance of HH before and after each patient contact, (4) consistent performance of HH before and after using disposable gloves, (5) appropriate use of protective goggles, and (6) appropriate use of gowns and aprons (Table 1). Each behavior could be in any of 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance (properties of this section and the statistical approach used for these measurements are subsequently presented). The 5 stages of change were represented on a 5-point Likert scale referring to the students’ intentions to comply with SPs and equivalent to progression across the TTMC model. The second section included knowledge regarding bloodborne pathogens (BBPs) and included 7 questions based on the questionnaire developed by Jeffe et al.14 Cronbach a ranged from .65 to .68 for the 3 times measured (knowledge 1). An additional 12 questions assessed the students’ knowledge regarding the need for using SPs in caring for various patients. Cronbach a was .75, .77, and .79 at times 1, 2, and 3, respectively (knowledge 2). Twenty-one questions assessed students’ knowledge regarding suitable selection of appropriate personal protective equipment and HH measures in various clinical situations. Cronbach a was .77, .76, and .68 at times 1, 2, and 3, respectively (knowledge 3). The third section on perception of professional risk of contracting BBPs was assessed using questions from Jeffe et al,14 ranging from very high to very low on a 4-point Likert scale (3 questions; Cronbach a ¼ .82, .78, and .80 at times 1, 2, and 3, respectively), and estimation of the BBP prevalence in the general population in the region (3 additional questions; Cronbach a ¼ .94, .71, and .82 at times 1, 2, and 3, respectively). The fourth section included the concept of the personality trait sense of coherence (SOC) from Antonovsky,19 which measured coping abilities with various general stressful life situations (13 questions on a 7-point Likert scale; Cronbach a ¼ .65, .77, and .84 at times 1, 2, and 3, respectively). The fifth section included an organizational safety climate (SC) questionnaire built by Gershon et al, 20 published 3 years prior the beginning of our cohort study, and measured HCWs’ perceptions regarding hospital SC with respect to institutional commitment to BBP risk management programs. We used the questionnaire by Gershon et al20 to assess students’ perceptions regarding the SPs SC in clinical settings (20 questions on a 5-point Likert scale; Cronbach a ¼ .90, .88, and .91 at times 1, 2, and 3, respectively). The final section included the emphasis given on SP compliance by formal educators in various areas of nursing education and was also measured on a Likert scale (6 questions on a 6point Likert scale; Cronbach a ¼ .56 and .75 at times 2 and 3, respectively). Time 1 was missing because most of the students were unfamiliar with most of the formal educational leaders in the different clinical areas of nursing.
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Table 1 Factor analysis with varimax orthogonal rotation for items of intentions to comply with SPs at times 1, 2, and 3 Time 1 (n ¼ 71) Item*
Mean SD
Always using disposable gloves as indicated by SPs Always disposing of sharps into a safe container immediately after use Always performing HH before and after each contact with a patient Always performing HH before and after using disposable gloves Always using protective goggles when a splash of blood or body fluids is anticipated Always using apron or gown when a splash of body fluids or discharges is anticipated Eigen value Explained variance (%)
4.18 4.06 4.17 4.15 2.20
0.87 0.87 0.79 0.86 1.27
Factor 1y,z
Time 2 (n ¼ 53) Factor 2y,z
0.85 0.70 0.94 0.85
2.18 1.28 2.94 49.07
Mean SD
0.94
4.57 4.60 4.51 4.55 2.58
0.93
2.96 1.34
1.74 29.07
0.53 0.49 0.72 0.57 1.34
Factor 1y,z
Time 3 (n ¼ 65) Factor 2y,z
0.97 0.93 0.72 0.91
3.18 53.09
Mean SD
0.89
4.63 4.62 4.37 4.32 2.65
0.89
3.58 1.40
1.58 26.46
0.65 0.72 0.97 0.95 1.45
Factor 1y,z
Factor 2y,z
0.97 0.93 0.92 0.73 0.88 0.87 2.46 49.94
1.34 22.35
*The students were asked to mark 1 box that best describes their behavior or their intentions to behave in a clinical setting. The answers range from 1-5: 1 (precontemplation; no plans); 2 (contemplation; may start in 3-6 months); 3 (preparation; may start in 1 month); 4 (action; doing it now); and 5 (maintenance; doing it for >6 months). y Factor loadings < .20 are suppressed. z Factor 1 concerns CUSPs and factor 2 concerns LUSPs.
Table 2 Intention to comply with CUSPs and LUSPs as reported by nursing students 3 times during their formal education*
CUSPsy LUSPsx
Time 1
Time 2
Time 3
n
Mean SD
Mean SD
Mean SD
F
P value
45 41
4.13 0.69 2.20 1.31
4.54 0.51 2.67 1.21
4.47 0.69 3.11 1.20
6.612,88 7.492,80
.002z .001z
*Measured on 5-point Likert scale corresponding with the TTMC stages of change from 1-5: 1 (precontemplation; no plans); 2 (contemplation; may start in 36 months); 3 (preparation; may start in 1 month); 4 (action; doing it now); and 5 (maintenance; doing it for >6 months). y CUSPs included HH, use of gloves, and disposal of sharps. z P < .01. x LUSPs included use of aprons/gowns and goggles.
Statistical analysis Data redaction by Factor Analysis (SPSS Inc, Chicago, IL)21 with varimax orthogonal rotation was performed on questions addressing the intention to comply with SPs (Table 1). Scales converged to a single factor revealed 2 categories of behavioral intentions within SP domains: (1) commonly used standard precautions (CUSPs), including HH, use of gloves, and disposal of sharps, and (2) less commonly used standard precautions (LUSPs), including use of aprons/gowns and goggles. Internal reliabilities, as measured with Cronbach a, were .88, .89, .76 for CUSPs and .85, .72, .49 for LUSPs at times 1, 2, and 3, respectively. Scales of intention to comply with SPs were regarded as quasi-interval. Analysis of variance was performed with repeated measurements to describe the changes in intentions to comply with SPs over the years. Bonferroni post hoc contrast was applied to determine pairwise comparison between the measured intentions to comply with SPs in the second, third, and fourth years of nursing education. Polynomial contrast trend analysis was performed to detect the direction of the trend.22 An exploratory analysis of associations through Pearson correlation tests of the cognitive-social factors, educational emphasis of formal educators, clinical SC, and intention to comply with SPs were performed at times 1, 2, and 3. The same analysis of correlations was performed for the CUSPs and LUSPs at time 3 with all other variables retrieved from earlier stages of the study to detect delayed effect. Linear regression models were used to predict the intention to comply with CUSPs and LUSPs with knowledge, personal, and social factors after extracting the associated variables, including variables with possible delayed effect (eg, perceived SC at time 1, intention to
comply with CUSPs at time 3). Statistical analysis was performed using SPSS version 15 software (SPSS Inc, Chicago, IL). A P value <.05 was considered significant.
RESULTS Of 82 graduating students, 45 fully completed the intention to comply with SP questionnaires 3 times (55% compliance rate). The compliance by class was 25 out of 37 students (68%) and 21 out of 45 students (47%) of the first and second cohort classes, respectively. However, at any given time measured, the compliance rate for completing the questionnaire, with both cohorts combined, was different (85/91, 93% at time 1; 57/88, 65% at time 2; and 70/82, 85% at time 3). The mean overall ages of the two consecutive classes at time 1 were 24.1 2.16 and 24.4 1.83 years. Women comprised 85% and 75.5% of the classes, respectively. No significant difference between classes was detected in age or sex. Furthermore, no difference was found in proportions of native and immigrant students in each class (52.5% and 54.5% native Israelis in classes 1 and 2, respectively). Mean overall scores of CUSPs at times 1, 2, and 3 were 4.13 0.69, 4.54 0.51, and 4.47 0.69, respectively (Table 2). Although it was imbedded in the action stage, the fourth stage of the behavioral change within the TTMC, there was a statistically significant difference in the scores along the 3 years measured. Bonferroni post hoc pairwise comparisons21 revealed that the intentions to comply with CUSPs were significantly higher at time 2 than at time 1 (P ¼ .001). However, intentions to comply with LUSPs started with an overall mean score of 2.20 1.31 at time 1 and then rose to 2.67 1.21 and 3.11 1.20 at times 2 and 3, respectively, moving from the contemplation to preparation stage. In this case, the Bonferroni pairwise comparisons revealed that the significant difference was between times 1 and 3. Polynomial contrast trend analysis (Fig 1) displayed the CUSPs’ significant quadratic slope (mean sum of squares ¼ 1.793, F1,44 ¼ 7.97, P ¼ .007) and the LUSPs’ statistically significant ascending linear slope (mean sum of squares ¼ 17.149, F1,40 ¼ 14.68, P < .001). The exploratory analysis of association between intentions to comply with SPs and social cognitive and personality trait variables discovered that CUSPs were not related to any of the social and cognitive variables examined at time 1. It was positively associated with SOC (r ¼ 0.31, P ¼ .05, n ¼ 57) and perceived SC (r ¼ 0.27, P ¼ .05, n ¼ 57) at time 2; it was positively associated with none of the variables examined at time 3.
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Fig 1. Trend analysis of the intentions to comply with Commonly Used Standard Precautions (CUSPs) (n ¼ 45) and Less Commonly Used Standard Precautions (LUSPs) (n ¼ 41) on the stages of the Transtheoretical Model of Change (TTMC).
Table 3 Linear regression model, compliance with CUSPs at time 3 (n ¼ 42) Predictor variable Overall grade of knowledge, time 2 SC, time 1 Risk perception, time 3 Summary: F3,38 ¼ 3.52, R2 ¼ 0.22, P ¼
B
SE
b
t
P value
2.51 0.39 0.28 .02*
0.98 0.2 0.17
0.37 0.28 0.24
2.57 1.95 1.65
.01* .058 .11
*P < .05.
On the other hand, intentions to comply with LUSPs were negatively associated with 2 domains of knowledge in 2 separate measurements: (1) at time 1, knowledge 2 (r ¼ 0.34, P < .01, n ¼ 85), and (2) at time 2, knowledge 1 (r ¼ 0.29, P < .05, n ¼ 57). At time 3, intentions to comply with LUSPs were positively associated with estimation of BBP prevalence as a form of perceived risk (r ¼ 0.38, P < .01, n ¼ 70) and emphasis of their formal educators on the importance of SPs (r ¼ .29, P < .05, n ¼ 70). By exploring correlations between the intention to comply with SPs during the fourth year and all other variables measured in previous years, we found that CUSPs were positively associated with students’ total knowledge (which was the average grade for the knowledge sections) from the third year (r ¼ 0.40, P ¼ .004, n ¼ 50) and SC perception at time 1, which was after minimal clinical exposure (r ¼ 0.23, P ¼ .07, n ¼ 62). The LUSPs were positively associated with higher evaluation of professional risk at time 2 (r ¼ 0.28, P ¼ .048, n ¼ 49). In the linear regression model for the intention to comply with CUSPs at the end of the educational program (Table 3), we included factors from the knowledge, organizational, and personal domains. We found that level of knowledge at time 2 was a significant predictor. Risk perception of contracting BBPs and SC as perceived by the students in the early stages of their clinical exposure contributed to the model (P ¼ .02), explaining 22% of the variance in CUSPs. The linear regression model that aimed to find the predictors to comply with LUSPs (Table 4) at the end of formal education, on the other hand, included another form of risk perception, prevalence of BBPs in the region’s population (P ¼ .001), and emphasis given on SPs by formal educators at the same time (P ¼ .003). SOC and overall
grade of knowledge (with a negative regression coefficient, b ¼ 1.14) at time 3 explained 29% of the variance in intention to comply with LUSPs. DISCUSSION The current study aimed to describe the natural development of nursing students’ intentions to comply with SP guidelines as they progress through their formal educational training. The behavioral intentions evaluated in this study address behaviors the student has to decide to perform (eg, performing HH, using protective equipment). This study did not include behaviors that are typically not performed by students (eg, environmental cleaning, allocating patient placement). It became evident that intentions to comply with SP guidelines cannot be regarded as a homogeneous set of behaviors. The students classified each SP-related behavior into 1 of the following 2 categories: (1) less commonly used SP behavior, or (2) more commonly used SP behavior. The intentions to comply with CUSPs and LUSPs were located at different stages on the continuum of the TTMC along the study. The 2 sets of behavioral intentions evolved in a diverse manner. The intentions to comply with CUSPs remained in the action stage during the 3 years of the study. However, within this stage, the finding of the significant quadratic slope suggests that the intention to comply with CUSPs increases from the second to the third year, after which the level of intentions moderately declined. This finding, by itself, is not surprising and may be related to the students’ position in the clinical environment. As the students approach the end of the formal educational program, they become more involved in the real world of the clinical practice scene, and they draw away from the controlled educational environment. This moderate decline in the trend of intentions to comply with CUSPs might be explained, at least to some extent, by several factors, including increased workload and increased responsibility. Additional explanations may include a phenomenon called theorypractice gap. This phenomenon in nursing education refers to the conflict and difficulties nursing students experience when they move from the formal educational environment and encounter a
I. Livshiz-Riven et al. / American Journal of Infection Control xxx (2014) 1-6 Table 4 Linear regression model, compliance with LUSPs at time 3 (n ¼ 60) Predictor variable, time 3
B
Estimation of the BBP prevalence 0.05 Emphasis given on SP compliance by 0.75 formal educators Overall grade of knowledge 1.35 SOC 0.01 Summary: F4,55 ¼ 5.55, R2 ¼ 0.29, P ¼ .001
SE
b
t
0.01 0.24
0.43 0.39
3.61 3.13
1.19 0.2
0.14 0.01
1.14 0.09
P value .001* .003* .26 .93
*P < .01.
different reality in clinical settings. At this point, the students usually have to choose sides, and more often than not the students or young graduates decide to drop previously learned knowledge or behavior in favor of new ways in order to facilitate their acceptance by surrounding clinicians in the new clinical setting.23,24 In contrast with CUSPs, the intention to comply with LUSPs, which were in the contemplation stage at the beginning of the study, maintained a positive linear progression from the second to fourth year. The LUSPs trend analysis results imply that students continue to increase their intentions to comply with LUSPs linearly from the second to fourth year. This puzzle might be explained by an external force majeure that forced dramatic changes in the hospital environment. A national outbreak of carbapenem-resistant Klebsiella pneumoniae, a multidrug resistant organism with extremely high epidemiologic significance, affected almost all hospitals in Israel during 2007.25 This outbreak created a new reality in many aspects, one of which was the enhanced utilization of gowns and aprons. Prochaska et al26 identified that different stages of behavior change are influenced by different factors. In their work they found that in the first stages of behavioral change people are more influenced by considering the pros and cons and emotional processes. Advanced stages of behavioral change are influenced more by social processes. In accord with their observations, we found that the intentions to comply with CUSPs, which were located on a high stage of behavioral change, were significantly associated with clear social factors (eg, SC). In addition, risk perception, an emotional process, is significantly associated with the intention to comply with LUSPs that were consistently located at the beginning stages of behavioral change during the 3 measurements. Knowledge is considered an important component of any program to change behaviors.8,15 In our study, knowledge demonstrated a strong predictive capacity for CUSPs during the final year in the nursing program, but its effect is subject to a long delay. Therefore, it may be that previously learned knowledge can serve as reinforcement of behaviors encountered frequently in the clinical setting. SOC was found to be significantly and positively associated with intentions to comply with CUSPs during the third year of formal education (time 2). This finding coincides with the claim that SOC is positively related to health19,27 and probably to health-related choices. In conclusion, the intentions to comply with CUSPs are positively associated with high levels of knowledge, strong SOC, and supportive SC. The intention to comply with LUSPs was associated positively with high-risk perception of contracting BBPs and by emphasis of formal educators on the subject. Moreover, the different location of CUSPs and LUSPs on the stages of the TTMC may further suggest that different strategies may be needed to increase the distinct SP behaviors. Educators and infection preventionists may consider SC improvement and personalprofessional empowerment when aiming to encourage HH or the use of disposable gloves as part of CUSPs. Then, it might be appropriate to highlight risks to encourage wearing goggles and masks as part of LUSPs, which is located on a much lower level on the stages of change.
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The current findings support the idea that cognitive-social, organizational, and personality factors together with perceived risk may be valuable elements to incorporate and consider when preparing programs to promote the desired behavior of learners in infection control. It is important to be aware of the varied roles of each element at different stages of behavioral evolution during the vulnerable period of formal education of health care professionals. The main limitation of the current study is that it was conducted in a natural cohort environment. In such circumstances, it is not unusual to meet major unexpected changes in the research background settings. Additionally, 45% of the population did not complete all 3 questionnaires. There may be some characteristics of those persons that differ in some way from those who did complete all data sets. An additional limitation is the fact that the relationship between intentions and actual behaviors of the students is unknown, and predictive validity of the intentions to comply with SPs is yet to be explored. Further investigation of methods to improve intentions to comply with SPs in light of the associated factors may clarify the utilization potential of the current findings. References 1. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(10 Suppl 2):S65-164. 2. Mayhall CG. Hospital epidemiology and infection control. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004. 3. Eber MR, Laxminarayan R, Perencevich EN, Malani A. Clinical and economic outcomes attributable to health careeassociated sepsis and pneumonia. Arch Intern Med 2010;170:347-53. 4. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Washington, DC: Centers for Disease Control; 2009. 5. World Health Organization. WHO guidelines on hand hygiene in health care. Geneva: World Health Organization Press; 2009. 6. Tarrac SE. Application of the updated CDC isolation guidelines for health care facilities. AORN J 2008;87:534-46. 7. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand Hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283-94. 8. Gammon J, Morgan-Samuel H, Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. J Clin Nurs 2008;17:157-67. 9. Perry J, Jagger J, Parker G, Phillips EK, Gomaa A. Disposal of sharps medical waste in the United States: impact of recommendations and regulations, 19872007. Am J Infect Control 2012;40:354-8. 10. Stringer B, Haines AT, Goldsmith CH, Berguer R, Blythe J. Is use of the handsfree technique during surgery, a safe work practice, associated with safety climate? Am J Infect Control 2009;37:766-72. 11. Sax H, Uçkay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol 2007;28:1267-74. 12. Kermode M, Jolley D, Langkham B, Thomas MS, Holmes W, Gifford SM. Compliance with universal/standard precautions among health care workers in rural north India. Am J Infect Control 2005;33:27-33. 13. Prochaska JO, Redding CA, Harlow LL, Rossi JS, Velicer WF. The transtheoretical model of change and HIV prevention: a review. Health Educ Behav 1994;21: 471-86. 14. Jeffe DB, Mutha S, Kim LE, Evanoff BA, L’Ecuyer PB, Fraser VJ. Does clinical experience affect medical students’ knowledge, attitudes, and compliance with universal precautions? Infect Control Hosp Epidemiol 1998;19:767-71. 15. Chan MF, Ho A, Day MC. Investigating the knowledge, attitudes and practice patterns of operating room staff towards standard and transmission-based precautions: results of a cluster analysis. J Clin Nurs 2008;17:1051-62. 16. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307-12. 17. Huis A, van Achterberg T, de Bruin M, Grol R, Schoonhoven L, Hulscher M. A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 2012;7:92. 18. Israel Ministry of Health. Standard precautions in hospitals [in Hebrew]. Jerusalem: Ministry of Health; 2010. 19. Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass; 1987. 20. Gershon RR, Karkashian CD, Grosch JW, Murphy LR, Escamilla-Cejudo A, Flanagan PA, et al. Hospital safety climate and its relationship with safe work
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21. 22. 23. 24.
I. Livshiz-Riven et al. / American Journal of Infection Control xxx (2014) 1-6 practices and workplace exposure incidents. Am J Infect Control 2000;28: 211-21. Hairs JF, Anderson RE, Tatham RL, Black WC. Multivariate data analysis: with readings: Prentice Hall; 1995. Tabachnick BG, Fidell LS. Using multivariate statistics: international edition. Pearson; 2012. Swain J, Pufahl E, Williamson GR. Do they practise what we teach? A survey of manual handling practice amongst student nurses. J Clin Nurs 2003;12:297-306. Maben J, Latter S, Clark JM. The theory-practice gap: impact of professionalbureaucratic work conflict on newly-qualified nurses. J Adv Nurs 2006;55:465-77.
25. Schwaber MJ, Lev B, Israeli A, Solter E, Smollan G, Rubinovitch B, et al. Containment of a country-wide outbreak of carbapenem-resistant Klebsiella pneumoniae in Israeli hospitals via a nationally implemented intervention. Clin Infect Dis 2011;52:848-55. 26. Prochaska JM, Paiva AL, Padula JA, Prochaska JO, Montgomery JE, Hageman L, et al. Assessing emotional readiness for adoption using the transtheoretical model. Child Youth Serv Rev 2005;27:135-52. 27. Eriksson M, Lindström B. Antonovsky’s sense of coherence scale and the relation with health: a systematic review. J Epidemiol Community Health 2006;60:376-81.