- Email: [email protected]
Opinions, knowledge, and self-reported practices related to infection control among nursing personnel in long-term care settings
Opinions, knuw practices rela among nursing care settings
f-reported control BUW in lang=term
Martha S. Alvaran, RN, MSNa Arlene Butz, RN, ScDb Elaine Larson, RN, PhD, CIC, FAANc Baltimore,
Maryland,
and Washington,
D.C.
Background: Because educational needs of staff in long-term care facilities regarding infection control have, not been well studied, we conducted this study to measure long-term care staff members’ knowledge, self-reported practices, and opinions about infection control and handwashing. Methods: A pilot study was conducted with 24 staff members of one long-term care facility to examine psychometric properties of study instruments. All nursing staff members (n = 105) from two additional long-term care facilities then completed a 14-item knowledge questionnaire, 22-item opinion survey, and 26-item survey of self-reported handwashing practices. Results: Respondents were predominantly female with mean age of 46 years; most had completed high school. Mean length of employment in the study facility was 12.4 years. Registered nurses and licensed practical nurses scored significantly higher on knowledge (p = 0.0002) but significantly lower on self-reported practices (p = 0.01) than did trained nursing assistants. There was no significant correlation between self-reported practices and opinions regarding handwashing (p = 0.55). Neither level of knowledge nor positive opinion about the value of handwashing was associated with self-reported increases in handwashing practices. Conclusion: We conclude that education alone is not likely to be associated with changes in handwashing behavior. Instruments developed and tested in this study can be used in further research to correlate self-reported with observed behavior and to evaluate the effects of interventions on knowledge, opinions, and self-reported handwashing behavior. (AJIC AM J INFECT CONTROL 1994;22:367-70)
There are now almost 30 million Americans aged 65 years and older.’ Predictions indicate that this population will more than double by the year 2030, raising the proportion to 18.2% of the total population.’ The number of nursing homes in the United States has increased concomitantly. As a person ages, ability to resist infection decreases.3 Few studies, however, have addressed
From Jenkins Memorial Incorporateda and The Johns University School of Nursing,b Baltimore, and Georgetown sity School of Nursing,C Washington, D.C. Copyright 0 1994 by the Association Control and Epidemiology, Inc. 0196-6553194
$3.00
+ 0
17147166677
for Professionals
Hopkins Univerin Infection
infection control problems in long-term care (LTC) facilities. Those studies that have been done report prevalences of infection among residents ranging from 10% to 30% at any given time.4 It has been reported, however, that 24.7% of the nation’s 15,000 nursing homes participating in the Medicaid program do not follow isolation techniques aimed at preventing the spread of infection.’ One important way to address this problem is to assess the infection control educational needs of patient care staff members in LTC facilities. Although the need for standardized infection control programs in LTC facilities was recently highlighted,6 few data are available regarding the extent of knowledge related to infection control among LTC staff members. 367
368
Alvaran, Butz, and Larson
The purpose of this descriptive study was to measure knowledge of infection control, describe self-reported practices and opinions regarding handwashing as a means for infection control, and correlate knowledge with self-reported practices among LTC nursing staff members. Self-reported practices and opinions, rather than observed practices, were solicited in this study to measure factors that predispose individuals to practice (what they believe they should be or are doing). METHODS Theoretic framework This study used the health education model PRECEDE, addressing predisposing (e.g., knowledge, attitudes), reinforcing (e.g., skills, training), and enabling factors (e.g., feedback) that need to be assessed for educational diagnosis and evaluation. This model has been used in numerous health education and research programs7 attempting to effect such changes in behavior as use of infant car seats and smoking cessation. The framework consists of a multiphased process for diagnosing health problems, developing and implementing health education interventions, and evaluating program outcomes. Phases of the model include epidemiologic, social, behavioral, educational, and administrative diagnosis. This study was designed to focus on the diagnostic phase for predisposing factors. The PRECEDE framework places emphasis on outcomes rather than inputs, forcing the educator to begin the planning process by defining outcomes and then determining factors likely to result in those outcomes. Study setting
and subjects
The study population was the permanent fulltime staff of registered nurses (RNs), licensed practical nurses (LPNs), and trained aides (TAs) of two facilities, a SOO-bed LTC psychiatric facility and a 155-bed nursing home operated by the Department of Health and Mental Hygiene of the State of Maryland. Instruments The knowledge instrument, developed as part of a doctoral dissertation, had undergone considerable psychometric testing and had been used in three previous studies6, ‘29 to measure knowledge about infection control practices. Because this instrument had not been used previously with LTC staff members, we conducted a pilot study and psychometric evaluation of the instrument during the summer of 1989 among 24 permanent nursing staff volunteer subjects: one third RNs and two
December
AJIC 1994
thirds TAs, representing five nursing units from a 223-bed urban, unionized nursing home primarily serving elderly individuals. This group was comparable to the subjects who would be used in the larger study. Readability level was measured by the SMOG test,” at the eighth grade level. Testretest reliability was determined to assess the stability of respondents’ answers across time. All tests were administered twice, with a l-week interval between administrations. The test-retest reliability coefficient for the knowledge test was 0.85. Content validity was examined by a panel of five expert ICPs. A slightly revised knowledge instrument contained 14 dichotomous (true-false) statements such as, “People who are very young or very old are especially prone to infection,” and, “Droplets released from an infected person can travel several feet.” A second instrument measuring handwashing practices and opinions was also pilot tested. With permission from the author, two S-point Likert scales were adapted from the Handwashing Practice Inventory.’ ’ These self-reporting subscales contained 26 items measuring self-reported practices related to handwashing and 22 items eliciting opinions regarding handwashing. Correlation coefficient on test-retest for both scales was 0.8 1; Cronbach’s cu(to test for internal consistency) was 0.76 for the practice scale and 0.87 for opinion scale. The practice scale contained such items as, “I wash my hands before I prepare food,” “I wash my hands when there is a rule that says I am supposed to,” and, “I wash my hands after touching materials soiled by patient urine.” The maximum score was 130, with higher scores indicating more frequent self-reported handwashing practices. The opinion scale contained such items as, “Washing my hands can make them feel is inconvenient,” bad to touch,” “ Handwashing and, “If I wear gloves, handwashing is unnecessary.” The maximum score was 110; negative items were reverse scored so that a higher score represented more positive opinions about handwashing. On the basis of these pilot psychometric tests, we determined that the instruments had sufficient stability, internal consistency, and validity for use with a larger sample. Data collection
procedure
At the psychiatric facility, the instruments were distributed by the researcher on three occasions at the beginning of a voluntary in-service program. At the nursing home, the questionnaires were distributed on a single working day during man-
AJIC Volurne
22,
‘4 ,d3er
6
datory in-service educational programs. In both cases, the forms were completed immediately and collected by the investigator (M. S. A).
Analysis of variance was used to examine knowledge practice, and opinion scores by level of education, nursing category (RN, LPN, TA), and site (psychiatric facility or nursing home). Pearson correlation coefficients were used to examine potential associations between such demographic variables as age and length of employment and knowledge, practice, and opinion scores. RESULTS The number of subjects eligible for the study at the nursing home was 54; 51 eligible subjects attended the voluntary in-service program at the psychiatric facility. There were no refusals among staff members approached at either facility. The mean age 01 subjects was 46 years (range 23 to 62 years) and subjects were predominantly female (96/105). Most respondents (71%) reported that they had at. !east a high school education. Nursing category breakdown was TAs, 36%: RNs, 33%; and LPNs, 30%. The length of employment in health care ranged from 1 to 35 years, with a mean of 19.3 years. Knowkdge? Most items (9/l 4) were answered correctly by at least 75% of respondents. RNs and LPNs had significantly higher scores (means of 9.4 and 9.8, respectively) than did TAs (mean 9.0, p = 0.0002). There were no significant differences in knowledge scores by age (p = 0.70), length of employment (p I- 0.08), place of employment (psychiatric facility or nursing home, p = 0.93) and sex Ip = 0.50). Handwashing
practices
Self-reported mean total handwashing practice scores were as follows: RNs, 109.6; LPNs, 114.4; and TAs, 117.3 (p - 0.0007). All subjects reported that they always washed their hands after contact with infected body sites or blood, and about three fourths reported that they would wash their hands if a rule said they should. Men had significantly lower handwashing practice scores than women (107.4 and I 14.5, respectively, p = 0.02). Nat&w-
opinlans
Mean opinion scores out of a total possible of 110 were 81.6, 84.2, and 79.0 respectively for RNs, LPNs, and TAs @ = 0.15). There were no
Alvamn,
Butz, and Larson
369
significant differences in opinion by sex (p = 0.89) and level of education (p = 0.36). There was no significant correlation between scores on the handwashing practice and opinion scales (p = 0.55). Additionally, there was no significant association between infection control knowledge and handwashing practices (p = 0.2 1) or opinions (p = 0.46). DISCUSSION This study was designed to identify educational needs of LTC staff members with regard to infection control, with the PRECEDE model used to examine educational factors that predispose individuals to behave in certain ways (in this case, to practice handwashing). Such predisposing factors include knowledge, attitudes, values, and perceptions. We measured general knowledge about infection control, self-reported practices (perceptions), and opinions (attitudes) about handwashing. Although RNs scored significantly higher than LPNs or TAs on knowledge related to infection control, the opposite trend occurred for selfreported practices, on which TAs scored significantly higher. This suggests that knowledge and self-reported practices are not highly correlated. Level of professional education and general knowledge of infection control are therefore probably poor predictors of behavior. This study was designed to examine the relationship between what individuals know about infection control and what they report doing. Studies have previously demonstrated that handwashing is generally overreported by health care personnel12, ” and that there is, in fact, an association between profession and frequency of handwashing. Physicians have been repeatedly shown to wash their hands less frequently than other health professionals.‘“, ” It is thus quite possible that TAs do in fact wash their hands more frequently and are more likely to comply with institutional policy in this regard. Consistent with our findings regarding sex differences in handwashing practices, Karaffa” reported that women had more positive beliefs about the benefits of handwashing than did men. It is, in fact, possible that differences between physicians and nurses in handwashing practices may be confounded by sex. This study was not designed to determine the “ideal” practices or opinions or to set a standard for how much LTC staff should in fact know about infection control. On the basis of these descriptive data, however, we can conclude that there were certain knowledge deficits in this population and that there was little
AJIC 370
Alvaran, Butz, and Larson
December
apparent correlation between subjects’ attitudes and their perceived practices with regard to handwashing. Because there seems to be little correlation among knowledge, opinions, and self-reported practices, a simple educational approach to improving infection control practices in LTC facilities is unlikely to meet with much success (the assumption that improved knowledge will be followed by improved practice is probably not valid). The advantage of a diagnostic model such as PRECEDE is that it uses a multifaceted approach to behavior change, considering not only the person’s need for information but also the need for organizational and social structures that facilitate, enhance, or enforce compliance. The prevention and control of infections in LTC facilities deserve increasing attention. The findings of this study can be used to plan educational interventions related to handwashing and other infection prevention and control strategies with LTC staff and also to plan further research in LTC practice settings. The knowledge tool used in this study could be expanded to include more items or to measure application rather than recall of knowledge. The practice and opinion questionnaires could be useful to evaluate the effect of behavioral interventions on attitudes and self-reported practices. They could also be used in observational studies to correlate reported with actual practices.
3. 4.
5.
6.
7.
8.
9.
10. 11.
12.
13.
14.
References 1. US Bureau of the Census. Statistical abstract of the United States. 110th ed. Washington, DC: US Government Printing Office, 1990. 2. Skipwith D. Major community health problems of the older
I
Bound
volumes
15.
available
1994
adult. In: Stanhope M, Lancaster J, eds. Community health nursing. St. Louis; Mosby, 1984:648-65. Larson E, Edwards WI?. Infections. Am J Gerontol Nurs 1986;12:17-22. Jackson MM, Fierer J. Infections and infection risk in residents of long-term care facilities. AM J INFECT CONTROL 1985; 13:63-77. Health Care Financing Administration. Nurse aide training and competency program. Publication no 7, transmittal no 223. Washington, DC: HCFA, 1989. Goldrick BA, Larson E. Assessing the need for infection control programs: a diagnostic approach. J Longterm Care Admin 1992;20:20-3. Green LW, Kreuter MW, Deeds SG, Partridge KB. Health education planning: a diagnostic approach. 1st ed. Palo Alto, California: Maylield Publishing, 1980. Goldrick BA. Effectiveness of an infection control programmed unit of instruction in nursing education. AM J INFECT CO~OL 1987;15:16-9. Goldrick BA, Steven SA, Larson E. Infection control programmed instruction: an alternative to classroom instruction in baccalaureate nursing education. J Nurs Educ 1990;29:20-5. McLaughlin GH. SMOG grading: a new readability formula. J Reading 1969;12:639-46. Karaffa MJ. Handwashing practices of university students: development of an instrument to test health belief model. [Dissertation]. Carbondale, Illinois: Southern Illinois University, 1989. Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 1990:11:589-94. Larson E, McGinley K, Grove G, Leyden J, Talbot G. Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. AM J INFECT CONTROL 1986;14:51-9. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel. AM J INFECT CONTROL 1982;10:93-9. Albert RK, Condie F. Handwashing patterns in medical intensive care units. N Engl J Med 1981;304: 1465-6.
to subscribers I
Bound volumes of AJIC: AMERICAN JOURNAL OF INFECTION CONTROL are available to subscribers (only) for the 1994 issues from the Publisher, at a cost of $29.00 for domestic, $38.03 for Canadian, and $36.00 for international subscribers for Vol. 22 (FebruaryDecember). Shipping charges are included. Each bound volume contains a subject and an author index. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Subscription Services, 11830 Westline Industrial Drive, St. Louis, Missouri 63 146-33 18, USA; phone 800-453-4351, or 314-453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
f-reported control BUW in lang=term
Martha S. Alvaran, RN, MSNa Arlene Butz, RN, ScDb Elaine Larson, RN, PhD, CIC, FAANc Baltimore,
Maryland,
and Washington,
D.C.
Background: Because educational needs of staff in long-term care facilities regarding infection control have, not been well studied, we conducted this study to measure long-term care staff members’ knowledge, self-reported practices, and opinions about infection control and handwashing. Methods: A pilot study was conducted with 24 staff members of one long-term care facility to examine psychometric properties of study instruments. All nursing staff members (n = 105) from two additional long-term care facilities then completed a 14-item knowledge questionnaire, 22-item opinion survey, and 26-item survey of self-reported handwashing practices. Results: Respondents were predominantly female with mean age of 46 years; most had completed high school. Mean length of employment in the study facility was 12.4 years. Registered nurses and licensed practical nurses scored significantly higher on knowledge (p = 0.0002) but significantly lower on self-reported practices (p = 0.01) than did trained nursing assistants. There was no significant correlation between self-reported practices and opinions regarding handwashing (p = 0.55). Neither level of knowledge nor positive opinion about the value of handwashing was associated with self-reported increases in handwashing practices. Conclusion: We conclude that education alone is not likely to be associated with changes in handwashing behavior. Instruments developed and tested in this study can be used in further research to correlate self-reported with observed behavior and to evaluate the effects of interventions on knowledge, opinions, and self-reported handwashing behavior. (AJIC AM J INFECT CONTROL 1994;22:367-70)
There are now almost 30 million Americans aged 65 years and older.’ Predictions indicate that this population will more than double by the year 2030, raising the proportion to 18.2% of the total population.’ The number of nursing homes in the United States has increased concomitantly. As a person ages, ability to resist infection decreases.3 Few studies, however, have addressed
From Jenkins Memorial Incorporateda and The Johns University School of Nursing,b Baltimore, and Georgetown sity School of Nursing,C Washington, D.C. Copyright 0 1994 by the Association Control and Epidemiology, Inc. 0196-6553194
$3.00
+ 0
17147166677
for Professionals
Hopkins Univerin Infection
infection control problems in long-term care (LTC) facilities. Those studies that have been done report prevalences of infection among residents ranging from 10% to 30% at any given time.4 It has been reported, however, that 24.7% of the nation’s 15,000 nursing homes participating in the Medicaid program do not follow isolation techniques aimed at preventing the spread of infection.’ One important way to address this problem is to assess the infection control educational needs of patient care staff members in LTC facilities. Although the need for standardized infection control programs in LTC facilities was recently highlighted,6 few data are available regarding the extent of knowledge related to infection control among LTC staff members. 367
368
Alvaran, Butz, and Larson
The purpose of this descriptive study was to measure knowledge of infection control, describe self-reported practices and opinions regarding handwashing as a means for infection control, and correlate knowledge with self-reported practices among LTC nursing staff members. Self-reported practices and opinions, rather than observed practices, were solicited in this study to measure factors that predispose individuals to practice (what they believe they should be or are doing). METHODS Theoretic framework This study used the health education model PRECEDE, addressing predisposing (e.g., knowledge, attitudes), reinforcing (e.g., skills, training), and enabling factors (e.g., feedback) that need to be assessed for educational diagnosis and evaluation. This model has been used in numerous health education and research programs7 attempting to effect such changes in behavior as use of infant car seats and smoking cessation. The framework consists of a multiphased process for diagnosing health problems, developing and implementing health education interventions, and evaluating program outcomes. Phases of the model include epidemiologic, social, behavioral, educational, and administrative diagnosis. This study was designed to focus on the diagnostic phase for predisposing factors. The PRECEDE framework places emphasis on outcomes rather than inputs, forcing the educator to begin the planning process by defining outcomes and then determining factors likely to result in those outcomes. Study setting
and subjects
The study population was the permanent fulltime staff of registered nurses (RNs), licensed practical nurses (LPNs), and trained aides (TAs) of two facilities, a SOO-bed LTC psychiatric facility and a 155-bed nursing home operated by the Department of Health and Mental Hygiene of the State of Maryland. Instruments The knowledge instrument, developed as part of a doctoral dissertation, had undergone considerable psychometric testing and had been used in three previous studies6, ‘29 to measure knowledge about infection control practices. Because this instrument had not been used previously with LTC staff members, we conducted a pilot study and psychometric evaluation of the instrument during the summer of 1989 among 24 permanent nursing staff volunteer subjects: one third RNs and two
December
AJIC 1994
thirds TAs, representing five nursing units from a 223-bed urban, unionized nursing home primarily serving elderly individuals. This group was comparable to the subjects who would be used in the larger study. Readability level was measured by the SMOG test,” at the eighth grade level. Testretest reliability was determined to assess the stability of respondents’ answers across time. All tests were administered twice, with a l-week interval between administrations. The test-retest reliability coefficient for the knowledge test was 0.85. Content validity was examined by a panel of five expert ICPs. A slightly revised knowledge instrument contained 14 dichotomous (true-false) statements such as, “People who are very young or very old are especially prone to infection,” and, “Droplets released from an infected person can travel several feet.” A second instrument measuring handwashing practices and opinions was also pilot tested. With permission from the author, two S-point Likert scales were adapted from the Handwashing Practice Inventory.’ ’ These self-reporting subscales contained 26 items measuring self-reported practices related to handwashing and 22 items eliciting opinions regarding handwashing. Correlation coefficient on test-retest for both scales was 0.8 1; Cronbach’s cu(to test for internal consistency) was 0.76 for the practice scale and 0.87 for opinion scale. The practice scale contained such items as, “I wash my hands before I prepare food,” “I wash my hands when there is a rule that says I am supposed to,” and, “I wash my hands after touching materials soiled by patient urine.” The maximum score was 130, with higher scores indicating more frequent self-reported handwashing practices. The opinion scale contained such items as, “Washing my hands can make them feel is inconvenient,” bad to touch,” “ Handwashing and, “If I wear gloves, handwashing is unnecessary.” The maximum score was 110; negative items were reverse scored so that a higher score represented more positive opinions about handwashing. On the basis of these pilot psychometric tests, we determined that the instruments had sufficient stability, internal consistency, and validity for use with a larger sample. Data collection
procedure
At the psychiatric facility, the instruments were distributed by the researcher on three occasions at the beginning of a voluntary in-service program. At the nursing home, the questionnaires were distributed on a single working day during man-
AJIC Volurne
22,
‘4 ,d3er
6
datory in-service educational programs. In both cases, the forms were completed immediately and collected by the investigator (M. S. A).
Analysis of variance was used to examine knowledge practice, and opinion scores by level of education, nursing category (RN, LPN, TA), and site (psychiatric facility or nursing home). Pearson correlation coefficients were used to examine potential associations between such demographic variables as age and length of employment and knowledge, practice, and opinion scores. RESULTS The number of subjects eligible for the study at the nursing home was 54; 51 eligible subjects attended the voluntary in-service program at the psychiatric facility. There were no refusals among staff members approached at either facility. The mean age 01 subjects was 46 years (range 23 to 62 years) and subjects were predominantly female (96/105). Most respondents (71%) reported that they had at. !east a high school education. Nursing category breakdown was TAs, 36%: RNs, 33%; and LPNs, 30%. The length of employment in health care ranged from 1 to 35 years, with a mean of 19.3 years. Knowkdge? Most items (9/l 4) were answered correctly by at least 75% of respondents. RNs and LPNs had significantly higher scores (means of 9.4 and 9.8, respectively) than did TAs (mean 9.0, p = 0.0002). There were no significant differences in knowledge scores by age (p = 0.70), length of employment (p I- 0.08), place of employment (psychiatric facility or nursing home, p = 0.93) and sex Ip = 0.50). Handwashing
practices
Self-reported mean total handwashing practice scores were as follows: RNs, 109.6; LPNs, 114.4; and TAs, 117.3 (p - 0.0007). All subjects reported that they always washed their hands after contact with infected body sites or blood, and about three fourths reported that they would wash their hands if a rule said they should. Men had significantly lower handwashing practice scores than women (107.4 and I 14.5, respectively, p = 0.02). Nat&w-
opinlans
Mean opinion scores out of a total possible of 110 were 81.6, 84.2, and 79.0 respectively for RNs, LPNs, and TAs @ = 0.15). There were no
Alvamn,
Butz, and Larson
369
significant differences in opinion by sex (p = 0.89) and level of education (p = 0.36). There was no significant correlation between scores on the handwashing practice and opinion scales (p = 0.55). Additionally, there was no significant association between infection control knowledge and handwashing practices (p = 0.2 1) or opinions (p = 0.46). DISCUSSION This study was designed to identify educational needs of LTC staff members with regard to infection control, with the PRECEDE model used to examine educational factors that predispose individuals to behave in certain ways (in this case, to practice handwashing). Such predisposing factors include knowledge, attitudes, values, and perceptions. We measured general knowledge about infection control, self-reported practices (perceptions), and opinions (attitudes) about handwashing. Although RNs scored significantly higher than LPNs or TAs on knowledge related to infection control, the opposite trend occurred for selfreported practices, on which TAs scored significantly higher. This suggests that knowledge and self-reported practices are not highly correlated. Level of professional education and general knowledge of infection control are therefore probably poor predictors of behavior. This study was designed to examine the relationship between what individuals know about infection control and what they report doing. Studies have previously demonstrated that handwashing is generally overreported by health care personnel12, ” and that there is, in fact, an association between profession and frequency of handwashing. Physicians have been repeatedly shown to wash their hands less frequently than other health professionals.‘“, ” It is thus quite possible that TAs do in fact wash their hands more frequently and are more likely to comply with institutional policy in this regard. Consistent with our findings regarding sex differences in handwashing practices, Karaffa” reported that women had more positive beliefs about the benefits of handwashing than did men. It is, in fact, possible that differences between physicians and nurses in handwashing practices may be confounded by sex. This study was not designed to determine the “ideal” practices or opinions or to set a standard for how much LTC staff should in fact know about infection control. On the basis of these descriptive data, however, we can conclude that there were certain knowledge deficits in this population and that there was little
AJIC 370
Alvaran, Butz, and Larson
December
apparent correlation between subjects’ attitudes and their perceived practices with regard to handwashing. Because there seems to be little correlation among knowledge, opinions, and self-reported practices, a simple educational approach to improving infection control practices in LTC facilities is unlikely to meet with much success (the assumption that improved knowledge will be followed by improved practice is probably not valid). The advantage of a diagnostic model such as PRECEDE is that it uses a multifaceted approach to behavior change, considering not only the person’s need for information but also the need for organizational and social structures that facilitate, enhance, or enforce compliance. The prevention and control of infections in LTC facilities deserve increasing attention. The findings of this study can be used to plan educational interventions related to handwashing and other infection prevention and control strategies with LTC staff and also to plan further research in LTC practice settings. The knowledge tool used in this study could be expanded to include more items or to measure application rather than recall of knowledge. The practice and opinion questionnaires could be useful to evaluate the effect of behavioral interventions on attitudes and self-reported practices. They could also be used in observational studies to correlate reported with actual practices.
3. 4.
5.
6.
7.
8.
9.
10. 11.
12.
13.
14.
References 1. US Bureau of the Census. Statistical abstract of the United States. 110th ed. Washington, DC: US Government Printing Office, 1990. 2. Skipwith D. Major community health problems of the older
I
Bound
volumes
15.
available
1994
adult. In: Stanhope M, Lancaster J, eds. Community health nursing. St. Louis; Mosby, 1984:648-65. Larson E, Edwards WI?. Infections. Am J Gerontol Nurs 1986;12:17-22. Jackson MM, Fierer J. Infections and infection risk in residents of long-term care facilities. AM J INFECT CONTROL 1985; 13:63-77. Health Care Financing Administration. Nurse aide training and competency program. Publication no 7, transmittal no 223. Washington, DC: HCFA, 1989. Goldrick BA, Larson E. Assessing the need for infection control programs: a diagnostic approach. J Longterm Care Admin 1992;20:20-3. Green LW, Kreuter MW, Deeds SG, Partridge KB. Health education planning: a diagnostic approach. 1st ed. Palo Alto, California: Maylield Publishing, 1980. Goldrick BA. Effectiveness of an infection control programmed unit of instruction in nursing education. AM J INFECT CO~OL 1987;15:16-9. Goldrick BA, Steven SA, Larson E. Infection control programmed instruction: an alternative to classroom instruction in baccalaureate nursing education. J Nurs Educ 1990;29:20-5. McLaughlin GH. SMOG grading: a new readability formula. J Reading 1969;12:639-46. Karaffa MJ. Handwashing practices of university students: development of an instrument to test health belief model. [Dissertation]. Carbondale, Illinois: Southern Illinois University, 1989. Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 1990:11:589-94. Larson E, McGinley K, Grove G, Leyden J, Talbot G. Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. AM J INFECT CONTROL 1986;14:51-9. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel. AM J INFECT CONTROL 1982;10:93-9. Albert RK, Condie F. Handwashing patterns in medical intensive care units. N Engl J Med 1981;304: 1465-6.
to subscribers I
Bound volumes of AJIC: AMERICAN JOURNAL OF INFECTION CONTROL are available to subscribers (only) for the 1994 issues from the Publisher, at a cost of $29.00 for domestic, $38.03 for Canadian, and $36.00 for international subscribers for Vol. 22 (FebruaryDecember). Shipping charges are included. Each bound volume contains a subject and an author index. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Subscription Services, 11830 Westline Industrial Drive, St. Louis, Missouri 63 146-33 18, USA; phone 800-453-4351, or 314-453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.