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Survey of purchasers of the APIC curriculum for infection control practice: Findings and recommendations
Survey of purchasers of The APE Curriculum for lnfec tion Control Practice: Findings and recommendations Patricia J. Checko, M.P.H. Barbara M. Soule, R.N., B.S., CIC Marguerlte M. Jackson, R.N., M.S. Hartford, Connecticut, Olympia, Washington, and San Diego, California A survey of purchasers of The APIC Curriculum for Infection Control Practice was conducted in early 1985 by the APIC Curriculum Committee to determine characteristics of purchasers, usability of the text, reasons for purchase, and availability of references cited. Data were obtained from 342 (54.3%) respondents to a nationwide mail survey sent to a 20% sample (630) of all who were purchasers prior to January 1985. The average purchaser was an Infection Control Practitioner (ICP) who was a nurse employed by an acute care community hospital and had 6.9 years experience in infection control practice; 41% of purchasers worked in hospitals with >300 beds. APIC members represented 93% of the respondents, and their disciplines were similar to those of the membership. Primary reasons for purchasing the Curriculum were to use it as the major reference for infection control information and to study for the Infection Control Certification Examination. Almost half of the respondents had taken and passed the examination. The overall satisfaction with format and style suggests that it was well-received and usable. Purchase of the Curriculum was strongly associated with hospital size. ICPs practicing in hospitals with ~100 beds were less likely to have purchased the book than those in larger hospitals. Availability of references was also associated with hospital size. Future editions of the Curriculum need to reflect consideration of the relationship between hospital size and availability of references in their approach to completeness of information. Responses suggest that the Curriculum has achieved its purpose of providing a major infection control reference for ICPs, but many ICPs in small hospitals do not have the benefit of this resource. This survey represents an example of a formal evaluation of an APIC project that can provide a model for evaluation of future APIC activities. (AM J INFECT CONTROL 13: 250-258, 1985.)
The APZC Curriculum for Infection Control Practice was published in July of 1983 .I The Curriculum was developed by a committee of volunteers who worked together for 3 years. The project was sponsored by the Association for Practitioners in Infection Control (APIC) as a service to the profession. The total cost to APIC in development and promotion of the Curriculum was $74,756. None of the members of the
committee nor the technical editor received any salary remuneration. As of September 15, 1985, 3656 copies of the Curriculum have been sold. Sale of these copies generated revenue of $38,391 to offset the cost to APIC. The Curriculum was intended to serve several purposes: l
l
From the Curriculum in Infection Control, Reprint delein,
250
requests: IL 60060.
Committee, Mundelein, APIC National
Association Illinois. Office,
for Practitioners
505 E. Hawley
l l
St., Munl
A resource for the beginning to advanced practitioner A reference for use in daily practice An individual study guide Use in preparation for the Infection Control Certification Examination Use in designing educational programs
Volume13Number6
Survey of Curriculum purchasers
December,1985
Table 1. Comparison
of distribution
of total U.S. hospital9
and Curriculum
purchasers
by bed size category
U.S. hospitals Hospital
bed sire
5100 101-200 201-300 301-500 >500
Not employed by a hospital Totals 'Statistically
signiflcM
No.
%
3246 1619 816 840 574
45.7 22.8 11 5 11.9 8.1
39 83 61 84 53
11.6* 24.7 181% 25.0* 15.8*
7095
100.0
l l
l
Sample
4.8
336
100.0
was a total
of 94 questions
1985, with a requested response date of March 1, 1985. Each addressee received a cover letter, survey form, and stamped addressed return envelope. Each return envelope was preceded to correspond to a master mailing list so that nonresponders could be sent a second copy of the questionnaire, if necessary. Sample size calculations were based on methods for estimating a proportion, specifying that a proportion estimate be within a decile of the true population proportion, with a confidence of 95%.2 Data analysis
Demographic information about the purchasers Reasons for purchase of the Curriculum Evaluation of format and style Frequency of use Availability of references cited in the Curriculum Questions about a second edition
There survey.
16
global x2 (p c 0.0001).
A task force of the Curriculum Committee developed a qwestionnaire with six components:
l
purchasers
%
MATERIAL AND METHODS Survey development
l
Curriculum
NO.
Because of the magnitude of the project, the expense to the Association, and the need to evaluate the quality of the product, the Curriculum Committee conducted a formal evaluation of the Curriculum during early 1985. In addition, the evaluatio:n was intended to address the need for and scope of a second edition. This article summarizes the finding of a survey mailed in February 1985 to a randomly selected sample of Curriculum purchasers since its publication.
l
251
on the
sectlion
A systematic random sample of 20% of the purchasers was generated by computer from an alphabetized mailing list maintained by the APIC national office. Six hundred thirty mailing labels were prepared by this method. Of these, 55 represented institutions and the remainder were addressed to individuals. Questionnaires were mailed on February 15,
Each questionnaire was coded, keypunched, and verified prior to analysis. Ninety-five percent confidence intervals for proportions were generated in the manner suggested by Fleiss.3 Global tests of hypothesized counts (Tables 1 and 2) were performed by using Pearson’s x2 test, with the expected cell counts based upon the appropriate population fractions (the populations being U.S. hospitals for Table 1 and candidates for 1983 and 1984 Infection Control Certification Examinations for Table 2). Individual counts were tested by their contributions to the global x’s, with Bonferroni adjustments for multiple comparisons.5 Global tests of differences among means across categories were performed with one-way analysis of variance (ANOVA). The Duncan multiple range test6 was used to assess comparisons of means between specific categories, given that the global ANOVA test was significant. The type I (alpha) error level was set at 0.05 for confidence intervals (CI) and significance testing.
American
252
Checko, Soule, and Jackson
INFECTION
Table 2. Comparison Infection
of distribution of Curriculum purchasers and candidates Certification Examination by bed size category
Control
Curriculum Hospital
bed size
5100
39
101-200 201-300 301-500 >500
83 61 84 53
Not employed by a hospital Totals *Statistically
significant
(p < 0.005) after Bonferroni
Table 3. Distribution Highest
of Curriculum
purchasers
1983 and 1994
%
No.
%
11.6 24.7 18.1 25.0 15.8
138 243 258 383 384
10.0 17.0 18.0 26.8
4.8
-2J
26.9’ 1.3*
336
100.0
1426
100.0
for multiple comparisons
by highest
degrse
Bachelor’s degree Diploma nursing program Master’s degree Associate degree (A.A., AS.) Medical degree (M.D., D.O.) Doctoral degree (Ph.D., Ed.D.) Other Total
RESULTS Demographic
Test takers
16 adjustment
of
for the 1983 and 1984
purchasers
No.
Journal CONTROL
information
Response rate. From the February 15, 1985, mailing of questionnaires, 342 survey forms were returned (response rate = 54.3%). Six returned forms had no data and were eliminated from further analysis. There was no difference in the response rate between surveys returned from institutional addresses and individuals. The response rate did not differ significantly by geographic region and was almost equally distributed between individuals who had and had not taken the Infection Control Certification Examination (160 vs. 176). Because surveys with low response rates may be subject to nonresponder bias, a second mailing to a systematic sample of 100 of the 294 nonresponders was undertaken in April 1985. Thirty-seven questionnaires were returned from the second mailing. One individual had already completed an initial questionnaire addressed to her place of employment; two had not responded initially because they were new to their positions and the Curriculum
degree
earned
No.
%
132 122 42 23 8 5 4
36.3 12.5 6.8 2.4 1.5
336
39.3
1.2
99% Cl 34.1-44.8 31.2-41.7
9.3-16.6 4.5-10.2 1.1-4.8 0.6-3.6 0.4-3.2
100.0
was not in the hospital; and one questionnaire was returned “addressee unknown” (10.8%). The 33 remaining responders from the second mailing did not differ in any parameter from those who had returned their initial surveys. Although there remained an underrepresentation of individuals from hospitals with cl00 beds, the authors did not believe that nonresponder bias affected the representativeness of purchasers who responded to the questionnaire. Second questionnaire responses were not included in the analysis. Characteristics of responders. Regional distribution of the responders was similar to the regional distribution of the targeted sample of the 1982 National Task Analysis of Infection Control Practitioners.’ The Task Analysis targeted sample represented a modified randomized stratified sample deliberately skewed toward hospitals with >200 beds. Eighty percent of Curriculum purchases represented acute care hospitals, with 67.6% (CI 62.3 to 72.5) describing their facilities as community or community-teaching hospitals.
Volume 13 Number December. 1985
6
Long-term care facilities were the work-places for 6.9% (CI 4.5 to 10.3) of the purchasers, and 4.5% (CT 2.6 to 7,s) were not employed by a health care facility. Table 1 presents a comparison of the distribution of total U.S. hospitals and Curriculum purchasers by bed size category. The distribution was significantly different for all bed size categories except 101 to 200 beds, with a marked underrepresentation of those hospitals with ~100 beds, and an overrepresentation in those with >;!OO beds. Table 2 compares the distribution of Curriculum purchasers and candidates for the 1983 and 1984 Infection Control Certification Examination by bed size category.8,p The distribution was significantly different for two of the five bed size categories, with a marked overrepresentation of purchasers from hospitals in the lOl- to 200-bed category, and an underrepresentation in those with. >500 beds. Responders were aged 20 to 75 years, with a mean age of 44.7 + 9.2 years. They reported an average number of years in infection control practice of 6.9 + 3.5 years, with a range of 0 to 20 years. Ninety-three percent were members of APIC. Ninety percent of responders identified their primary role as ICP. The remaining individuals described their role as hospital epidemiologist, infection control committee chairman, consultant, laboratorian, educator, or administrator. About 3.5% were employed by a regulatory agency or were not directly employed in infection control practice. By discipline, 89% (CI 85.1 to 92.1) of the purchasers were nurses; 3.3% (CI 1.8 to 6), microbiologists; 2.7% (CI 1.3 to 5.2), medical technologists; 2.1% (CI 0.9 to 4.5), physicians; 1.8% (CI 0.7 to 4.1), epidemiologists (non-M.D.); and the remainder were faculty members or in other disciplines. Table .3 lists highest educational degree earned by order of frequency. Of the purchasers who reported taking the Infection Control Certification Examination, 120 (75.5%; CI 67.9 to 81.8) took the examination in 1983; 35 (22.0%; CI 16.0 to 29.4) in 1984; and four (2.5%; CI 0.8 to 6.7) in both years. About 95% of .these reported using the Curric-
Survey of Curriculum purchasers
253
Table 4. Considerations of format and style purchasers were asked to apply for comparison of the Curriculum with most other books To find specific information* For completeness of material* To locate information quickly* For association of references with content* For presentation of tabular data Use of charts rather than text Repetition of material Use of graphic material (drawings) Ability to readily identify an infection control risk and associated intervention* Holds your interest/attention For development of educational programs (e.g., inservices)* Cross-referencing to other sections* For assessment of your own learning needs* For ease of understanding material presented* *Characteristics of the Curriculum rate “much most books by >70% of responders
better”
or “better”
than
ulum to study for the examination and 7.6% reported that they failed to pass the examination. This is in contrast to the 13% failure rate reported by the Certification Board of Infection Control for both years.’ Reasons
for purchase
The following reasons for purchase of the Curriculum were rated “very important” or “important” by >70% of responders: To use as a major reference for infection control program To study for the Infection Control Certification Examination To develop or improve hospital’s infection control program To develop hospital policies and/or procedures To supplement current library resources Of the other reasons given for purchase, only the willingness of the facility to purchase the book was viewed as “unimportant” or “very unimportant” by more than half of the respondents. Evaluation
of format
and style
Table 4 presents characteristics of format and style of the Curriculum that purchasers were asked to compare to the format and style of most other books. The characteristic of the Cur-
American
254
Checko, Soule, and Jackson
Table 5. Relation
of availability
Reference No.
1
2
3 4 5 6
7 8
9 10 11
12 13 14 15 16 17 18 19
‘Not statistically
INFECTION
of frequently
Title or category
referenced
textbooks Available %
ot textbook
Bennett JV, Brachman PS, eds. Hospital Infections. Boston, 1979, Little, Brown & Co Barrett-Connor E, Brandt SL, Simon HJ, Dechairo DC, eds. Epidemiology for the infection control nurse. St. Louis, 1978, CV Mosby Co Castle M. Hospital infection control: Principles and practice. New York, 1980, John Wiley & Sons Wenzel RP ed. Handbook bf hospitalacquired infections. Boca Raton Fla, 1981, CRC Press Axnick KJ, Yarbrough MC, eds. Infection control: An integrated approach. St. Louis, 1984, CV Mosby Co Centers for Disease Control. Guidelines for the prevention and control of nosocomial infections. Atlanta, 19811984, CDC American Hospital Association. Infection Control in the hospital, 4th ed. Chicago, 1979, The Association American Academy of Pediatrics. Report of the Committee on Infectious Diseases (1982 Redbook), 19th ed. Evanston, Ill, 1982, The Academy Basic epidemiology text Basic statistics book Benenson AS, ed. Control of communicable diseases in man, 13th ed. Washington, DC, 1981, American Public Health Association General microbiology text published within past 5 years General infectious disease and/or internal medicine text General textbook on sterilization and disinfection General medical and surgical nursing text published within the past 5 years Review of nursing procedures Text on education of the adult learner Management text Arking L, McArthur B. Infection control (symposium volume). Nursing Clinics of North America, vol 15, no 4, 1980. significant
when individuals
not employed
in hospitals
riculum rated highest (84.7% rated it “better” or “much better”) was the “Ability to readily identify an infection control risk and associated intervention.” All of the. characteristics were rated better or much better by more than half of the respondents.
were
and publications 95% Cl
and hospital Associated hospital
Journal
of
CONTROL
size with size
p Value
74.2
69.0-78.7
Yes
60.2
54.7-65.6
Yes
47.7
42.2-65.6
No
N’S
46.5
41.1-52.1
Yes
38.6
33.3-44.1
No
NS
98.5
96.3-99.4
No
NS
82.4
77.7-86.2
No
NS
54.9
49.3-60.3
Yes
34.4 34.7 82.6
29.3-39.9 29.6-40.1 78.0-86.5
Yes Yes Yes
co.01
77.4
72.5-81.8
Yes
co.01
70.5
65.2-75.3
Yes
co.01
58.1
52.5-63.5
Yes
76.4
71.4-80.8
No
NS
71.5 37.4 41.8 55.7
66.2-76.2 32.2-43.0 36.4-47.4 50.1-61.2
No No No Yes
NS NS* NS
deleted
from analysis.
Compared with hardbound books of similar size, the Curriculum was rated better than hardbound books for ease of photocopying and lying flat in use. It was rated the same in terms of showing wear and tear from use and having pages stay in the binding. The Curriculum was
Volume
13 Number
December,
6
Survey of Curriculum purchasers
1985
loo-
Isi
>I. Q
(N=39)
(N=144)
l-10 References
Hospital
255
100,
11-19 References
(N-136)
Bed Size Category
~100 BEDS (N=39)
Hospital
101-300 BEDS (N=143)
>300 BEDS (N=136)
Bed Size Category
Fig. 1. Bar graph
represents the number of general references reported as available by respondents to the survey. Numbers in parentheses represent total number of respondents by bed size category.
Fig. 2. Bar graph represents the number of infection control references reported as available by respondents to the survey. Numbers in parentheses represent total number of respondents by bed size category.
rated worse than hardbound books in its ability to sit on a bolokshelf without falling. Of those aspects of the Curriculum associated with locating material, the index at the back of each volume was identified as the most helpful. The Procedure/Devise-Risk-Intervention Tables in the Patient Care Practices section were rated as “very helpful” by 48% of the respondents.
Guidelines and periodical publications such as journals. Individuals were asked to indicate which of the references were readily available to them in their facility. Nineteen references were listed (Table 5). The mean number of references reported as readily available was 11.25 (median = 11; mode = 13). Availability of references was significantly associated with hospital size (Fig. 1). Seven of the references were specific to the practice of infection control (Table 5; references l-7). The mean, median, and modal number of references in this category was 4. This number was also significantly associated with hospital size (Fig. 2). Those texts not associated with hospital size were nursing oriented (Table 5; references 15 and 16), available at no cost (reference 6), published by the hospital association (reference 7), and two specific references for infection control practice (references 3 and 5). Seventeen periodicals were listed (Table 6). Availability of journals was significantly asso-
Frequency
of use
Frequency of use of the Curriculum did not differ by year of purchase or year in which the examination was taken. However, it was associated with years in practice. Individuals in practice <5 years were more likely to use the Curriculum one time per day or more whereas those in practice longer used it a few times per month (Duncan multiple range test, p < 0.05; ANOVA F = 4.8, p < 0.001). Availability
sf references
References were divided into frequently cited textbooks and publications such as the CDC
American
256
Checko, Soule, and Jackson
Table 6. Relation of availability TM
INFECTION
of frequently
referenced Available %
of publication
American Journal of Diseases of Children American Journal of Epidemiology American Journal of Infection Control American Journal of Medicine American Journal of Nursing American Journal of Public Health Annals of Internal Medicine Hospital Infection Control Infection Control Journal of the American Medical Association Journal of Continuing Education in Nursing Journal of Infectious Diseases Journal of Nursing Management Journal of Pediatrics Morbidity and Mortality Weekly Report New England Journal of Medicine Nursing ‘80-‘84 ‘Not statistically
significant
when
individuals
not employed
in hospitals
about
a second
edition
of or
of the
Finally, purchasers were asked if they would purchase a copy of the Curriculum if a second edition were published in 1988 and they were still in an infection control position. More than half (55.8%; CI 50.3 to 61.3) responded that they “would purchase a second edition,” a third (35.9%; CI 30.7 to 41.4) “did not know,” and 8.3% (CI 5.6 to 12) responded “no.” About two thirds of the respondents indicated that they were unwilling to pay an additional charge for the option of a hardbound book in a second edition. DISCUSSION
One of the major purposes of the Curriculum was to serve as a resource for beginning to advanced practitioners. As such, it was intended to provide comprehensive information for infection control programs, help professionals answer infection control questions, recognize current practices and controversial issues, and formulate methods for solving problems. Although the questionnaire did not specifically measure
publications 95% Cl
33.7 32.4 91.3 73.3 91.9 35.1 76.1 77.8 88.9 83.4 31.8 49.2 72.9 52.8 89.5 82.8 88.9
ciated with hospital size with the exception journals specific to infection control practice related to the nursing profession. Questions Curriculum
periodical
28.7-39.2
27.5-37.8 87.6-94.0 68.1-77.9 88.3-94.5 30.0-40.5 71 .O-80.5 72.9-82.1 84.9-91.9 78.9-87.2 26.8-37.2 43.8-54.8 67.7-77.5 47.2-58.3 85.5-92.5 78.2-86.6 84.9-92.0
were deleted
and hospital Associated hospital
Yes Yes No Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No
Journal
of
CONTROL
size with size
p Value
NS*
NS”
from analysis.
each of these objectives, some inferences can be based upon the respondents’ frequency of use, reasons for purchase, and anecdotal comments. Frequency of reported use suggests that the Curriculum is used as a major reference for daily practice. Furthermore, 90% of respondents reported that use of the Curriculum for the infection control program was an important reason for purchase. The Curriculum’s usefulness as a study guide and for preparation for the Infection Control Certification Examination were supported by the results of this survey. Anecdotal comments by several individuals described its usefulness in designing in-service and educational programs. In addition, two thirds of the respondents rated this quality as an important or very important reason for purchase. This survey suggests that hospital size is the most important predictor of purchase of the Curriculum and that individuals in hospitals with < 100 beds are much less likely to purchase it. We hypothesize that this underrepresentation may be the result of one or more of the following factors: (1) lack of targeted marketing to this population, (2) the part-time status of many ICPs in these facilities,” (3) the multiple concurrent roles that they hold,” and (4) the
Volume December,
13 Number
6
Survey of Curriculum purchasers
1985
price of the Curriculum for an individual without full-time (commitment to the practice of infection control or a facility to purchase it. The relationship between .purchase of the Curriculum and use as a study guide for the Infection Contr’ol Certification Examination suggests that persons in small hospitals may see its major purpose as a study guide for the examination and may not recognize it as serving other purposes. This is supported by the finding that the proportion of Curriculum purchasers from hospitals with < 100 beds is similar to the proportion of test takers from that stratum. In the stratum 101 to 200 beds, there were significantly fewer test takers than Curriculum purchasers. This may suggest that for this group, the Curriculum is used as a reference for daily practice and corresponds with less availability of primary reference sources. In addition, there was a disproportionately higher number of test takers than purchasers of the Curriculum from hospitals with ,500 beds. This may suggest that one copy of the Curriculum has been purchased for a department with several ICPs or that ICPs in large facilities have access to primary reference sources and see less need for the Curriculum. A major fa.ctor in determining the scope of the Curriculum was a desire to meet the needs of those individuals in. small hospitals who might not otherwise have access to current and appropriate resources to meet the multidisciplinary demands of infection control practice. Our findings support the initial belief that persons working in small hospitals are less likely to have access to published textbooks and periodicals related to the field. In this respect, the Curriculum serves as a major reference for this subgroup. Even though 45.7% of U.S. hospitals have < 100 beds, only 11.6% of Curriculum purchasers are from this stratum (Table 1). These results indicate that there may be hundreds of potential users in small hospitals throughout the country. The Curriculum has not yet achieved its objective of meeting the needs of ICPs in small hospitals, and targeted marketing efforts are indicated. The Curriculum Committee was careful to include sufficient information about most sub-
257
jects to make access to primary reference sources an option but not a necessity. If future editions of the Curriculum are also intended to address the specific needs of ICPs in small hospitals, it is important that content be complete enough to stand alone. This survey indicates the Curriculum at present is used as a reference for daily practice. The need for a second edition should be further evaluated and significant changes in practice and new directions of the discipline should be taken into account. In addition, medical practice and knowledge is constantly changing, and these changes should be integrated into the Curriculum. Whether the Curriculum will require a complete revision or merely a supplement must be determined by the next Curriculum Committee. Survey results suggest that the format and style of the present Curriculum are satisfactory to the users and should be retained. Although most users preferred the spiral binding, many suggested that a hard cover spiral-bound book would be desirable; however, they did not wish to pay an additional fee for a traditionally bound hardcover book. SUMMARY
The results APIC Curriculum
of this survey for Infection
suggest that The Control Practice
met its intended goals of creating a resource that would serve as both a reference and study guide for purchasers. However, many small hospitals still do not have the benefit of this resource. APIC should direct attention to that subgroup of ICPs if the Curriculum is to meet the needs of all practitioners. Future editions must take into account the availability of primary references in institutions in which ICPs are practicing. This will become increasingly important as competition for limited resources increases and practice extends to nonacute care facilities. Finally, in a professional organization in which funds provided by the membership are used to support special activities, those projects should undergo formal evaluation that is used for future planning. The results of these evaluations should be published in the association’s
American
258
Checko, Soule, and Jackson
professional journal to be responsive and responsible to the members whose dues support these projects. We thank Peter Charpentier, M.P.H., for statistical support, and Bonnie Matson for coordination of survey preparation and mailing.
References 1. Soule BM, editor: The APIC curriculum for infection control practice. Dubuque, Iowa, 1983, Kendall/Hunt Publishing Co. 2. Levy PS, Lemeshaw S: Sampling for health professionals. Belmont, Calif., 1980, Lifetime Learning Publications, p 56. 3. Fleiss JL: Statistical methods for rates and proportions, 2nd ed. New York, 1981, John Wiley & Sons, p 14. 4. American Hospital Association: Hospital statistics. Chicago, 1982, The Association. 5. Morrison DF: Multivariate statistical methods, 2nd ed. New York, 1976, McGraw-Hill, pp 33-34.
INFECTION
Journal
of
CONTROL
6. Freund RJ, Littell RC: SAS for linear models. North Carolina, 198 1, SAS Institute, pp 58-60. 7. McArthur BJ, Pugliese G, Weinstein S, et al: A national task analysis of infection control practitioners, 1982. Part one: Methodology and demography. AM J INFECT CONTROL 12:88-95, 1984. 8. Certification Board of Infection Control: Development and results of the first Certification Examination in Infection Control, November 19, 1983. AM J INFECT CONTROL 12(4):31A-34A, 1984. 9. Certification Board of Infection Control: Development and results of the second Certification Examination in Infection Control, November 17,1984. AM J INFECTCONTROL 13(3):24A-276, 1985. 10. Pugliese G, McArthur BJ, Weinstein S, et al: A national task analysis of infection control practitioners, 1982. Part three: The relationship between hospital size and tasksperformed. AMJINFECTCONTROLI~:~~~-~~~,~~~~. 11. Emori TG, Haley RW, Stanley RC: The infection control nurse in U.S. hospitals, 1976-1977: Characteristics of the position and its occupant. Am J Epidemiol 111:592607, 1980.
The APZC Curriculum for Infection Control Practice was published in July of 1983 .I The Curriculum was developed by a committee of volunteers who worked together for 3 years. The project was sponsored by the Association for Practitioners in Infection Control (APIC) as a service to the profession. The total cost to APIC in development and promotion of the Curriculum was $74,756. None of the members of the
committee nor the technical editor received any salary remuneration. As of September 15, 1985, 3656 copies of the Curriculum have been sold. Sale of these copies generated revenue of $38,391 to offset the cost to APIC. The Curriculum was intended to serve several purposes: l
l
From the Curriculum in Infection Control, Reprint delein,
250
requests: IL 60060.
Committee, Mundelein, APIC National
Association Illinois. Office,
for Practitioners
505 E. Hawley
l l
St., Munl
A resource for the beginning to advanced practitioner A reference for use in daily practice An individual study guide Use in preparation for the Infection Control Certification Examination Use in designing educational programs
Volume13Number6
Survey of Curriculum purchasers
December,1985
Table 1. Comparison
of distribution
of total U.S. hospital9
and Curriculum
purchasers
by bed size category
U.S. hospitals Hospital
bed sire
5100 101-200 201-300 301-500 >500
Not employed by a hospital Totals 'Statistically
signiflcM
No.
%
3246 1619 816 840 574
45.7 22.8 11 5 11.9 8.1
39 83 61 84 53
11.6* 24.7 181% 25.0* 15.8*
7095
100.0
l l
l
Sample
4.8
336
100.0
was a total
of 94 questions
1985, with a requested response date of March 1, 1985. Each addressee received a cover letter, survey form, and stamped addressed return envelope. Each return envelope was preceded to correspond to a master mailing list so that nonresponders could be sent a second copy of the questionnaire, if necessary. Sample size calculations were based on methods for estimating a proportion, specifying that a proportion estimate be within a decile of the true population proportion, with a confidence of 95%.2 Data analysis
Demographic information about the purchasers Reasons for purchase of the Curriculum Evaluation of format and style Frequency of use Availability of references cited in the Curriculum Questions about a second edition
There survey.
16
global x2 (p c 0.0001).
A task force of the Curriculum Committee developed a qwestionnaire with six components:
l
purchasers
%
MATERIAL AND METHODS Survey development
l
Curriculum
NO.
Because of the magnitude of the project, the expense to the Association, and the need to evaluate the quality of the product, the Curriculum Committee conducted a formal evaluation of the Curriculum during early 1985. In addition, the evaluatio:n was intended to address the need for and scope of a second edition. This article summarizes the finding of a survey mailed in February 1985 to a randomly selected sample of Curriculum purchasers since its publication.
l
251
on the
sectlion
A systematic random sample of 20% of the purchasers was generated by computer from an alphabetized mailing list maintained by the APIC national office. Six hundred thirty mailing labels were prepared by this method. Of these, 55 represented institutions and the remainder were addressed to individuals. Questionnaires were mailed on February 15,
Each questionnaire was coded, keypunched, and verified prior to analysis. Ninety-five percent confidence intervals for proportions were generated in the manner suggested by Fleiss.3 Global tests of hypothesized counts (Tables 1 and 2) were performed by using Pearson’s x2 test, with the expected cell counts based upon the appropriate population fractions (the populations being U.S. hospitals for Table 1 and candidates for 1983 and 1984 Infection Control Certification Examinations for Table 2). Individual counts were tested by their contributions to the global x’s, with Bonferroni adjustments for multiple comparisons.5 Global tests of differences among means across categories were performed with one-way analysis of variance (ANOVA). The Duncan multiple range test6 was used to assess comparisons of means between specific categories, given that the global ANOVA test was significant. The type I (alpha) error level was set at 0.05 for confidence intervals (CI) and significance testing.
American
252
Checko, Soule, and Jackson
INFECTION
Table 2. Comparison Infection
of distribution of Curriculum purchasers and candidates Certification Examination by bed size category
Control
Curriculum Hospital
bed size
5100
39
101-200 201-300 301-500 >500
83 61 84 53
Not employed by a hospital Totals *Statistically
significant
(p < 0.005) after Bonferroni
Table 3. Distribution Highest
of Curriculum
purchasers
1983 and 1994
%
No.
%
11.6 24.7 18.1 25.0 15.8
138 243 258 383 384
10.0 17.0 18.0 26.8
4.8
-2J
26.9’ 1.3*
336
100.0
1426
100.0
for multiple comparisons
by highest
degrse
Bachelor’s degree Diploma nursing program Master’s degree Associate degree (A.A., AS.) Medical degree (M.D., D.O.) Doctoral degree (Ph.D., Ed.D.) Other Total
RESULTS Demographic
Test takers
16 adjustment
of
for the 1983 and 1984
purchasers
No.
Journal CONTROL
information
Response rate. From the February 15, 1985, mailing of questionnaires, 342 survey forms were returned (response rate = 54.3%). Six returned forms had no data and were eliminated from further analysis. There was no difference in the response rate between surveys returned from institutional addresses and individuals. The response rate did not differ significantly by geographic region and was almost equally distributed between individuals who had and had not taken the Infection Control Certification Examination (160 vs. 176). Because surveys with low response rates may be subject to nonresponder bias, a second mailing to a systematic sample of 100 of the 294 nonresponders was undertaken in April 1985. Thirty-seven questionnaires were returned from the second mailing. One individual had already completed an initial questionnaire addressed to her place of employment; two had not responded initially because they were new to their positions and the Curriculum
degree
earned
No.
%
132 122 42 23 8 5 4
36.3 12.5 6.8 2.4 1.5
336
39.3
1.2
99% Cl 34.1-44.8 31.2-41.7
9.3-16.6 4.5-10.2 1.1-4.8 0.6-3.6 0.4-3.2
100.0
was not in the hospital; and one questionnaire was returned “addressee unknown” (10.8%). The 33 remaining responders from the second mailing did not differ in any parameter from those who had returned their initial surveys. Although there remained an underrepresentation of individuals from hospitals with cl00 beds, the authors did not believe that nonresponder bias affected the representativeness of purchasers who responded to the questionnaire. Second questionnaire responses were not included in the analysis. Characteristics of responders. Regional distribution of the responders was similar to the regional distribution of the targeted sample of the 1982 National Task Analysis of Infection Control Practitioners.’ The Task Analysis targeted sample represented a modified randomized stratified sample deliberately skewed toward hospitals with >200 beds. Eighty percent of Curriculum purchases represented acute care hospitals, with 67.6% (CI 62.3 to 72.5) describing their facilities as community or community-teaching hospitals.
Volume 13 Number December. 1985
6
Long-term care facilities were the work-places for 6.9% (CI 4.5 to 10.3) of the purchasers, and 4.5% (CT 2.6 to 7,s) were not employed by a health care facility. Table 1 presents a comparison of the distribution of total U.S. hospitals and Curriculum purchasers by bed size category. The distribution was significantly different for all bed size categories except 101 to 200 beds, with a marked underrepresentation of those hospitals with ~100 beds, and an overrepresentation in those with >;!OO beds. Table 2 compares the distribution of Curriculum purchasers and candidates for the 1983 and 1984 Infection Control Certification Examination by bed size category.8,p The distribution was significantly different for two of the five bed size categories, with a marked overrepresentation of purchasers from hospitals in the lOl- to 200-bed category, and an underrepresentation in those with. >500 beds. Responders were aged 20 to 75 years, with a mean age of 44.7 + 9.2 years. They reported an average number of years in infection control practice of 6.9 + 3.5 years, with a range of 0 to 20 years. Ninety-three percent were members of APIC. Ninety percent of responders identified their primary role as ICP. The remaining individuals described their role as hospital epidemiologist, infection control committee chairman, consultant, laboratorian, educator, or administrator. About 3.5% were employed by a regulatory agency or were not directly employed in infection control practice. By discipline, 89% (CI 85.1 to 92.1) of the purchasers were nurses; 3.3% (CI 1.8 to 6), microbiologists; 2.7% (CI 1.3 to 5.2), medical technologists; 2.1% (CI 0.9 to 4.5), physicians; 1.8% (CI 0.7 to 4.1), epidemiologists (non-M.D.); and the remainder were faculty members or in other disciplines. Table .3 lists highest educational degree earned by order of frequency. Of the purchasers who reported taking the Infection Control Certification Examination, 120 (75.5%; CI 67.9 to 81.8) took the examination in 1983; 35 (22.0%; CI 16.0 to 29.4) in 1984; and four (2.5%; CI 0.8 to 6.7) in both years. About 95% of .these reported using the Curric-
Survey of Curriculum purchasers
253
Table 4. Considerations of format and style purchasers were asked to apply for comparison of the Curriculum with most other books To find specific information* For completeness of material* To locate information quickly* For association of references with content* For presentation of tabular data Use of charts rather than text Repetition of material Use of graphic material (drawings) Ability to readily identify an infection control risk and associated intervention* Holds your interest/attention For development of educational programs (e.g., inservices)* Cross-referencing to other sections* For assessment of your own learning needs* For ease of understanding material presented* *Characteristics of the Curriculum rate “much most books by >70% of responders
better”
or “better”
than
ulum to study for the examination and 7.6% reported that they failed to pass the examination. This is in contrast to the 13% failure rate reported by the Certification Board of Infection Control for both years.’ Reasons
for purchase
The following reasons for purchase of the Curriculum were rated “very important” or “important” by >70% of responders: To use as a major reference for infection control program To study for the Infection Control Certification Examination To develop or improve hospital’s infection control program To develop hospital policies and/or procedures To supplement current library resources Of the other reasons given for purchase, only the willingness of the facility to purchase the book was viewed as “unimportant” or “very unimportant” by more than half of the respondents. Evaluation
of format
and style
Table 4 presents characteristics of format and style of the Curriculum that purchasers were asked to compare to the format and style of most other books. The characteristic of the Cur-
American
254
Checko, Soule, and Jackson
Table 5. Relation
of availability
Reference No.
1
2
3 4 5 6
7 8
9 10 11
12 13 14 15 16 17 18 19
‘Not statistically
INFECTION
of frequently
Title or category
referenced
textbooks Available %
ot textbook
Bennett JV, Brachman PS, eds. Hospital Infections. Boston, 1979, Little, Brown & Co Barrett-Connor E, Brandt SL, Simon HJ, Dechairo DC, eds. Epidemiology for the infection control nurse. St. Louis, 1978, CV Mosby Co Castle M. Hospital infection control: Principles and practice. New York, 1980, John Wiley & Sons Wenzel RP ed. Handbook bf hospitalacquired infections. Boca Raton Fla, 1981, CRC Press Axnick KJ, Yarbrough MC, eds. Infection control: An integrated approach. St. Louis, 1984, CV Mosby Co Centers for Disease Control. Guidelines for the prevention and control of nosocomial infections. Atlanta, 19811984, CDC American Hospital Association. Infection Control in the hospital, 4th ed. Chicago, 1979, The Association American Academy of Pediatrics. Report of the Committee on Infectious Diseases (1982 Redbook), 19th ed. Evanston, Ill, 1982, The Academy Basic epidemiology text Basic statistics book Benenson AS, ed. Control of communicable diseases in man, 13th ed. Washington, DC, 1981, American Public Health Association General microbiology text published within past 5 years General infectious disease and/or internal medicine text General textbook on sterilization and disinfection General medical and surgical nursing text published within the past 5 years Review of nursing procedures Text on education of the adult learner Management text Arking L, McArthur B. Infection control (symposium volume). Nursing Clinics of North America, vol 15, no 4, 1980. significant
when individuals
not employed
in hospitals
riculum rated highest (84.7% rated it “better” or “much better”) was the “Ability to readily identify an infection control risk and associated intervention.” All of the. characteristics were rated better or much better by more than half of the respondents.
were
and publications 95% Cl
and hospital Associated hospital
Journal
of
CONTROL
size with size
p Value
74.2
69.0-78.7
Yes
60.2
54.7-65.6
Yes
47.7
42.2-65.6
No
N’S
46.5
41.1-52.1
Yes
38.6
33.3-44.1
No
NS
98.5
96.3-99.4
No
NS
82.4
77.7-86.2
No
NS
54.9
49.3-60.3
Yes
34.4 34.7 82.6
29.3-39.9 29.6-40.1 78.0-86.5
Yes Yes Yes
co.01
77.4
72.5-81.8
Yes
co.01
70.5
65.2-75.3
Yes
co.01
58.1
52.5-63.5
Yes
76.4
71.4-80.8
No
NS
71.5 37.4 41.8 55.7
66.2-76.2 32.2-43.0 36.4-47.4 50.1-61.2
No No No Yes
NS NS* NS
deleted
from analysis.
Compared with hardbound books of similar size, the Curriculum was rated better than hardbound books for ease of photocopying and lying flat in use. It was rated the same in terms of showing wear and tear from use and having pages stay in the binding. The Curriculum was
Volume
13 Number
December,
6
Survey of Curriculum purchasers
1985
loo-
Isi
>I. Q
(N=39)
(N=144)
l-10 References
Hospital
255
100,
11-19 References
(N-136)
Bed Size Category
~100 BEDS (N=39)
Hospital
101-300 BEDS (N=143)
>300 BEDS (N=136)
Bed Size Category
Fig. 1. Bar graph
represents the number of general references reported as available by respondents to the survey. Numbers in parentheses represent total number of respondents by bed size category.
Fig. 2. Bar graph represents the number of infection control references reported as available by respondents to the survey. Numbers in parentheses represent total number of respondents by bed size category.
rated worse than hardbound books in its ability to sit on a bolokshelf without falling. Of those aspects of the Curriculum associated with locating material, the index at the back of each volume was identified as the most helpful. The Procedure/Devise-Risk-Intervention Tables in the Patient Care Practices section were rated as “very helpful” by 48% of the respondents.
Guidelines and periodical publications such as journals. Individuals were asked to indicate which of the references were readily available to them in their facility. Nineteen references were listed (Table 5). The mean number of references reported as readily available was 11.25 (median = 11; mode = 13). Availability of references was significantly associated with hospital size (Fig. 1). Seven of the references were specific to the practice of infection control (Table 5; references l-7). The mean, median, and modal number of references in this category was 4. This number was also significantly associated with hospital size (Fig. 2). Those texts not associated with hospital size were nursing oriented (Table 5; references 15 and 16), available at no cost (reference 6), published by the hospital association (reference 7), and two specific references for infection control practice (references 3 and 5). Seventeen periodicals were listed (Table 6). Availability of journals was significantly asso-
Frequency
of use
Frequency of use of the Curriculum did not differ by year of purchase or year in which the examination was taken. However, it was associated with years in practice. Individuals in practice <5 years were more likely to use the Curriculum one time per day or more whereas those in practice longer used it a few times per month (Duncan multiple range test, p < 0.05; ANOVA F = 4.8, p < 0.001). Availability
sf references
References were divided into frequently cited textbooks and publications such as the CDC
American
256
Checko, Soule, and Jackson
Table 6. Relation of availability TM
INFECTION
of frequently
referenced Available %
of publication
American Journal of Diseases of Children American Journal of Epidemiology American Journal of Infection Control American Journal of Medicine American Journal of Nursing American Journal of Public Health Annals of Internal Medicine Hospital Infection Control Infection Control Journal of the American Medical Association Journal of Continuing Education in Nursing Journal of Infectious Diseases Journal of Nursing Management Journal of Pediatrics Morbidity and Mortality Weekly Report New England Journal of Medicine Nursing ‘80-‘84 ‘Not statistically
significant
when
individuals
not employed
in hospitals
about
a second
edition
of or
of the
Finally, purchasers were asked if they would purchase a copy of the Curriculum if a second edition were published in 1988 and they were still in an infection control position. More than half (55.8%; CI 50.3 to 61.3) responded that they “would purchase a second edition,” a third (35.9%; CI 30.7 to 41.4) “did not know,” and 8.3% (CI 5.6 to 12) responded “no.” About two thirds of the respondents indicated that they were unwilling to pay an additional charge for the option of a hardbound book in a second edition. DISCUSSION
One of the major purposes of the Curriculum was to serve as a resource for beginning to advanced practitioners. As such, it was intended to provide comprehensive information for infection control programs, help professionals answer infection control questions, recognize current practices and controversial issues, and formulate methods for solving problems. Although the questionnaire did not specifically measure
publications 95% Cl
33.7 32.4 91.3 73.3 91.9 35.1 76.1 77.8 88.9 83.4 31.8 49.2 72.9 52.8 89.5 82.8 88.9
ciated with hospital size with the exception journals specific to infection control practice related to the nursing profession. Questions Curriculum
periodical
28.7-39.2
27.5-37.8 87.6-94.0 68.1-77.9 88.3-94.5 30.0-40.5 71 .O-80.5 72.9-82.1 84.9-91.9 78.9-87.2 26.8-37.2 43.8-54.8 67.7-77.5 47.2-58.3 85.5-92.5 78.2-86.6 84.9-92.0
were deleted
and hospital Associated hospital
Yes Yes No Yes No Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No
Journal
of
CONTROL
size with size
p Value
NS*
NS”
from analysis.
each of these objectives, some inferences can be based upon the respondents’ frequency of use, reasons for purchase, and anecdotal comments. Frequency of reported use suggests that the Curriculum is used as a major reference for daily practice. Furthermore, 90% of respondents reported that use of the Curriculum for the infection control program was an important reason for purchase. The Curriculum’s usefulness as a study guide and for preparation for the Infection Control Certification Examination were supported by the results of this survey. Anecdotal comments by several individuals described its usefulness in designing in-service and educational programs. In addition, two thirds of the respondents rated this quality as an important or very important reason for purchase. This survey suggests that hospital size is the most important predictor of purchase of the Curriculum and that individuals in hospitals with < 100 beds are much less likely to purchase it. We hypothesize that this underrepresentation may be the result of one or more of the following factors: (1) lack of targeted marketing to this population, (2) the part-time status of many ICPs in these facilities,” (3) the multiple concurrent roles that they hold,” and (4) the
Volume December,
13 Number
6
Survey of Curriculum purchasers
1985
price of the Curriculum for an individual without full-time (commitment to the practice of infection control or a facility to purchase it. The relationship between .purchase of the Curriculum and use as a study guide for the Infection Contr’ol Certification Examination suggests that persons in small hospitals may see its major purpose as a study guide for the examination and may not recognize it as serving other purposes. This is supported by the finding that the proportion of Curriculum purchasers from hospitals with < 100 beds is similar to the proportion of test takers from that stratum. In the stratum 101 to 200 beds, there were significantly fewer test takers than Curriculum purchasers. This may suggest that for this group, the Curriculum is used as a reference for daily practice and corresponds with less availability of primary reference sources. In addition, there was a disproportionately higher number of test takers than purchasers of the Curriculum from hospitals with ,500 beds. This may suggest that one copy of the Curriculum has been purchased for a department with several ICPs or that ICPs in large facilities have access to primary reference sources and see less need for the Curriculum. A major fa.ctor in determining the scope of the Curriculum was a desire to meet the needs of those individuals in. small hospitals who might not otherwise have access to current and appropriate resources to meet the multidisciplinary demands of infection control practice. Our findings support the initial belief that persons working in small hospitals are less likely to have access to published textbooks and periodicals related to the field. In this respect, the Curriculum serves as a major reference for this subgroup. Even though 45.7% of U.S. hospitals have < 100 beds, only 11.6% of Curriculum purchasers are from this stratum (Table 1). These results indicate that there may be hundreds of potential users in small hospitals throughout the country. The Curriculum has not yet achieved its objective of meeting the needs of ICPs in small hospitals, and targeted marketing efforts are indicated. The Curriculum Committee was careful to include sufficient information about most sub-
257
jects to make access to primary reference sources an option but not a necessity. If future editions of the Curriculum are also intended to address the specific needs of ICPs in small hospitals, it is important that content be complete enough to stand alone. This survey indicates the Curriculum at present is used as a reference for daily practice. The need for a second edition should be further evaluated and significant changes in practice and new directions of the discipline should be taken into account. In addition, medical practice and knowledge is constantly changing, and these changes should be integrated into the Curriculum. Whether the Curriculum will require a complete revision or merely a supplement must be determined by the next Curriculum Committee. Survey results suggest that the format and style of the present Curriculum are satisfactory to the users and should be retained. Although most users preferred the spiral binding, many suggested that a hard cover spiral-bound book would be desirable; however, they did not wish to pay an additional fee for a traditionally bound hardcover book. SUMMARY
The results APIC Curriculum
of this survey for Infection
suggest that The Control Practice
met its intended goals of creating a resource that would serve as both a reference and study guide for purchasers. However, many small hospitals still do not have the benefit of this resource. APIC should direct attention to that subgroup of ICPs if the Curriculum is to meet the needs of all practitioners. Future editions must take into account the availability of primary references in institutions in which ICPs are practicing. This will become increasingly important as competition for limited resources increases and practice extends to nonacute care facilities. Finally, in a professional organization in which funds provided by the membership are used to support special activities, those projects should undergo formal evaluation that is used for future planning. The results of these evaluations should be published in the association’s
American
258
Checko, Soule, and Jackson
professional journal to be responsive and responsible to the members whose dues support these projects. We thank Peter Charpentier, M.P.H., for statistical support, and Bonnie Matson for coordination of survey preparation and mailing.
References 1. Soule BM, editor: The APIC curriculum for infection control practice. Dubuque, Iowa, 1983, Kendall/Hunt Publishing Co. 2. Levy PS, Lemeshaw S: Sampling for health professionals. Belmont, Calif., 1980, Lifetime Learning Publications, p 56. 3. Fleiss JL: Statistical methods for rates and proportions, 2nd ed. New York, 1981, John Wiley & Sons, p 14. 4. American Hospital Association: Hospital statistics. Chicago, 1982, The Association. 5. Morrison DF: Multivariate statistical methods, 2nd ed. New York, 1976, McGraw-Hill, pp 33-34.
INFECTION
Journal
of
CONTROL
6. Freund RJ, Littell RC: SAS for linear models. North Carolina, 198 1, SAS Institute, pp 58-60. 7. McArthur BJ, Pugliese G, Weinstein S, et al: A national task analysis of infection control practitioners, 1982. Part one: Methodology and demography. AM J INFECT CONTROL 12:88-95, 1984. 8. Certification Board of Infection Control: Development and results of the first Certification Examination in Infection Control, November 19, 1983. AM J INFECT CONTROL 12(4):31A-34A, 1984. 9. Certification Board of Infection Control: Development and results of the second Certification Examination in Infection Control, November 17,1984. AM J INFECTCONTROL 13(3):24A-276, 1985. 10. Pugliese G, McArthur BJ, Weinstein S, et al: A national task analysis of infection control practitioners, 1982. Part three: The relationship between hospital size and tasksperformed. AMJINFECTCONTROLI~:~~~-~~~,~~~~. 11. Emori TG, Haley RW, Stanley RC: The infection control nurse in U.S. hospitals, 1976-1977: Characteristics of the position and its occupant. Am J Epidemiol 111:592607, 1980.