Australian graduating nurses’ knowledge, intentions and beliefs on infection prevention and control: a cross-sectional study

In recent years, there has been an effort by organisations internationally to reduce the spread of healthcare-associated infections (HAIs). Healthcare associated infection is the contemporary term used to refer to infections acquired in healthcare facilities and infections that occur as a result of healthcare interventions [1]. The effect of HAIs are not only felt by individual patients through increased morbidity and mortality, but also by a health service through higher costs associated with infections. The magnitude of the effect of HAIs on patients is evidenced by a report from the World Health Organisation, which suggests that 7.6% of hospitalised patients will acquire a HAI [2]. This is support by other point prevalence studies who have found similar incidence of infections [3]-[5]. In response to the prevention of HAIs in Australia, the Australian Commission on Safety and Quality in Health Care (ACSQHC) launched the Healthcare Acquired Infection Prevention Program in 2009 [6], and the National Health and Medical Research Council (NHMRC) released the Australian Guidelines for the Prevention and Control of Infection in Healthcare in 2010 [1].

The ACSQHC developed initiatives which aim to standardise infection prevention and control (IPC) practice across Australia as a part of a wide strategy to reduce the incidence of HAIs. However, in the approach to reducing HAIs in Australia, there has been little mention of the role of undergraduate education. This is despite evidence pointing towards the pivotal role of the undergraduate environment in shaping attitude and building the knowledge of healthcare professionals [7].

The prevention of infection requires a multifaceted approach. Infectious agents can be transmitted from their sources to a susceptible host by a variety of methods, which include direct spread on the hands of healthcare workers, carriage on equipment, and through airflow. The prevention of transmission via these methods can be routinely prevented in healthcare settings using ‘standard precautions’. Standard precautions include hand hygiene and the use of personal protection equipment when anticipating contact with blood or bodily fluids. Contact precautions are applied to the care of all patients at all times [1],[8]. Other modes of transmission for infectious agents are via direct or indirect contact, mucous membrane contact with respiratory secretions (droplet transmission) or inhalation of infectious agents suspected in the air (airborne transmission). These three processes fall under the umbrella term ‘transmission based precautions’ [1],[8].

Despite the well documented use of standard and transmission based precautions to prevent infection, there is a lack of conceptual and theoretical frameworks in the field of IPC [9]. None the less, the first step in informing IPC education in undergraduate curricula is to determine a baseline, described as surveillance in a theoretical framework proposed by Mitchell and Gardner [10]. The current study measures the knowledge, intentions and beliefs of third-year Australian nursing students on key infection prevention and control (IPC).

Clinician education is a key strategy in the reduction of HAIs through IPC programs. The ACSQHC names education as a central tenet in effective IPC strategies [6],[11]. Overseas, the United States (US) Department of Health and Human Services highlights the critical role of education in IPC, and numerous National Health Service trusts and government departments in the United Kingdom (UK) emphasise the importance of education in IPC [12],[13]. Despite local and international acknowledgement that education is key, however, concerns surrounding deficits in IPC knowledge amongst clinicians, including attitude towards IPC, continue to be reported [14]-[16]. Knowledge is a precursor to changing entrenched attitude, and numerous studies have emphasised the importance of both of these components for a sustainable behavioural change amongst clinicians [17]. This relationship among knowledge, attitude and behavioural change has been specifically researched in relation to IPC [14],[18].

Pre-registration training plays a crucial role in improved clinician compliance to IPC [7], and the NHMRC asserts that undergraduate clinician programs serve as a key environment where knowledge acquisition on IPC should occur [1]. A number of studies highlight the inadequacy of many undergraduate programs to effectively train students of various clinical disciplines [7],[13],[19]-[22]. This finding implies the possible causal link between undergraduate education and the lack of clinician compliance to IPC policy.

A number of authors have pointed out the lack of research which examines the effectiveness of IPC programmes in undergraduate nursing curricula [13],[19],[23]. This case is particularly notable in Australia. Nurses represent the largest healthcare service labour group which has a high frequency of contact with patients [24], so IPC education of nurses in undergraduate programmes warrants attention. To the best of our knowledge, no study which examines undergraduate nursing IPC programmes in Australia has been undertaken.

The data collected in this study measured IPC knowledge, intentions and beliefs of final-year nursing students across six universities in Australia. We believe that this research can act as a starting point to inform undergraduate curricula in Australia on effective IPC training.

The nursing students in this study demonstrated inadequate knowledge on IPC, more specifically transmission based precautions, a finding consistent with those of previous studies [13],[21],[23]. The participants demonstrated a considerably stronger level of knowledge on the topic of standard precautions than transmission-based precautions, with 88.9% of standard precaution questions correctly answered. The literature indicated mixed results in relation to this theme. Undergraduate healthcare students were found to have an acceptable level of standard precaution knowledge in some studies [19],[25],[29] and knowledge deficit in others [8]. The low level of knowledge in relation to transmission-based precautions observed in our study is consistent with the findings in the literature [19],[30]. We identified only 27.2% of transmission-based precaution questions correctly answered. This result suggests that undergraduate education on transmission-based precautions may be inadequate; this observation is particularly pertinent because of the increasing presence of new and evolving pathogens in healthcare environments and the effect of clinician education on reducing the spread of HAIs [11].

We found negative correlations between the participants’ increased knowledge of transmission-based precautions and whether they thought specific issues posed an IPC problem in Australian hospitals. Neither gastroenteritis outbreaks, nor hand hygiene compliance were considered to pose a problem. We postulate that a possible reason for this finding is the respondents’ experiences and exposure to these issues during their undergraduate education and more specifically, during their clinical placements. For example, graduating nurses may have had little or no nursing experience of a gastroenteritis outbreak. Unless a student nurse has worked in a healthcare setting during an outbreak, he or she may not consider outbreaks as an IPC issue. Furthermore, the participants’ view that hand hygiene compliance was less of a problem relative to other scenarios posed can be explained by the popularity of hand hygiene in Australia. The National Hand Hygiene Initiative was introduced across Australia in 2009. This major initiative and its subsequent publicity may have led to the perception that hand hygiene is no longer an issue in healthcare.

Our study also identified some interesting themes on how student nurses obtain IPC information. Several well-reported international studies suggest that nurses prefer to approach colleagues for information rather than access evidence-based resources [31]-[35]. This pattern of information-seeking behaviour is also evident in graduate and undergraduate nurses, primary health nurses, and acute and critical care nurses [36]-[38]. As an example, three quarters of the nurses studied by O’leary and Mhaolŕunaigh [35] consulted human sources of information on a daily or weekly basis. The literature also reveals that nurses generally ask for information from a colleague perceived to be more knowledgeable or experienced than they are, whereas they considered text-based resources as useful only when these are readily available [35],[37]. The fact that the participants in our study were more likely to seek information from an infection control professional is supported by the themes previously discussed and is consistent with the information-seeking behaviour amongst all grades of nurses.

The participants in our study, aged 25 years or younger, were more likely to seek information from senior nurses, compared with those participants who were over 25 years. This finding is consistent with that of an Irish study, which found that compared with more experienced nurses, less experienced ones were reported to more heavily rely on other people for information [35]. Similarly, a UK study found that other staff were likely to influence student nurses’ IPC practice [13]. As nurses gain experience, they are more likely to seek information from the next most available information source, for example, policies and guidelines [35]. The reasons cited in the literature for consulting human sources instead of evidence-based information include convenience and efficiency, a perceived lack of computer skills, and avoidance of large amounts of retrieved information which are still to be read, analysed and evaluated [37],[38]. O’Leary and Mhaolrunaigh [35] suggest that nurses only search for a limited time to find information which they self-determine to be an acceptable solution and that they do not search long enough to find a solution which they can consider as the ‘best decision’. Evidence-based information is therefore recommended to be relevant for practice and must be made readily available [35]. Furthermore, undergraduate nursing curricula should be designed in such a way that they develop the necessary skills for students to understand the importance of and ability to access evidence-based practice.

We found that in the final phase of their undergraduate education, Australian student nurses had adequate levels of knowledge on standard precautions principles of IPC. However, their knowledge on transmission-based precautions was substandard. Transmission-based precautions are the foundation of IPC for serious organisms and infections, so several implications can be determined. Those responsible for developing undergraduate nursing curricula should consider whether the current approach to IPC used in their respective institutions is effective. For organisations which employ nursing graduates, whether additional IPC training is required should also be seriously considered. Infection prevention and control professionals are often responsible for delivering education in hospitals, and the findings from our study can help them understand the current knowledge gaps in newly qualified nurses to allow for targeted education.