Jordanian nursing students' knowledge of, attitudes towards, and compliance with
infection control precautions
Muhammad W. Darawad ⁎, Mahmoud Al-Hussami
1
Faculty of Nursing, University of Jordan, Amman, 11942 Jordan
summaryarticle info
Article history:
Accepted 14 June 2012
Keywords:
Nursing students
Infection control
Compliance
Jordan
Nursing students' noncompliance with infection control precautions has its effects not only on patients, but
also on nursing students themselves. Little is known about the actual status of infection control knowledge
and compliance among Jordanian nursing students. This correlational descriptive study used a
cross-sectional survey design to explore Jordanian nursing students' knowledge of, attitudes toward, and
compliance with infection control precautions. The target population was all nursing students at the faculty
of nursing—University of Jordan. Participants were found to have inadequate knowledge about infection
control precautions (M=49.64%), positive attitudes (M=89.8%), and moderate compliance (M=75.91%).
Participants' attitudes toward infection control precautions was the only variable that predicts (B=.410,
p=0.000) and correlates (r=.51, pb0.01) with their compliance score. Special courses for infection control
precautions within nursing schools in Jordan are recommended with special focus on students' attitudes.
© 2012 Elsevier Ltd. All rights reserved.
Introduction
According to the Centers for Disease Control and Prevention
(2002), hospital-associated infections occur due to healthcare profes-
sionals' non-adherence to the universal precautions of infection
control during the process of patient care, and primarily because
of their noncompliance with hand hygiene guidelines. Hospital-
associated infections occur in both developed and developing countries
and are among the major causes of increased morbidity and mortality
in hospitalized patients, which constitutes a significant burden for
patients and their families and for public health (World Health
Organization, 2005). In addition to their effect on hospitalized patients,
the cost of hospital-associated infections is huge that was estimated to
range from 28.4 to 33.8billion dollars in the United States alone
(Scott, 2009). Even though the burden of hospital-associated infections
is applied to all countries worldwide, Pittet et al. (2006) reported that
the problem of hospital-associated infections in the developing coun-
tries is worse with a rate of 25%.
As the largest group among the healthcare professionals that has the
greatest amount of direct patient care (Cole, 2009), nurses' adherence
to the universal precautions of infection control constitutes an impor-
tant factor in determining the rate of hospital-associated infections
(French and Friedman, 2003). However, Ghabrah et al. (2007) reported
that nurses' compliance with the universal precautions of infection
control was variable. Also, their knowledge of infection control was
found to be inadequate, and their application of infection control pre-
cautions was found to be improper and inadequate (Chan et al., 2002).
Nursing schools are believed to be the main source of knowledge
regarding infection control for nurses. However, nursing students
were found to have inadequate level of infection control knowledge
(Wu et al., 2009), inadequate knowledge regarding hand hygiene
(Mann and Wood, 2006), improbable hand hygiene compliance
(Celik and Kocasli, 2008; Cole, 2009), and negative attitudes toward
tuberculosis (Akin et al., 2011). Therefore, nursing students' contribution
to hospital-associated infections seems to be unavoidable (Addis and
Karadag, 2003).
Nursing students' noncompliance with infection control precautions
has its effects not only on patients, but also on nursing students them-
selves. For instance, 1144 incidents of needle stick injuries were
reported in a Chinese hospital, among which 100% were among nursing
students with an average of 4.65 times per student (Yao et al., 2010). In
addition, the frequency of needle stick injuries among those students
was found to be higher than that for healthcare professionals (Yang et
al., 2004).
Jordan is a developing country that has limited resources, which
affects the control of hospital-associated infections (Pittet et al.,
2006), and has a high Hepatitis-B endemicity (Andre, 2000). Knowing
that makes strategies to promote compliance with infection control
precautions a priority, which can start at nursing schools where
nurses receive their infection control knowledge. However, it is
believed that Jordanian nursing schools do not provide nursing students
with sufficient information regarding universal precautions of infection
control as no special courses are devoted for this topic. Also, little is
Nurse Education Today 33 (2013) 580–583
⁎Corresponding author. Tel.: +962 6 5355000x23162.
E-mail addresses: [email protected] (M.W. Darawad), [email protected]
(M. Al-Hussami).
1
Tel.: +962 6 5355000x23138.
0260-6917/$ –see front matter © 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2012.06.009
Contents lists available at SciVerse ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt
known about the actual status of infection control knowledge and
compliance among Jordanian nursing students, which makes this
study to be the first within this context. The aim of this study is to
explore Jordanian nursing students' knowledge of, attitudes toward,
and compliance with infection control precautions.
Methods
Design
This is a correlational descriptive study that used the cross-sectional
survey design through distributing a self-administered questionnaire.
Sample Size Estimation
Based on the literature concerning nursing students' compliance
with infection control precautions (Akin et al., 2011; Wu et al., 2009)
an effect size of 0.15 was estimated using Cohen's Tables (Cohen,
1992). Therefore, the estimated sample size needed to run the regression
analysis, using ά=0.05 and power=0.80 with six predictors, was 97
subjects. However, a larger sample size was considered to compensate
for attrition and incomplete questionnaires.
Study Setting and Sample
This study was conducted among Jordanian nursing students at
the University of Jordan, one of the largest public universities in
Jordan. Jordanian nursing students have their clinical training at
hospitals of different health sectors including governmental, military,
private, and teaching. This university is located in Amman, the capital
of Jordan, in the middle region of Jordan, which contains more than
750 nursing students. One hundred and sixty eight students (third
and fourth years) were invited to participate in this study, out of
which 114 students accepted participation giving a response rate of
68%.
Instrument
The instrument of this study contained four sections. The first
section asked participants to complete their demographic details
including age, gender, high school average, and university grade-point
average (GPA). The second section measures students' knowledge
regarding infection control precautions using an assessment test devel-
oped by the researchers, which had 25 items (four true/false items and
21 multiple choice questions, each of which has four alternative choices
with one correct answer only). The total grade of the assessment tool is
25, with higher grades indicating more knowledge of infection control
precautions. The face and content validity were established by an expert
panel of four nurses with PhD degree.
The third section measures the nursing students' attitudes towards
infection control precautions, which used the attitude section of infec-
tion control knowledge, attitudes, and practices instrument (Chan et
al., 2007). This scale measures attitudes toward different aspects of
infection control precaution such as choosing personal protective
equipment (PPE), and perception in attiring PPE and handling high-
risk procedures. This section contains 11 items of 5-point Likert scale
ranging from 1 “Strongly disagree”to 5 “Strongly disagree”,givinga
range between 11 and 55 with higher scores indicating stronger
agreement with the mentioned attitudes. The content validity of this
attitude scale was established by Chan et al. (2007) who also tested
its internal consistency and reported a Cronbach's alpha of 0.80. In the
current study, the Cronbach's alpha was found to be 0.83.
The fourth section examined nursing students' compliance with
the universal infection control precautions using a scale developed
by Chan et al. (2002). This scale contains 15 items of 4-point Likert
scale, ranging from 1 “Never”to 4 “Always”, giving a range between
15 and 60 with higher scores indicating more compliance with the
universal precautions. The areas addressed within this scale include
the use of PPE, sharps and wastes disposal, decontamination, and pre-
vention of nosocomial infections. The content validity of this compli-
ance scale was established by Chan et al. (2002) who reported a
Cronbach's alpha of 0.72. In the current study, the Cronbach's alpha
was found to be 0.61, which is considered acceptable (Frankel and
Wallen, 2003).
An expert panel of four nurses with PhD degree participated in
pre-pilot work to review the study instrument, and was asked to
identify ambiguous information and to comment on the ease of reading
and presentation. Then, a pilot study was carried out to assess the feasi-
bility of the study in terms of the acceptability to participants, and to
ascertain the clarity and understandability of the instrument before
being introduced to the participants. Minimal changes have been
made based on participants' response.
The instrument used the original tools that are in English language.
Even though the native language of the participants is the Arabic
language, the nursing education in Jordan is carried out using the
English language, and Jordanian nursing students are expected to com-
prehend written English. However, research assistants were available
for the participants to explain ambiguous terms.
Data Collection
After obtaining the permission from the Scientific Research
Committee at the participating university to conduct the study, an
advertisement was made for students inviting them to participate in
this study. Those who were interested were asked to report to an
office specially recognized for this purpose, where a self-administered
questionnaire package in closed envelope was distributed directly by
the researchers to the participants. The package had a cover letter that
described the study purposes and participants' rights, and invited
students to voluntarily participate. Students who accepted to participate
in this study were given the choice to fill out the questionnaire immedi-
ately in the target office or to take it home. Returning the filled out ques-
tionnaires was considered the consent for participation in the study.
Data were collected over a period of three months from May 2011 to
July 2011. Anonymity of the respondents was ensured throughout the
study. Moreover, the demographic data sheets were coded by numbers
with no names to maintain confidentiality, and no one except the prin-
cipal investigator has an access to that data. Respondents were advised
that participation in the study was voluntary, and that they could with-
draw from the study without any consequences.
Statistical Analysis
Descriptive statistics were used to describe sample characteristics
through frequencies, means, and standard deviations. All tests were
two-sided using significance levels of p≤0.05 estimated from the
Statistical Package for Social Sciences (SPSS-17.0). Partially missing
values were automatically excluded from the analysis. The Average
compliance with infection control precautions was the dependent
variable, with which a number of independent variables (including
demographic variables) were examined for possible association using
Pearson correlation coefficient test. Also, multiple regression was used
to find the strongest predictors (among the independent variables) of
compliance with infection control precautions.
Results
Of the 168 distributed questionnaires, 114 were valid for analysis.
Of the participants, 76% (n=87) were females. The students' average
age was 21.37years (SD=1.12, R=19–26). Their university GPA
ranged from 1.75 to 4 out of four (M=2.85, SD=0.55), and the
high school GPA ranged from 69 to 94 out of 100 (M=84.43, SD=7).
581M.W. Darawad, M. Al-Hussami / Nurse Education Today 33 (2013) 580–583
Table 1 shows the rates for the knowledge, attitude, and compli-
ance scales of infection control precautions among nursing students.
In general, results revealed that students have inadequate knowl-
edge about infection control precautions (knowledge rate=49.64%,
SD=13.08), positive attitudes (attitude rate=89.8%, SD=4.16),
and moderate compliance (compliance rate=75.91%, SD=10.33).
Pearson correlation test was used to examine the relationship
between the study variables (students' knowledge, attitude, and
compliance with infection control precautions) and variables of
participants' background. Students' GPA was found to be correlated
with knowledge of infection control precautions (r=0.37, pb0.01).
Also, participants' attitude towards infection control precautions
was found to be significantly correlated (r=0.51, pb0.01) with their
compliance with those precautions (Table 2).
Multiple regression analysis was used to estimate the probability of
recorded variables including attitudes towards infection control pre-
cautions, knowledge of infection control precautions, age, GPA, high
school average, and gender. As shown in Table 3, analysis revealed a
predictive model of students' attitudes (B=0.41, p=0.000), which
was significantly related to students' compliance with infection control
precautions. However, knowledge, age, GPA, high school average, and
gender were not able to predict students' compliance about infection
control precautions.
Discussion
This is a descriptive study that aimed to explore Jordanian nursing
students' knowledge of, attitudes toward, and compliance with infec-
tion control precautions, which is considered the first Jordan study in
this field. Also, this study provides future researchers with reliable
instruments within this field as the results of examining the reliability
of the study instruments revealed reliable instruments.
It was noteworthy that participants' average score of infection
control knowledge was 12.27/25 (49%). This score is considered low
when compared with 90% among nursing students in South Korea
(Kim et al., 2001), 59% among nursing students in Taiwan (Wu et al.,
2009), and 61% among nursing students in Hong Kong (Chan et al.,
2002). Such a low score indicates that Jordanian nursing students
lack the sufficient knowledge regarding infection control, which can
be confirmed by the lack of special courses for this important topic
within nursing schools in Jordan.
Participants' attitudes toward infection control precautions were
found to be positive (83.9%), which was close to 86% that was
reported among Italian healthcare providers (Nobile et al., 2002),
and 85% among Indian dental students (Singh and Purohit, 2011).
Participants' positive attitudes confirm that nursing schools are the
right place to start and focus the efforts that aim to improve compliance
with infection control precautions within the healthcare settings.
Regarding participants' compliance with infection control precau-
tions, the mean compliance rate was 75%. This rate is considered
acceptable when compared with 67% among dental students in India
(Singh and Purohit, 2011), 72% among Taiwanese nursing students
(Wu et al., 2009), and 76% among South Korean nursing students
(Kim et al., 2001). However, participants' compliance rate is considered
moderate when compared with 83% among registered nurses (RNs) in
Hong Kong (Chan et al., 2002), and 85% among RNs in China (Chan et
al., 2007). The participants' moderate compliance rate indicates that
more work is needed in order to promote their compliance.
Of concern was the result that participants' attitudes toward infec-
tion control precautions was the only variable that predicts and corre-
lates with their compliance score, and that their knowledge did not
have the same correlation. The same result was reported among Indian
dental students (Singh and Purohit, 2011), and among Chinese RNs
(Chan et al., 2007). Such a result indicates the importance of nursing
students' attitudes toward infection control precautions in order to pro-
mote their compliance with those precautions. Also, nursing educators
in nursing schools need to take this result in consideration during the
teaching process where nursing students' attitudes are formulated.
Finally, the relatively small sample size used in this study along
with including nursing students from only one university are among
the limitations of this study, which hinder the generalizability of the
study results. Also, using self-reported instruments for measuring
nursing students' compliance with infection control precautions is
another limitation, for which a combination of a self-reported and
observation methodology would be more beneficial. However, being
the first study in this field could open the door for future studies in
this important field. Therefore, replicating this study among a larger
sample size from many universities is recommended.
Conclusion
Jordanian nursing students were found to have insufficient knowl-
edge regarding infection control precautions. Knowing that participants
had positive attitudes towards and moderate compliance with infection
control precautions supports the need to offer them special courses
Table 1
Knowledge, attitude, and compliance rates.
Variable Number Range Mean score Stand. dev.
Knowledge 114 16–64 49.64 13.08
Attitude 114 70–95 89.81 4.16
Compliance 114 60–88 75.91 10.33
Table 2
Pearson correlation coefficient of study variables (N=114).
Variable Age Gender GPA High school average Knowledge Compliance Attitude
Age 1
Gender −.14 1
GPA −.16 .23
a
1
High school average −.25
b
.27
b
.39
b
1
Knowledge .06 .07 .37
b
.15 1
Compliance .13 −.00 −.18 −.14 −.04 1
Attitude .08 .05 −.1 −.12 −.05 .51
b
1
a
Correlation is significant at α=0.05 (2-tailed).
b
Correlation is significant at α=0.01 (2-tailed).
Table 3
Stepwise linear regression analysis of predictors of compliance (N=114).
Variables B SE ß t pvalue
Attitude .410 .041 .699 10.099 .000
a
Knowledge .060 .103 .043 .580 .563
Age .152 .329 .039 .461 .646
GPA −.859 .654 −.110 −1.313 .192
High school average .006 .050 .009 .111 .912
Gender .184 .748 .002 .024 .981
a
Predictors of compliance final model produced at α=0.05, F=16.19, p>0.001,
R
2
=0.424.
582 M.W. Darawad, M. Al-Hussami / Nurse Education Today 33 (2013) 580–583
for this important topic within nursing schools in Jordan. Also, only par-
ticipants' attitude toward infection control precautions had a correla-
tion with their compliance score, and that their knowledge did not
have the same correlation, which needs to be taken in consideration
during the teaching process where nursing students' attitudes are
formulated.
Author Contributions
Muhammad W. Darawad (primary author). He was responsible
for the design, method, data collection, and data analysis.
Identified the topic and specified goals and objectives of the survey.
Defined the research problem and evaluated study designs.
Formulated hypotheses; concepts, and operational definitions.
Wrote and reviewed the relevant theoretical and research literature.
Selected the population of interest and methods for data collection:
assessed reliability and validity.
Chose sampling procedures; calculated sample size.
Developed and pretested questionnaire, and consent procedures.
Prepared an analysis plan, revise methods, restate the research
problem; write and submit protocol to scientific research committee.
Implemented data collation procedures and monitored progress.
Coded and analyzed data; answered the research questions, tested
hypotheses thoroughly and explained results.
Prepared research report, seek comments and criticism.
Send report to publisher and distribute to interested audiences.
Mahmoud Al-hussami (second author). He participated in coding
and analyzing data, and reviewing the research manuscript.
Acknowledgment
The authors are grateful for the University of Jordan for funding
this study.
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