Nurse Education Today 33 (2013) 580–583 Contents lists available at SciVerse ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/nedt 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 a r t i c l e i n f o Article history: Accepted 14 June 2012 Keywords: Nursing students Infection control Compliance Jordan s u m m a r y 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 professionals' 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. Hospitalassociated 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 33.8 billion 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 countries 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 important 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 ⁎ 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 control was variable. Also, their knowledge of infection control was found to be inadequate, and their application of infection control precautions 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 themselves. 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 M.W. Darawad, M. Al-Hussami / Nurse Education Today 33 (2013) 580–583 581 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. 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 prevention of nosocomial infections. The content validity of this compliance 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 feasibility 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 comprehend written English. However, research assistants were available for the participants to explain ambiguous terms. Study Setting and Sample Data Collection 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%. 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 immediately in the target office or to take it home. Returning the filled out questionnaires 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 principal investigator has an access to that data. Respondents were advised that participation in the study was voluntary, and that they could withdraw from the study without any consequences. 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 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 developed 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 infection 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 highrisk procedures. This section contains 11 items of 5-point Likert scale ranging from 1 “Strongly disagree” to 5 “Strongly disagree”, giving a 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 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 21.37 years (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). 582 M.W. Darawad, M. Al-Hussami / Nurse Education Today 33 (2013) 580–583 Table 1 Knowledge, attitude, and compliance rates. Table 3 Stepwise linear regression analysis of predictors of compliance (N=114). Variable Number Range Mean score Stand. dev. Variables B SE ß t p value Knowledge Attitude Compliance 114 114 114 16–64 70–95 60–88 49.64 89.81 75.91 13.08 4.16 10.33 Attitude Knowledge Age GPA High school average Gender .410 .060 .152 −.859 .006 .184 .041 .103 .329 .654 .050 .748 .699 .043 .039 −.110 .009 .002 10.099 .580 .461 −1.313 .111 .024 .000a .563 .646 .192 .912 .981 Table 1 shows the rates for the knowledge, attitude, and compliance scales of infection control precautions among nursing students. In general, results revealed that students have inadequate knowledge 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 precautions, 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. a Predictors of compliance final model produced at α=0.05, F=16.19, p>0.001, R2 =0.424. 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 precautions, 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 infection control precautions was the only variable that predicts and correlates 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 promote 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. Discussion This is a descriptive study that aimed to explore Jordanian nursing students' knowledge of, attitudes toward, and compliance with infection 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). Conclusion Jordanian nursing students were found to have insufficient knowledge 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 2 Pearson correlation coefficient of study variables (N=114). Variable Age Age Gender GPA High school average Knowledge Compliance Attitude 1 −.14 −.16 −.25b .06 .13 .08 a b Correlation is significant at α=0.05 (2-tailed). Correlation is significant at α=0.01 (2-tailed). Gender GPA High school average Knowledge Compliance 1 −.04 −.05 1 Attitude 1 .23a .27b .07 −.00 .05 1 .39b .37b −.18 −.1 1 .15 −.14 −.12 .51b 1 M.W. Darawad, M. Al-Hussami / Nurse Education Today 33 (2013) 580–583 for this important topic within nursing schools in Jordan. Also, only participants' attitude toward infection control precautions had a correlation 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. References Addis, G., Karadag, A., 2003. An evaluation of nurses' clinical teaching role in Turkey. Nurse Education Today. 23 (1), 27–33. Akin, S., Gorak, G., Unsar, S., Mollaoglu, M., Ozdilli, K., Durna, Z., 2011. 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