For every 100 patients admitted to hospital, at least seven will be diagnosed with a nosocomial infection, and the rate is 2-3 times higher in developing countries (World Health Organization (WHO), 2011). The total yearly cost associated with nosocomial infection is estimated to be €7 billion in Europe and $6.5 billion in the USA (WHO, 2011). Although bacteria and viruses come in different shapes and types, they spread and propagate through a similar set of conditions, known as the chain of infection. Infection is a result of the interaction between agent, host and environment. Transmission happens when an agent leaves its reservoir or host by a portal of exit, is transported by some route of transmission, and infects a susceptible host through an appropriate portal of entry. Healthcare providers are required to break the chain of infection (Schrank and Branch-Elliman, 2017).
Nosocomial infection, also known as healthcare-associated infection (HCAI) presents in patients under medical care in hospital or other healthcare facilities that was not detected or incubated at the time of admission (Khan et al, 2017). It is important to stress that a nosocomial infection is one that becomes evident within 48 hours or more after admission to hospital (Bag, 2018).
Patients are exposed to pathogens and micro-organisms from various sources including cross-contamination, the healthcare environment and from other patients (Khan et al, 2017). Several factors associated with nosocomial infection are shortage of staff, poor infrastructure, overcrowding and lack of knowledge among healthcare workers (Sun, 2016; Halain et al, 2018). Studies show that inadequate knowledge is a major predictor of poor compliance with standard precautions and strongly correlates with an increased rate of nosocomial infection (AL-Rawajfah and Tubaishat, 2015; Cheung et al, 2015). Another factor associated with a high incidence of nosocomial infection is the lack of procedures and policies for the prevention and control of nosocomial infection (Weinshel et al, 2015).
Nosocomial infection is associated with many adverse healthcare-related outcomes, including an increase in mortality rate (Rahiman et al, 2018), antimicrobial resistance, long-term disabilities (Rahiman et al, 2018), prolonged hospitalisation, increased financial burden on the hospitals (Jia et al, 2019), and the socio-economic burden for patients and their families (Filetoth, 2008; WHO, 2011; Khan et al, 2017). Greater knowledge regarding the prevention of nosocomial infection among staff nurses can reduce the cost of patient care through needing less treatment and fewer diagnostic tests (Chacko et al, 2017). In fact, more than one-third of nosocomial infection cases can be avoided by following appropriate infection control measures (Barchitta et al, 2012).
Student nurses who are exposed early to hospitals during their education have a role in either spreading or preventing nosocomial infection, therefore assessment of their knowledge of its prevention is crucial (Bag, 2018; Majidipour et al, 2019). One study found that none of the nursing students studied had an exceptional level of knowledge about prevention; 16 (50%) had good knowledge; 12 (37.5%) had an average level of knowledge and 4 (12.5%) had poor knowledge (Mayanlambam and Devi, 2016). Regardless of knowledge level, researchers recommend periodic checking of students' level of knowledge to fill any gaps, improve their training, and reduce the incidence of nosocomial infection (Brosio et al, 2017; Goyal and Chaudhry, 2019).
Students' knowledge about the topic is important because infection can affect patients' health in many ways. Nosocomial infection may lead to severe chronic illness, permanent disabilities and, ultimately, death (Rahiman et al, 2018). In addition, students' knowledge of infection control will help in developing effective precaution and treatment strategies, reducing the incidence, as well as morbidity and mortality rates, among patients diagnosed with nosocomial infection (Khan et al, 2017). Increasing knowledge of nosocomial infection will prepare students who become registered nurses to prevent infection among patients in the future (Brosio et al, 2017), strengthening the importance of this study.
According to WHO (2011), nosocomial infection is the most common adverse event in health care, resulting in a significant burden on patients, their families and healthcare systems. Increasing knowledge among students is considered to be one of the most effective measures for reducing and preventing nosocomial infection (Brosio et al, 2017). Students play an important role in the transmission of pathogens and the prevention of infectious diseases as they spend time interacting with patients during their clinical rotation. Examining their knowledge of and compliance with infection control measures is therefore imperative. As the level of nosocomial infection knowledge among Omani students has not yet been explored, the aim of this study was to assess their knowledge and test the relationship between level of knowledge and the demographics of Omani student nurses.
Materials and methods
A cross-sectional design was used to assess the level of knowledge regarding nosocomial infection among student nurses in Oman. The data were collected between March and June 2020. This design was used because it is not expensive and gives a snapshot of the phenomenon under investigation at a fixed point in time.
Participants and setting
A convenience sampling technique was used to recruit students from the Sultan Qaboos University College of Nursing. The inclusion criteria for participants was:
- Students aged 18 years and over
- Students who had completed at least one clinical course and would have completed three infection control modules
- Students who were able to read and write English
- Students who agreed to participate in the study.
The exclusion criteria were students who failed to complete the clinical course and who preferred not to participate.
The required sample size was estimated through Sloven's formula, n=N/(1+N e2), where n=number of samples, N=total population (500) and e=margin of error (0.05). Therefore, a minimum of 222 participants was required.
Procedure
An email was sent to all 500 BSc nursing students, explaining the purpose of the study, outlining the inclusion and exclusion criteria and providing a link to the consent form and the study survey. Once a participant had agreed to take part in the study, the survey was opened. A total of 330 student nurses completed the online survey, a response rate of 66%.
Ethical approval
Appropriate ethical approval was obtained from the Ethical Committee at the university (CON/GP/2020/18). The nature and purpose of the study was explained in detail to the participants in the email. Participants were also assured that they had the right to withdraw at any time, that they could decline to answer any question, that the results would be used only for the study and that their anonymity would be maintained.
Instrument
The Infection Control Standardized Questionnaire (ICSQ) (Tavolacci et al, 2008) was used to measure the level of knowledge about nosocomial infection. The original English form of the questionnaire was used, as English is the language of study for all nursing student at the university. The survey consisted of two parts: the first section included questions about participants' demographics, including age and source of knowledge; the second comprised 25 questions with yes/no answers, with one point given for each correct answer. The test re-test reliability was established, and Cronbach's alpha ranged between 0.61 and 0.84, indicating an acceptable level of internal consistency (Tavolacci et al, 2008; Bello et al, 2011).
Statistical analysis plan
The data were downloaded from Google Forms to Excel format and exported to SPSSv22. Mean, standard deviation, frequency and percentages were used to describe the sample. An independent t-test was used to explore whether there was a difference between the group means. The level of significance was set at P<0.05.
Results
Of the 330 students who completed the online survey, the average age was 21.57 (SD=1.9), and the cumulative grade point average (CGPA) 2.86, (SD=0.512). Only 51 participants (SD=15.5) scored 70 or more in the survey. In terms of demographic characteristics, over half the participants (186) were female. Female students had a higher mean score for their total knowledge than male students, a finding that concurs with a previous study (Rahiman et al, 2018) but contradicted other findings (Darawad and Al-Hussami, 2013). Other studies found no statistical difference in the total knowledge scores between male and female students (AL-Rawajfah and Tubaishat, 2015), possibly attributable to cultural differences. The main source of information about nosocomial infection was the internet (153, 46.4%) followed by clinical experience (128, 39.8%). Further details are provided in Table 1.
Table 1. Student demographics
| Variable | n | % |
|---|---|---|
| Gender | ||
| Male | 144 | 43.6 |
| Female | 186 | 56.4 |
| Source of information | ||
| Curriculum | 49 | 14.8 |
| Internet | 153 | 46.4 |
| Clinical | 128 | 39.8 |
| Total survey score | ||
| Less than 70 | 279 | 84.5 |
| 70 and more | 51 | 15.5 |
| M | SD | |
| Age | 21.6 | 1.9 |
| Credit hours completed | 86 | 2.1 |
| Cumulative grade point average | 2.9 | 0.51 |
| Average survey score | 51.5 | 0.89 |
Participants were required to answer 25 questions to evaluate their knowledge of nosocomial infection and standard precautions. The mean total corrected score was 51.53% (SD=0.89), ranging from 16% to 96%. None of the participants obtained a perfect score. Fifteen of the questions were answered correctly by more than 50% of participants. For example, over two-thirds (228, 69.1%) answered question number 22 correctly: ‘The healthcare provider can use alcohol-based hand rub instead of traditional hand washing (for 30 seconds)’, consistent with a previous study (Nair et al, 2014), while only 101 (30.6%) responded to question 1 correctly: ‘The environment (air, water, inert surfaces) is the major source of bacteria responsible for nosocomial infection.’ Frequencies and percentages of the top and bottom five questions answered correctly are presented in Figure 1 and Figure 2 respectively.
The independent t-test was conducted to compare the mean scores based on gender. Female students had higher mean scores (M=53.84; SD=16.81) than male students (M=45.03; SD=11.8), t(328)=5.35, P<0.05. An ANOVA test was also conducted to identify any difference between students' mean scores in regard to their source of knowledge. There was a significant difference between the groups (F(2, 327)=6.67; P=0.001). Post-hoc comparisons using the Tukey test indicated that the mean score for the participants who relied on their clinical experience as the main sources of knowledge (M=3.53; SD=14.76) was significantly different compared with students who relied on the curriculum (M=5; SD=12; P=0.003) and the internet as their main source of knowledge (M=48.6; SD=16.4; P=0.022). However, the mean score for participants whose knowledge came from the internet was not significantly different from those who got their knowledge from the curriculum (P=0.337).
Discussion
The aim of the study was to assess the level of knowledge about nosocomial infection among student nurses. A low level of knowledge was reported, with only 51 students (15.5%) scoring more than 70 in the knowledge test. These results are consistent with those of a previous study in the Arab region (Darawad and Al-Hussami, 2013), but are different from two studies conducted in Italy and South Africa, which showed an acceptable level of knowledge about nosocomial infection among students (Tavolacci et al, 2008; Rahiman et al, 2018). There are several reasons for the low level of knowledge about nosocomial infection, the main one being the lack of belief in the usefulness of precautions (Zeigheimat et al, 2016) and lack of a specialist course to teach infection control topics within nursing curricula (AL-Rawajfah and Tubaishat, 2015). It is important to bridge the gap between theory and practice in courses as a means to address infection control measures within nursing curricula (Hassan, 2018).
Students need more formal education and training on nosocomial infection. Conducting workshops and seminars related to infection control and prevention standards could improve their level of knowledge (Nasiri et al, 2019). Alrubaiee et al (2017) recommended focusing on improving knowledge and practices about nosocomial infection among nurses by educational interventions, either by in-service refresher courses or training courses. The same techniques could be used with students. Regular educational and training programmes about nosocomial infection have a significant impact on the level of knowledge of students and staff (Zeigheimat et al, 2016; Goyal and Chaudhry, 2019).
Various teaching methods have been used to improve nursing knowledge related to nosocomial infection (Saffari et al, 2019). Sending short text messages to nurses' mobile phones has been found to be a useful training strategy implemented among intensive care unit nurses (Saffari et al, 2019). The implementation of health belief model-based educational programmes significantly improved knowledge about nosocomial infection, leading to better preventive behaviours (Zeigheimat et al, 2016; Jeihooni et al, 2018). Clinical simulations can also enhance knowledge of infection control measures (Kappes Ramirez, 2018).
In the clinical setting, preventing nosocomial infection is the responsibility of both qualified and student nurses (Majidipour et al, 2019), who must have an acceptable level of knowledge and skills about infection control and prevention standards (Majidipour et al, 2019). It is the role of policy makers in hospitals to establish guidelines and to ensure awareness and adherence to these guidelines through mandatory attendance in educational programmes, symposiums, seminars or workshops focused on infection control and prevention guidelines (Bag, 2018). This will reduce the impact of negative outcomes, including prolonged hospitalisation (Ohannessian et al, 2018), increased financial cost for both healthcare facilities and patients, high mortality rates and long-term disabilities among patients (Khan et al, 2017).
The majority of participants in the current study learnt about nosocomial infection from the internet and clinical experience. The main source of information in previous research was from the general curriculum (Tavolacci et al, 2008) or formal training in specialist classes (Bello et al, 2011). The current nursing curriculum needs to be reviewed to determine the proportion of the content devoted to infection control. Faculty members of the College of Nursing should introduce a module on infection prevention and control (IPC) at the earliest opportunity for students, and hospitals should take the initiative by mandating infection control guidelines before students start clinical practice in hospital wards. In addition, regular seminars, educational programmes, symposiums and workshops should be arranged by a continuing education department in hospitals (Bag, 2018).
Limitations
This study had some limitations; for example, a convenience sampling technique was used to recruit participants from one single place, limiting the generalisability of the study findings.
Nursing implications
This study offers useful information regarding the level of knowledge about nosocomial infection among students in one university, who are the staff nurses of the future. It provides evidence for the need to improve their nosocomial infection knowledge through theoretical and clinical courses.
Decision-makers in the College of Nursing should take responsibility for focusing on aspects of teaching to improve quality of care. The findings of the current study will guide nursing educators in revising curricula and ensuring that topics related to nosocomial infection are emphasised within both theory and clinical courses. Furthermore, as students can be vectors for the transmission of bacteria, they need to be equipped with the knowledge and skills to prevent transmission.
Limited research has been conducted on this topic in Oman, and there is a need for further research. Previous studies (Alrubaiee et al, 2021; Kim et al, 2021) found that educational interventions were successful in raising the level of knowledge about transmission and prevention of nosocomial infection and strengthening safety precautions related to nosocomial infection.
Conclusion
Although the main focus of the current study was nursing students, preventing nosocomial infection is a shared responsibility among all healthcare providers and is not limited to nursing alone. The study findings show that student nurses have insufficient knowledge about nosocomial infection. This calls for a review of nursing curricula to pave the way for more pragmatic infection control teaching in all nursing programmes.
This is an important issue to consider in the context of the global drive to improve nursing education and standards, and also the international recruitment of nurses.
KEY POINTS
- Nosocomial infection is associated with many adverse healthcare-related outcomes, including an increase in mortality rate, antimicrobial resistance, long-term disabilities among patients, a prolonged hospital stay, the increased financial burden on the hospitals, as well as placing a socio-economic burden on patients and their families
- Healthcare providers are the first line of prevention of nosocomial infection
- A study among nursing students in one university in Oman found that there was insufficient knowledge of nosocomial infection
- The authors suggest student nurses need further education and practical training on preventing nosocomial infection
CPD reflective questions
- Think about infection levels among patients in your area of practice. Could these be improved?
- What is the level of knowledge about nosocomial infection among student nurses in your area of practice?
- What approach is taken to improving knowledge about nosocomial infection among students and nurses in your workplace?