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Abstract
Background Despite both national and international recommendations for good practice in infection prevention and control (IPC), compliance can be low. Several reasons for this have been identified, including staff attitudes. There is little literature on how these attitudes are perceived by nursing students learning in clinical placements, and this study was undertaken to explore perceptions of both nursing students and their mentors in relation to attitudes towards IPC.
Methods Qualitative study involving semi-structured interviews with 31 nursing students and 32 nurse mentors recruited from one large university and one large NHS Trust in the North of England.
Results Nursing students generally perceived a negative attitude towards IPC from qualified staff and identified that it was considered to be an additional workload burden as opposed to an integral aspect of patient safety and quality care. Mentors identified more positive attitudes within their areas and organisation, but their comments did not always reflect this. Mentors were more of the opinion that staff attitudes could affect student practice and learning than were students.
Discussion Nurses in practice need to be more aware of how their attitudes towards IPC can be perceived by nursing students and the possible consequences of this for student learning and practice. Staff need to work towards identifying barriers to good infection prevention practice and ways to overcome these.
- Nursing students
- infection prevention and control
- mentor
- attitudes
- audit and feedback
- continuing education
- continuing professional development
- health professions education
- health services research
- healthcare quality improvement
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- Nursing students
- infection prevention and control
- mentor
- attitudes
- audit and feedback
- continuing education
- continuing professional development
- health professions education
- health services research
- healthcare quality improvement
Introduction and background
The prevention of healthcare-associated infections (HCAIs) has become a priority worldwide. Approximately 50 000 deaths are estimated to occur annually across Europe as a consequence of such infections.1 The WHO estimates that, at any one time, 1.4 million people have an HCAI globally.2 HCAIs are therefore a significant risk in healthcare organisations worldwide and they remain a global patient safety issue.3
A recent emphasis on infections such as Clostridium difficile and meticillin-resistant Staphylococcus aureus (MRSA) in the UK has reinforced the need for more action in infection prevention and control (IPC) in order to ensure that patients receive high-quality care.4 Flanagan5 has argued that the provision of more robust IPC measures within UK healthcare providers has become an even bigger priority following the introduction of both the Care Quality Commission and the Health and Social Care Act 2008.6 It has also been argued that programmes within IPC were among the first efforts in an organised structure that aimed to improve the quality of healthcare delivered to patients.7
In order to minimise the risk of HCAIs, standard IPC precautions should be applied to all patients. However, compliance has been shown to be low for several such precautions including hand hygiene,8 the use of gloves,9 and sharps management.10 Many reasons for non-compliance have been identified, including facilities, time and workload issues, knowledge and education, and staff attitudes towards IPC.11–14
It has been argued that there needs to be a robust approach to the IPC education of nursing students in the UK in both the university and clinical practice setting.4 The practice setting is of particular importance in nurse education, as students in the UK spend 50% of their 3-year pre-registration programme in practice placements, and this is where they gain most of their clinical skills. The Nursing and Midwifery Council,15 in their essential skills clusters for pre-registration nursing education, stated that students must, in order to register as qualified nurses, be able to demonstrate achievement of specific skills and behaviours. These include acting as an effective role model and adhering to IPC policies at all times, while ensuring that colleagues do the same. Surprisingly, given that both education and attitudes can affect practice both positively and negatively,16 17 there is little in the literature about how attitudes towards IPC in practice placement settings that educate nursing students could affect their learning. Jenner et al18 reported that exposure to suboptimal practice in hand hygiene had an adverse effect on the attitudes of student nurses towards hand hygiene, but they did not discuss how this affected practice or learning in students. This paper reports on one aspect of a research study involving nursing students and nurse mentors which aimed to investigate their experiences of IPC in clinical placements19 20; this aspect is attitudes towards IPC.
The study
Aim/objectives
The study aimed to explore attitudes towards IPC as perceived by both nursing students and the nurses who mentor and assess students in their clinical placements.
Methods
A qualitative study design was used to allow in-depth exploration of attitudes and beliefs. This design was chosen, as it is appropriate for studies where there is very little previous literature.21
Sample
The study occurred at the largest Trust used by the university for clinical placements for nursing students. This Trust has exceeded requirements for performance targets in relation to reductions in MRSA and C difficile and has reported improvements in audit scores in both hand hygiene compliance and aseptic non-touch technique performance and is therefore considered to have good IPC standards locally. All students in years 2 and 3 from both diploma and degree programmes were invited to participate (∼600 students). The resultant sample was a non-probability voluntary sample, as students who volunteered were interviewed until theoretical saturation was reached. Nurses who had mentored students in the preceding 12 months were recruited via the live register maintained by each NHS Trust to meet NMC standards. Invitations were sent to a sample stratified by clinical area of practice and the four hospitals within the Trust with a total of 75 mentors being invited to participate. In keeping with qualitative approaches, sample size was not decided in advance and a specific response rate was not required. The mentors' experience as qualified mentors ranged from 1 to 15 years, and the number of students previously mentored by each staff member ranged from two to over 40. All had a teaching/mentorship qualification, as this is a requirement to act as a mentor locally. Two mentors had previously undertaken an IPC qualification at the university. The majority were qualified to diploma level, but eight participants held bachelor degrees.
Data collection method
Semi-structured interviews were conducted at the university (for nursing students) and Trust sites (for mentors) by the principal investigator (PI). Interviews lasted up to 50 min and were audio recorded and transcribed verbatim. An interview guide (box 1) with open questions was used, which provided scope for individual views and opinions. Semi-structured interviews were used, as they are useful for addressing research aims and objectives that are based on perceptions, views and experiences.22 The PI was a lecturer at the university involved in the study, and, although she had not previously met any of the mentors interviewed, some of the students had been taught by her. The role of the PI as researcher as opposed to lecturer in this study was therefore emphasised, and students were informed both verbally and in writing that they could withdraw at any time or choose not to participate without this affecting their studies in any way. Interviews continued with both students and mentors until theoretical saturation was reached.
Interview guide (M denotes mentor, S denotes student)
Why do you think people don't always do what they should in IPC? (S&M)
What is the staff's attitude generally towards IPC in the placements that you've had? (S)
What's the general overall perception of IPC within the NHS? (S)
How has your practice changed during the time you've been on the course? (S)
Have you ever changed your practice on a placement to something different to what you would normally do, and, if so, why did you do that? (S)
What do you think the attitude is towards IPC in the area in which you work? (M)
What do you think the overall attitude is towards IPC in your organisation? (M)
Do you think attitudes towards IPC demonstrated by qualified nurses could have any effect on student learning, and, if so, what do you think these effects are? (M)
Research ethics and governance
Ethics approval for the study was gained from the relevant university and NHS committees and research governance approval was gained from the NHS Trust involved in the study. Written, informed consent was obtained from all study participants. Anonymity was preserved through the use of identification numbers, and care was taken to ensure that neither participants nor others could be identified in data extracts. It was identified that there was the potential for coercion among students who knew and had been taught by the interviewer. This was addressed by an invitation email being sent out to whole cohorts of students with the information leaflet attached, so that only students who volunteered were directly contacted by the interviewer. Participants were also made aware that the choice to not participate or to withdraw from the study at any point would not affect their studies in any way. This information was provided both verbally and in writing on the consent form. Some of the students had been taught by the interviewer and others had not, and students were asked to be as honest as possible. It was also ensured that participants were aware that the interviewer was seeing them in her role as researcher as opposed to lecturer in order to separate the two roles in the minds of the students.
Data analysis
Interview transcripts were thematically analysed using the framework analysis method.23 This method consists of the following stages:
Familiarisation
Identification of a thematic framework
Indexing
Charting
Mapping and interpretation
This approach to qualitative data analysis is systematic while being flexible and enables retrieval of data to show to others, so that each step of the analysis process can be demonstrated and scrutinised if necessary.24
Rigour
After transcription, interview transcripts were sent to participants to check for accuracy. After coding, information on the codes and themes identified was sent to a sample of participants to ensure that they agreed with the authenticity of the codes and themes. To improve rigour in coding of themes, the PI looked at all transcripts, and an additional three researchers from the Framework Analysis Group in the study university who were not involved with data collection were involved in the analysis of a sample of transcripts. No changes were made to the themes as a result of these processes.
Results
A total of 31 nursing students (table 1) and 32 nurse mentors were interviewed. Of the nurse mentors, six were male and 26 female, and years of experience as mentors ranged from 1 to 15. The number of students mentored by each qualified participant during their years as a mentor ranged between two and over 40. Across the four hospitals in the Trust from which participants were invited, three hospitals were represented. A variety of placement areas were represented by the nurse mentors and nursing students (box 2). In the data extracts used, S represents student and M represents mentor. Several themes emerged from the data (table 2).
Characteristics of participating students
Placement areas represented by participants
Mentors
Medicine
Surgery
Outpatients
Acute care (including critical care areas)
Ophthalmics
Paediatrics
Students
Medicine
Surgery
Outpatients
Critical care areas
Theatres
Primary care
Nursing homes
Themes with indicative quotes
a) Staff attitudes as perceived by nursing students
Although some students reported positive attitudes towards IPC in some of their practice placements, the general overall attitude was perceived to be negative, with IPC being perceived to be seen by qualified staff as an additional workload burden rather than a vital and integral aspect of patient care:Overall I think it's quite negative, just in that it's seen as more of a chore than a routine or a duty of care S16
I think some people see it as a ‘Oh, if we have to do it’ sort of thing, rather than thinking ‘We should be doing this as part of our routine’ S26
Students who perceived there to be a positive attitude towards IPC in their placement areas stated this to be in part due to the media focus on specific infections:I think people see it quite highly actually. There's … quite high profile now… what with MRSA and … C.diff, and it being in the media and in the public eye S19
The attitude of doctors was specifically mentioned by students as being particularly negative, with one student identifying a conversation between a ward sister and a consultant:one comment I heard was I can either “… practice infection control or I can treat the patients, you choose”. S12
This identifies a perception of not being able to practice good IPC in addition to other duties, again suggesting that infection control is seen to be an additional duty rather than an integral part of patient care and management.
Students identified that staff were aware when their practice was suboptimal, but they had a sometimes dismissive attitude to their practice:They realised they shouldn't have done it and then just went … ‘Oh, never mind’ so that's pretty disgusting. S19
Nursing student participants were clear about their perceptions of staff attitudes towards IPC and could identify them as positive or negative. None of the students interviewed reported allowing the attitudes of other staff to affect their own view of IPC.
b) Mentor views of student attitudes towards IPC
Some mentors felt that students entered practice placements with unrealistic expectations about standards of care without considering barriers, such as time, workload and skill mix, that might adversely affect practice:It's all very well but they expect too much infection control-wise…. They come from university with these big ideas about what practice should be like but the reality is different, we don't always have the time or the staff to do everything right. Students need to appreciate that and be taught to have realistic ideas about practice before they come to us M2
Students were, however, complimented on their practices and knowledge of IPC and their positive attitudes:I've found the students to have a good knowledge about the basic infection control standards when they come to us. Their practices seem okay and they're always quick to respond if we point something out that isn't quite right M6
However, in some cases, students' practices were seen as slow and therefore time consuming. Mentors sometimes perceived there to be time constraints and believed that certain procedures should be undertaken more quickly, even if this meant that corners may have to be cut in IPC practice:They do tend to be rather slow, to slow us down when we have a lot to do and we can't keep stopping to tell them what to do and how to do it, we have things to do M23
This mentor view was echoed by a student who described a conversation with her mentor:she said that aseptic technique was very important but sometimes you have to cut corners S4
c) Mentor views of attitudes towards IPC in their clinical area
Some mentor comments echoed those stated by students about IPC being an additional extra, rather than integral to care:Of course infection control is important but you have to realise that you can only do so much in a shift and sometimes infection control just takes too much time so you have to relax standards a bit M4
Despite what could be perceived as negative comments being made during interviews, however, when mentors were specifically asked for their opinion of the attitude towards IPC within both their clinical area and their organisation as a whole, it was generally stated to be positive:It's very positive I think, here and the Trust, because it's a national priority, isn't it? It's in the news a lot so we have to make sure that we do everything that we should, patients expect that M30
This echoes the influence of the media previously referred to by students. The view of a positive attitude within the Trust could also be confirmed by the fact that facilities in the organisation were not identified by staff as a reason for non-compliance with IPC precautions in terms of lack of availability.
Qualified staff were asked how they thought attitudes towards IPC impacted on student learning in their clinical area. Some commented on how a positive attitude might positively influence students:We have targets to meet and I think that… them seeing us striving to do that … I think it might actually have an impact on them and improve their infection control as well M5
Others talked about how negative attitudes towards IPC could affect students:I think negative attitudes could make a big difference - things like that can rub off. If we are complaining about it and students see that, they might think that's okay, that infection control is a pain and maybe not that important. I've never stopped to think about it before but it could have an impact on what students learn from their mentor M16
Discussion
This study identifies that student nurses enter clinical practice placements with a generally positive attitude towards IPC and that, despite often being exposed to negative attitudes from qualified nurses, they seem to maintain their positivity. This is important in terms of continuing positive attitudes once qualified in order to support good practice.
Mentors themselves confirmed that students have a positive attitude. However, many qualified nurses demonstrate negative attitudes. IPC precautions are often seen as time consuming and inconvenient, despite their value in preventing infection and improving patient safety and outcomes. These findings are important, as attitudes towards IPC have previously been demonstrated to affect practice.16 17 There seemed to be contradictions in the perceptions and views of mentors who stated that their attitude towards IPC was positive, but made remarks that could be, and indeed were, perceived by students to be negative. This suggests that perception and reality may be different and that there may not be a realisation among some staff that negative comments relating to IPC could be perceived by others as reflecting a negative attitude towards it. A recommendation for practice therefore emerges from this study in relation to mentors ensuring that their comments to students reflect the importance of IPC and the need for a more positive attitude towards it. Staff can do this by considering how their own views and attitudes may affect student learning, student practice, and the IPC practices of future nurses.
The identification by mentors of unrealistic expectations from students who do not consider the barriers to good practice which are a constant challenge in healthcare settings is a reflection of the literature relating to non-compliance with IPC precautions previously discussed. Factors that affect compliance may therefore also need to be considered as issues that can affect staff attitudes to their students and therefore possibly student learning and their view of their clinical placement experience. There clearly needs to be acknowledgement by nurse mentors that, while there are barriers to good practice, nurses and nursing students should be working with other healthcare professionals to identify and minimise these rather than accepting them as constants that will always adversely affect standards of care. This study contributes to the need for this through its identification of how the acceptance of poor practice as ‘the norm’ can influence the perceptions and views of student nurses. One of the indicators of future behaviour is the intention to perform this behaviour. This can be influenced by factors such as the views of other staff, attitudes and other barriers to performing the behaviour, in this case IPC precautions.
Negative attitudes towards what is an integral aspect of quality care is an important factor for nursing students, as negative attitudes can adversely affect learning.24
Although students in this study did not themselves perceive an impact on their learning related to the attitudes of staff, mentors were of the opinion that staff attitudes may have both positive and negative effects on student learning. It has previously been reported that the single most important influence on the learning of student nurses is the registered nurses with whom they work on a day-to-day basis.25 It is therefore possible that the attitudes of staff towards IPC can have an overall impact on what nursing students learn about IPC and how they themselves view it in the future. Nurses need to be aware of the impact that their own attitudes can have on students and their clinical practices and learning in practice placements. As nurse mentors in the UK have to undertake an approved programme of study to register as mentors, it is worth considering the inclusion in these programmes of how students perceive attitudes and how these can affect both learning and practice, so that mentors are better prepared for this aspect of their role. It is also worth mentors considering why they have such negative attitudes and what they can do to improve them, in collaboration with other professionals such as the IPC nurse or practitioner. While mentors may consider their own attitudes and the attitudes of their clinical areas and organisations to be positive, they need to be more aware of how what they say and do in relation to IPC might be perceived to reflect a negative attitude, and endeavour to emphasise the importance of IPC to both patients and staff while identifying possible barriers to good practice that need to be overcome.
Both students and mentors referred to the media as raising the profile of IPC, with mentors also identifying the impact of the media on patient expectations in IPC. It has previously been identified that the main source of information that patients utilise regarding HCAI is the media,26 and it is therefore positive that participants in this study identified the media as contributing to more positive attitudes towards IPC and possibly being the basis for patient expectations. However, the literature that discusses the misperceptions of media reporting relating to HCAI and the effects that this may have on patients and their experiences also need to be considered, as, while the media may raise the profile of IPC, it may also provide inaccurate and sensationalist information at times that may have a more negative impact.27 28 However, HCAI has risen upwards in the policy agenda in the UK in recent years, in part due to its media profile, and this therefore could be considered a positive consequence of the media focus, despite the attitudes of staff still demonstrating negativity towards IPC.
The findings of this study should be interpreted in light of its limitations. This was a qualitative study with a small sample size undertaken in one university and one NHS Trust in England and is therefore not necessarily transferable to nursing students and nurse mentors in other universities and healthcare organisations. The sampling was also voluntary and the perceptions of students who volunteered may not necessarily be the same as those who did not.
Acknowledgments
I thank Professor Ann-Louise Caress for her comments on the first draft of this paper.
References
Footnotes
Funding Funding for this study was provided by the General Nursing Council for England and Wales Trust and the University of Manchester.
Competing interests None.
Ethics approval Ethics approval was provided by the University of Manchester ethics committee and North West 9 NHS REC.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data available on request from the corresponding author.