INTRODUCTION:

Hospital-acquired infections remain a problem for all hospitals. It is assumed that most infections arise from contaminated staff hands, which has led to the current focus on hand-hygiene initiatives.^1,2 Whereas there has been some success in persuading staff to clean their hands, compliance rates frequently decrease when an intervention ceases.³ In addition, staff often forget hand hygiene when they are busy. Recent work has highlighted the role of the clinical environment in the transmission of ward-based infection.⁴Nosocomial bloodstream infections (NBSIs) in ICUs are associated with substantial morbidity and mortality, as well as increased length of stay and healthcare costs.⁵

“Standard precautions” are guidelines aim to prevent transmission of human Immunodeficiency virus (HIV), hepatitis B (HBV), and other blood borne pathogens.

The objective is to assume patients are infected with blood-borne pathogens, and ensuring health staffs minimize the risk of exposure to infected body fluids.⁶ Healthcare workers are at risk of occupational hazards as they perform their clinical activities in the hospital. This is supported by the findings of Beekmann in which the risk of seroconversion following a single needle stick from a source-patient with blood borne infection found in ranges from as low as 0.3% for human immunodeficiency virus (HIV), and 3% to 10% for hepatitis C to as high as 40% for hepatitis B.⁷

Compliance with standard precautions defined as the extent to which certain health care practices are implemented in accordance to known standard precautions.⁸ Compliance to standard precautions can reduce the healthcare infections up to one-third. However, despite both public and professional awareness of the dangers of blood-borne viruses, compliance with standard precautions among health care workers found to be low.⁹ Noncompliance with standard precautions guidelines has become a hot topic of late, perhaps because antibiotic-resistant pathogens have continued to proliferate and to spread, seemingly out of control.¹⁰Researchers identified education as an important aspect of improving health care workers compliance to standard precautions, and indicated the need for more comprehensive education programs which clearly links theory with practice rather than programs which emphasized only on the knowledge part of standard precautions. ^11-12

Associate Nursing Students as other health care workers who come into contact with patient blood and body fluids may be exposed to fatal infections. However, few studies examined the nursing students related to standard precautions as comprehensive.¹³

Recently, reflection and reflective practice have gained considerable interest both in nursing education and practice, with scholars’ agreement that reflection takes experience as its starting point and questioning are at the heart of reflective practice. In 1999, Bringle described reflection as a framework within which students’ process and synthesize information from their experiences, which can help students and nurses learn from experiences and improve their own practice.¹⁴ Many researchers mentioned the lack of empirical evidence to support the use of reflection in nursing education and practice as^.15 Thus this study could be the first which concerned the nursing students, and utilized the reflection as a learning strategy, where the students’ process and synthesize information from their experiences, and their compliance with standard precautions pre and post reflection will be empirically evaluated.

Accordingly, the specific objective of this study was to determine the degree to which the nursing students own reflection will facilitate their compliance with standard precautions.

MATERIALS AND METHODS:

Study Design

A pre – and post- intervention study with 2 weeks reflection and 14-weeks follow-up.

Study participants

This study was conducted at an applied science college - AL-Balqaa Applied University-Zarka College, with an approximate total enrolment of 3500 students in the middle of Jordan. The data were collected during the second semester in January – June 2012. A purposive, convenient sample represents the nursing students who were enrolled in the advanced nursing course, includes 31 students.

The Jordanian undergraduate associate nursing students’ curriculum is covered over a two-year period. Advanced nursing course is the final pre-graduate required the nursing student’s to practice in a preceptor ship base where they are allowed to carry out all the nursing procedures except the invasive procedure without direct supervision.

The supervisor of the advanced nursing course has to meet the students 2 hours weekly at the college for follow up, and to meet them at least once per week in the clinical placement in collaboration with the preceptors and the clinical placements administrators in planning, implementing, and evaluating the students’ achievements of their clinical objectives, which in relation to this study include: 1. Integrate knowledge from the biological, physical, behavioral, humanities and nursing science in the practice of clinical nursing 2. Accept personal responsibility and accountability for nursing practice 3. Serve as a change agent with clients and colleagues to meet changing health needs.

Intervention

During the advanced nursing course practice, students were required to report their total work in a base of daily activities and a total summary in a portfolio. One of the required assignments that the students have is to reflect in a 10 patient related or practice related critical events during their 16 weeks the allotted time for the course, where 5 of these events should be finished by the end of the first two weeks of their clinical practice (Schön1987) model (Fig1) which has four steps process.¹⁶ First, recognize an event or concrete experience. Second, critically analyze and reflect on what happened. Third step is identifying new needs. The fourth step is plan new strategies; test implications of new concepts in new situations were utilized for the process of reflection.

· Step 1: recognize an event or concrete experience.

· Step 2: critically analyze and reflect on what happened.

· Step 3: identifying new needs.

· Step 4: plan new strategies; test implications of new

concepts in new situations

Figure 1. Four steps of (Schön1987) Model of reflection

To ensure the students understanding for the process of reflection demonstration by the researchers and repeated re-demonstration by volunteered students in the use of reflection were carried out followed by discussion and clarification of any vague point in the process, questioning and clarification of any vague point was opened for all the students all over the training period.

Although completion of the assignment was a course requirement, but the student who choose to participate needed to select the 5 out of the 10 required reflective events from a non compliance with the standard precaution related experiences, and had to fill the questionnaire prepared for this study at least three or more times out of the scheduled course time during the 16 weeks of the study period. The researchers announced a meeting time for the students who are willing to participate, and informed the students about the study and the importance of their participation.

Students were informed that participation in this study is voluntary and would have no impact on the final course grade or evaluation, with an assurance that all responses would be confidential, the results will be analyzed and processed anonymously, the findings would not directly affect them but could impact future students who enrolled in the course.

All the thirty one students enrolled in the advanced nursing course choose to participate in the study, and filled the survey questionnaire at the first meeting.

DATA COLLECTION AND ANALYSIS:

In order to assess the nursing student’s compliance with standard precautions a self reported questionnaire consists of two sections. Section one seeks demographic information. Participants indicated their age, gender, academic achievement level as indicated by their accumulative average, expected advanced nursing course average, history of hepatitis B vaccine, and history of occupational exposure. Section two includes (15) items consisting of fixed choice items in the form of likert – type scale with scores ranging from 1 = never to 5 = always, derived from the standard practices¹ designed to elicit participant’s responses regarding compliance with standard precautions. Content validity of the instrument was established by a through review of the literature, consulting expert opinion and conducting a pilot study. Cronbach’s alpha analysis for reliability was performed and gave a result of 0.88.

In order to assess the students’ compliance with standard precautions, students were surveyed pre-intervention (reflection) as a baseline survey, 2 weeks after intervention, and the follow up survey which carried 16 weeks after the baseline (pre-intervention) survey. Student’s participation in the study was determined by completing the reflection on the 5 events related to noncompliance with standard precaution during the first two weeks of clinical training, and filled each of the three surveys at the same meeting the questionnaire provided to them. The justification for these time frames came from time constraints on the students’ course completion. All over the 16 weeks, which ended by the end of the semester, needle stick incident reported, and hepatitis B vaccine were monitored.

The data were analyzed with SPSS statistical package version 17. Descriptive statistics were also examined. An alpha level of 0.05 was used for all statistical tests.

RESULTS:

Thirty out of the thirty-one students completed the required procedure of the study all of them except 2 were female. Mean self-reported total academic achievement average of the participants was 65% [standard deviation (SD) =12%] (Fig 2). Mean self –reported expected course average for the participants in the advanced nursing course was 70% (SD=10%). (84%) of the students were 20-22 years of age (Fig 3).

Data analysis revealed statistically significant differences between pre – and post –reflection results in relation to Hepatitis B vaccine coverage among the participants and needle stick and sharp injury exposure. Hepatitis B vaccine coverage among the participants increased from 33% in the baseline survey ( before starting the reflection) to 67% (2 weeks) post - reflection, and 100% at follow up phase (16-weeks post –baseline) (P< 0.001).

Needle stick and sharp injury exposure declined among the participants from 57% pre-intervention to 33% (2weeks) post intervention, and 3% at follow up phase (16-weeks post –baseline) survey (P< 0.001).

Figure 2. Total averages distribution of the participants

Figure 3. Age distribution of the participants

Table 1. Standard precautions which got compliance of students with a total mean of four or more pre-reflection and the compliance change all over the study phases (N = 30)

Standard precaution item	Baseline survey (Pre-reflection)			Post – reflection (2wks)			Mean change	P	Post-Baseline (16 wks)			Mean change	P
Standard precaution item	Mean	SD	t	Mean	SD	t	Mean change	P	Mean	SD	t	Mean change	P
1	4.03	1.18	18.58	3.83	0.98	20.30	0.20	*	4.00	0.83	26.38	0.17	*
9	4.60	0.56	44.73	4.66	0.47	53.31	0.06	*	4.66	0.47	53.31	0.00	*
12	4.53	0.68	36.43	4.33	0.95	24.75	0.20	*	4.33	0.95	24.75	0.00	*
13	4.16	0.91	25.00	3.66	0.47	41.88	0.50	*	5.00	0.00	**	1.67	*
15	4.00	0.83	26.38	4.33	0.47	49.50	0.33	*	3.33	0.95	19.03	1.00	*

One - sample Test One- sample Statistics 2- tailed significance

* P<0.001

** t cannot be computed because the standard deviation ( Std) is 0.00

Standard Precautions Items (Appendix B)

Table 2. Standard precautions which got compliance of students with a total mean of three or less in the `baseline (pre- reflection) survey and compliance of students significantly improved P<0.001 through the study phases (N = 30)

Standard precaution item	Baseline survey (Pre-reflection)			Post – reflection (2wks)			Mean change	P	Post-Baseline (16 wks)			Mean change	P
Standard precaution item	Mean	SD	t	Mean	SD	t	Mean change	P	Mean	SD	t	Mean change	P
3	1.80	0.92	10.66	4.33	0.95	24.75	2.53	*	4.00	1.34	9.52	0.33	*
5	3.66	1.26	15.83	3.33	0.47	38.07	0.33	*	4.00	0.83	26.38	0.69	*
7	2.06	0.82	13.67	2.66	0.47	30.46	0.60	*	3.00	0.83	19.78	0.34	*
8	2.00	1.01	10.77	3.33	0.47	38.07	1.33	*	4.00	0.83	26.38	0.67	*
10	2.60	0.77	18.49	2.66	0.47	30.46	0.06	*	3.66	1.91	10.47	1.00	*
11	3.13	0.77	22.11	3.33	0.95	19.03	0.20	*	3.33	0.47	38.07	0.00	*

One - sample Test One- sample Statistics 2- tailed significance

* P<0.001

** t cannot be computed because the standard deviation ( Std) is 0.00

Standard Precautions Items (Appendix B)

Table 3. Standard precautions with compliance of students significantly improved in the second phase P<0.001 post reflection then the compliance of the students significantly declined P<0.001 in the follow up phase (N= 30)

Standard precaution item	Baseline survey (Pre-reflection)			Post – reflection (2wks)			Mean change	P	Post-Baseline (16 wks)			Mean change	P
Standard precaution item	Mean	SD	t	Mean	SD	t	Mean change	P	Mean	SD	t	Mean change	P
2	2.90	1.106	14.95	4.00	0.00	**	1.10	*	3.33	0.00	**	0.67	*
4	1.66	1.06	8.60	3.66	0.95	20.94	2.00	*	2.00	1.43	7.61	0.66	*
6	1.60	1.03	8.44	2.00	0.00	**	0.40	*	1.33	0.47	15.23	0.67	*
14	1.00	0.00	**	3.33	0.47	38.07	2.33	*	1.66	0.95	9.52	1.67	*
15	4.00	0.83	26.38	4.33	0.47	49.50	0.33	*	3.33	0.95	19.03	1.00	*

One - sample Test One- sample Statistics 2- tailed significance

* P<00.001

** t cannot be computed because the standard deviation ( Std) is 0.00

Results presented in Table 3 showed that respondents’ compliance with standard precautions 2, 4, 6, 14 and 15, which include wash hands before and after any procedure even removing disposable gloves, wear a disposable outer garment that is resistant to blood and body fluids whenever there is a chance of soiling clothes at work, wear protective eye shields whenever there is possibility of a splash or splatter in eyes, fill in an "Incident Report" following exposure to used needle stick or sharps object injury, Remind the work group of standard precautions were significantly declined in the follow up phase after it was significantly improved in the post reflection phase (P< 0.001).

DISCUSSION:

The overall findings of this study provided evidence to the potential value of reflection as a learning strategy, made the participants aware of their individual responsibility for their own health. Participants compliance improved significantly (P<0.001) with all of the standard precautions after reflection. These findings of positive impact of reflection on the participants’ compliance with standard precautions support the findings reported by the few studies carried out on the nursing students and find that reflection - on –action is a useful learning strategy, and it has a positive impact on learning especially when reflection used alongside other conventional methods.¹⁷

Also this study results support the findings of other studies in the field of infection control and management which highlighted the importance of educational approaches with a move from the traditional didactic methods to a more interactive approach, multifaceted rather than education only programs, and emphasized learning in practice rather than formal sources as a learning strategies and approaches to facilitate the workers compliance with standard precaution which in turn improves practice and reduce level of infection.¹⁸

Participants’ compliance with standard precautions that carried high risk for transmission of infection is inadequate with a mean average of 3 or less out of 5 (baseline) pre-reflection. In particular, compliance was very low with hand hygiene guidelines, labeling the infected patients' notes clearly with an identifiable warning sign, wear a gown when required, eye protection, mouth and nose protection, disposal of potentially contaminated materials, refrain from eating or drinking when there is a possibility of contamination, fill in an "Incident Report" following exposure to used needle stick or sharps object injury, remind the work group of standard precautions. Due to few published studies on nursing students at the international level, it was not possible to make comparisons. However, comparisons with baseline compliance of other healthcare workers' results indicated that the healthcare workers compliance with the mentioned standard precautions was 50% or less.¹⁹

Although the effect of nursing students own reflection facilitates their overall compliance with standard precaution as revealed by this study results. In the post reflection phase (2wks post-reflection), compliance rates means were higher than the baseline phase (pre-reflection) with all of the standard precautions (P<0.001). The participants sustained compliance rate with standard precautions at the follow up phase 14 wks after the post reflection phase was still significantly higher than the baseline phase (P< 0.001). However some results merited concern. An example is the participants compliance with hand hygiene guidelines, wear a gown when required, eye protection, fill in an "Incident Report" following exposure to used needle stick or sharps object injury and remind the work group of standard precautions significantly declined in the follow up phase, after it had significantly increased (P<0.001) in the post –reflection phase. These findings support previous studies results as the findings of Schlonka 2006.²⁰

Findings of this study can potentially provide valuable initial evidence about issues related to nursing students’ compliance with standard precautions.

The outcomes of this study provide evidence that the nursing students own reflection facilitates their compliance with standard precautions, so reflection as a learning strategy helped nursing students learn from their own experiences and improve their own practice. Taking into account that compliance with standard precautions minimizes the risk of hospital infection, a collaborative effort including the academics and hospital administrators to implement a multidisciplinary hospital based programs coupled with periodic practice audits and performance feedback is needed to increase compliance with standard precautions and reduce the hospital infection rate. At the end, faculty members in nursing college need to consider way in which they might contribute to affect positive evidence based change in clinical settings.

ACKNOWLEDGEMENTS:

The authors would like to thank all the students participated in this study as well as Rajaa Momani for her help in statistical consultation analysis

REFERENCES:

1. Kampf G and, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clinical Microbiology Review 17; 2004:863-893.

2. SJ, Smith V et al.. Where do hands go? An audit of sequential hand-touch events on a hospital ward. Journal of Hospital Infection 80; 2012:206-211

3. Gould D et al. The Clean Your Hands Campaign: critiquing policy and evidence base. Journal of Hospital Infection 65; 2007:95-101.

4. Januel JM et al. Estimating attributable mortality due to nosocomial infections acquired in intensive care units. Infection Control of Hospita Epidemiology 31; 2010:388–394

5. Dancer SJ. The role of environmental cleaning in the control of hospital-acquired infection. Journal of Hospital Infection 73; 2009: 378-385.

6. Denise M. Cardo, David and M. Bell Bloodborne pathogen transmission in health care workers. Infectious Diseases of Clinical North America 11; 1997: (2) 331-346

7. Doebbeling BN . et al. Percutaneous Injury, Blood Exposure, and Adherence to Standard Precautions: Are Hospital-Based Health Care Providers Still at Risk?. Journal of Clinical Infectious Diseases 37; 2003:1006 – 1013.

8. Haynes RB, Sackett DL and Taylor DW. Compliance in health care .John Hopkins University Press, Baltimore; 1979.

9. Luo Y et al. Factors impacting compliance with standard precautions in nursing, China. International Journal of Infectious Diseases 14 (12); 2010: 1106-14.

10. Daniel JM. et al. Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination. Critical Care Medicine. 40(4); 2012: 1045–1051.

11. Mikkelsen J, Reime MH and Harris AK. Nursing students' learning of managing cross-infections — scenario-based simulation training versus study groups. Nursing Education Today 27; 2007:664–671.

12. Reime MH et al. The most successful method in teaching nursing students infection control—e learning or lecture? Nursing Education Today 28; 2008: 798–806.

13. Wu CJ, Gardner G and Chang AM. Taiwanese nursing students' knowledge, application and confidence with standard and additional precautions in infection control. Journal of Clinical Nursing 18; 2009: 1105–1112.

14. Oelofsen N. Using reflective practice in frontline nursing Nursing Times. 108; 2012: (24):22-4.

15. Hargreaves J. So how do you feel about that? Assessing reflective practice. Nursing Education Today 24; 2004: 196-201.

16. Karen M, Jill G and Anna M. Reﬂection and reﬂective practice in health professions education: a systematic review Advances in Health Science Education 14; 2009:595–621

17. Paul B and Catherine M. Learning by reflection: the effect on educational outcomes. Journal of Advanced Nursing 27; 1998: 1030-1033.

18. Beers GW and Bowden S. The effect of teaching method on long-term knowledge retention. Journal of Nursing Education 44; 2005: 511–514.

19. Sadoh WE et al. Practice of universal precautions among healthcare workers. Journal of National Medical Association 98; 2006:722-726.

20. Schlonka RL et al. Sustained reductions in neonatal nosocomial infection rates following a comprehensive infection control intervention. Journal of Perinatology 26; 2006: 176–179.

Received on 05.06.2013 Modified on 05.08.2013

Asian J. Nur. Edu. and Research 3(4): Oct.- Dec., 2013; Page 248-253