REVIEW

Knowledge of nursing students about infection prevention and control: a scoping review

Mafalda Sofia Gomes Oliveira da Silva1,2, Maria Margarida Silva Vieira Ferreira1

1Instituto Piaget de Vila Nova de Gaia, Gulpilhares, Vila Nova de Gaia, Portugal

2Universidade Católica Portuguesa, Porto, Portugal

ABSTRACT

Objective: To assess the knowledge of nursing students regarding the prevention and control of healthcare-associated infections. Method: A scoping review was conducted using the methods set forth by Joanna Briggs Institute (JBI). The following databases were searched: PubMed, CINAHL Plus with Full Text, Nursing & Allied Health Collection, Cochrane Plus Collection, and MedicLatina (via EBSCOhost). Inclusion criteria were studies written in Portuguese, English, or Spanish and published in the last 5 years. The studies were extracted to the Qatar Computing Research Institute platform (Rayyan QCRI). Results: We identified 11 studies that demonstrated the need to involve facilitators in the teaching/learning process to raise awareness of training strategies for the prevention and control of healthcare-associated infections. Conclusion: Structured programs that include training and skill development for students need to be implemented.

Descriptors: Students, Nursing; Universal Precautions; Infection Control.

INTRODUCTION

Over the past few decades, patient safety concerns have grown exponentially due to the high number of adverse events that occur in healthcare facilities.

According to the World Health Organization (WHO)(1), 134 million adverse events occur annually as a result of unsafe care, contributing to 2.6 million deaths.

Patient safety has become a critical issue nationally, in Europe, and globally in recent decades because of inadequate working conditions, patient complexity, staff turnover and retention, technological advances, and increased patient and family literacy (PNSD).

Patient safety is an essential component and an indispensable variable of quality in health care delivery and is becoming the focus of health policies. Health policies include a set of appropriate patient-centered strategies and interventions to prevent and/or reduce inherent risks to a reasonable minimum. Thus, understanding the severity of harm caused to patients becomes essential and relies on a transparent system of incident reporting that allows healthcare workers to learn from the errors committed(2).

According to the Joint Commission International(3), the six international patient safety goals are: to correctly identify patients; to improve the effectiveness of communication; to improve the safety of high-risk medications; to ensure the right surgery and the right patient; to reduce the risk of healthcare-associated infections (HCAIs); and to reduce the risk of patient harm from falls. Similarly, in the 2021–2026 Brazilian National Patient Safety Plan (PNSD), some of its pillars emphasize the importance of a safety culture, effective communication, and the prevention and management of safety incidents to promote safe and quality health care.

Globally, Universal Precautions (UP) have been defined and implemented to reduce the risk of transmission of infectious microorganisms during the delivery of care by adopting preventive and infection control measures in health care services(4) to limit the spread of HCAIs(2). These guidelines have been adopted by Portugal and are known as Transmission-Based Precautions (TBPs)(5). TBPs are a set of procedures to be implemented in healthcare settings to prevent cross-transmission of multidrug-resistant microorganisms from known or unknown sources. They include the implementation of intervention bundles, standard operating procedures, the adoption of a culture of safety, training, and awareness of workers, and the monitoring of safe practices (PNSD).

TBPs contribute to the safety of the patient, the healthcare workers, and all those who come into contact with the patient as well as to the reduction of hospital stays and the minimization of morbidity and mortality(6).

Increasing the level of health literacy and the involvement of various healthcare facilitators is essential to prevent HCAIs and protect patients, healthcare workers, and families from exposure to infectious agents(4). Investment in the education of first-cycle nursing students as future healthcare workers is necessary(4). A study conducted to identify the psychoemotional impact and strategies used by nursing students during the COVID-19 pandemic demonstrates the need to expand knowledge of health promotion and infection prevention(7).

The present study aims to determine the knowledge of nursing students regarding the prevention and control of HCAIs. Based on the Participants/Population, Context, and Concept (PCC) framework (Figure 1), the following guiding review question was formulated: “What knowledge do nursing students have regarding universal precautions in the control of healthcare-associated infections?”.

Figure 1 – PCC framework. Porto, PT, Portugal, 2024.

METHOD

Type of study

The present scoping review has been conducted following the nine steps proposed by the Joanna Briggs Institute (JBI)(8): 1) title, 2) development of title and guiding question, 3) introduction, 4) inclusion criteria, 5) search strategy, 6) selection of evidence sources, 7) data extraction, 8) analysis of evidence, and 9) presentation of results. This type of study allows the implicit evidence for the topic under review to be mapped and gaps to be identified(9).

Protocol and registry

To ensure methodological rigor in the development of the study, we used the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR)(10). The protocol for this scoping review has been registered on the Open Science Framework (OSF) under DOI 10.17605/OSF.IO/59GAV and can be accessed via the link: https://osf.io/59gav/.

Eligibility criteria

The scoping review strategy is based on an exploratory review to understand the state of the art in a given context and to identify gaps in existing studies(4).

The inclusion criteria were studies published in the last five years (2017–2022), without design limitations, that addressed nursing students from any country and higher education institution. We decided that searching for studies published in the last five years was the most appropriate approach, due to the significant amount of existing primary information. It was also important to include the most recent studies as they reflect the current state of the art. Scoping reviews play an important role in bridging the gap between research findings and evidence-based health decision-making. To be reliable, these reviews must use reliable methods and include all the results of relevant research(11).

Reference lists of the literature were reviewed to identify additional studies. The search was conducted by two independent researchers in Portuguese, English, and Spanish, which were available in free full text.

Sources of information

The search was conducted in March 2022 in the following databases: PubMed, CINAHL Plus with Full Text, Nursing & Allied Health Collection, Cochrane Plus Collection, and MedicLatina (via EBSCOhost). No scoping review evidence was found on this topic. Keywords in English, Spanish, and Portuguese were used to search for information, as shown in Figure 2.

Figure 2 – Keywords used in the searches. Porto, PT, Portugal, 2024

Search strategy

Keywords extracted from the Descriptors in Health Sciences (DeCS) and the Medical Subject Headings (MeSH) were used. The Boolean operators 'AND' and 'OR' were used for combinations between descriptors, with “AND” used to find studies across topics and 'OR' used for synonyms(9) (Figure 3).

Figura 3 – Keywords used in database searches. Porto, PT, Portugal, 2024

Study selection

The articles identified according to the eligibility criteria were organized on the platform of the Qatar Computing Research Institute (Rayyan QCRI®). The titles and abstracts were then read, followed by a full-text reading of the identified studies. The search results were written according to the PRISMA-ScR(10) flowchart (Figure 4) and the predefined inclusion and exclusion criteria.

Source: PRISMA Flow Diagram adapted of Page et al., 2020.

Figure 4 - Flowchart of the study selection process. Porto, PT, Portugal, 2024

Data extraction

To facilitate data extraction, the researchers created an evidence table consisting of the following items: title, study type, and design, author(s)/year, objectives, population studied, context, and main results (Figure 5). Data were extracted and analyzed independently by two review authors, with a third review author in case of disagreement to decide on the inclusion or exclusion of the article.

RESULTS

A total of 91 articles were found in the PubMed database and 41 articles in EBSCO, of which 11 articles were included according to the defined criteria. Most of these studies were quantitative, cross-sectional, and descriptive (54.5%), quasi-experimental (36.4%), and qualitative (9.1%) (Figure 5). The study population ranged from 7 to 829, for a total of 1,772 nursing students. The studies demonstrate the need for students/teachers and tutors’ involvement in raising awareness of teaching/training strategies in the prevention and control of HCAIs (Figure 6).

Figure 5 - Data extraction table for the scoping review. Porto, PT, Portugal, 2024

Figure 6 - Knowledge of nursing students regarding universal precautions in infection control. Porto, PT, Portugal, 2024

DISCUSSION

The knowledge of nursing students regarding infection prevention and control is an area that has been minimally studied. Nursing students in clinical training provide care to a wide variety of patients and interact with healthcare workers and educators, playing a critical role in the spread of pathogenic microorganisms(23-24).

With technological changes and scientific advancements, the responsibilities of healthcare workers and students in complex healthcare settings are increasing, as they are a vulnerable group in terms of exposure to microorganisms (19).

Throughout clinical training, students are expected to demonstrate knowledge and skills in several areas, particularly infection control. However, studies(25-26) have shown low levels of knowledge and inconsistency or even failure to adopt behaviors by national and international guidelines.

Integrating the teaching of best practices in infection prevention and control into the educational process of students is of great importance. In this regard, there is a need to invest in HCAIs prevention and control in a structured, coordinated manner, aligning the content taught, innovative resources, pedagogical approaches, and coordination between faculty and tutors(25,27).

It is the responsibility of the instructor to guide and correct the student in the proper use of preventive measures, integrating clinical infection control practice with classroom knowledge. The tutor should be a facilitator in the student’s learning process, demonstrating up-to-date knowledge, interest, and availability to supervise and guide.

The integration of continuous peer mentoring programs in nursing education focused on students, with workshops and seminars, should be included in study plans to promote critical-reflective thinking and the promotion of autonomy and responsibility of future workers(12). Mentoring programs are a strategy that allows students to improve their learning and academic performance by improving the development of skills, namely teamwork, interpersonal relationships, motivation, and personal and professional development(28).

The studies that have been conducted suggest that student nurses’ adherence to TBPs is low, with limited knowledge of more specific aspects such as the origin of the microorganisms that cause these infections or the proper use of gloves. However, they do demonstrate a general knowledge of HCAIs(12,16).

Another study alludes to the importance of examining adherence to TBPs and identifying their predictors among students, reporting that they have higher adherence to using personal protective equipment, memorizing the proper use of sharps containers, protective eyewear, and recapping needles(17).

In this context, there is a need to implement continuous education programs to improve students' knowledge to adopt best practices in health care(12-13). It is necessary to evaluate the effectiveness of structured training programs to improve adherence to infection control practices, as shown in the study conducted(14). To ensure patient safety and the safety of future healthcare workers, students must be active agents of change in healthcare delivery. To this end, the World Health Organization has advocated the inclusion of formal infection prevention and control content in higher education curricula(30).

Improvement in student behavior and personal motivation tends to increase when learning combines different methods, including theoretical-practical classes, laboratory sessions, and simulation scenarios, which are essential pedagogical strategies for increasing student self-efficacy and awareness in infection prevention and control(28). Students have the opportunity to develop technical procedures in a collaborative learning environment, which helps them gradually gain confidence and facilitates the development of practical and communication skills(28).

During the COVID-19 pandemic, the need for courses aimed at the knowledge and attitudes of nursing students in infection prevention and control became more pronounced. At this stage, the learning environment influenced by the pandemic changed, with the integration of new nursing teaching methodologies emphasizing a virtual model, creating new challenges and opportunities for students' skill development(24-25,30).

The study conducted(12) points to the need to improve educational programs for healthcare workers, particularly in educational institutions and workplaces.

The contributions of this study relate to nursing students' knowledge of preventive and infection control measures. Further studies are needed to assess nursing students' attitudes, implementation, and compliance with preventive infection control measures. In this sense, the implementation of structured, systematic educational programs that include skills training is essential for the safety of the patient, the student, and all those involved in the delivery of care. To do so, close coordination between health care and higher education institutions, as well as between schools, students, and preceptors, is required.

Limitations of the study

The main limitation of the present study relates to the small number of studies available on the topic under review.

CONCLUSION

This study allowed for the analysis and systematization of the knowledge of nursing students regarding prevention and infection control measures in health care and reinforced the role of peer tutoring in clinical settings. To provide safer health care, it is necessary to adopt innovative, student-centered teaching and learning methods that emphasize the acquisition of theoretical knowledge through continuous education and the practice of practical skills in the context of TBPs.

Throughout the learning process, coordination between schools and healthcare institutions, as well as between faculty and tutors, is essential to promote the acquisition of knowledge, motivation, and self-efficacy for infection prevention and control among nursing students. Further studies in this area are inevitable and will contribute to the provision of quality health care in supportive working environments.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 16-Nov-2022

Approved: 22-Feb-2024