Clinical Experiences of Standard Precautions Among Nursing Students: Based on the Theory of Planned Behaviour

Purpose: Healthcare associated infections (HAIs) are a concern for healthcare workers (HCWs) as well as their patients. In addition, nursing students in long-term clinical placements may find themselves in close contact with patients and providing nursing interventions, which may lead to exposure to harmful pathogens. Even though nursing students should also practice SP compliance to limit infection exposure, they are thought to experience other barriers to this practice. Several studies focused on increasing the compliance rates of infection control practice by applying behavioral science theory have been conducted.^1,2,3 The Theory of Planned Behavior (TPB), developed by Icek Ajzen is widely used as a theoretical framework in behavioral studies and has successfully explained a variety of human behaviors and their determinants.⁴ Few studies have used TPB to explore SP compliance as a major concept of infection control for nursing students. The purpose of study is to explore clinical experiences of Standard Precaution compliance, using the Theory of Planned Behaviour among nursing students in clinical practice settings in South Korea. 

Methods: We conducted interviews with 6 focus groups of nursing students from two South Korean universities. A total of 38 senior nursing students were broken into 6 different focus groups and interviewed. All students had finished one year of clinical experience in tertiary hospitals in South Korea. The focus groups were all homogenous with respect to grade and clinical settings experience. The research team created a structured interview guide for this study and utilized the theoretical frameworks of TPB to guide the focus group interviews. Thematic content analysis was used to code and analyze the data from the focus group interviews. 

Results:

Attitudes Knowledge deficit Most of the students in the study did not know the exact concept of SP or had confused SP with general infection control practice. Students had heard the term but did not know the specific definition and measures of SP. Sensitivity Although participants had a vague understanding about SP concepts, they were aware of the risk of being exposed to specific pathogens during clinical practices. Their experience was limited to a cognitive understanding as opposed to practical demonstration.
Subjective norm Negative role models Most students shared negative SP experiences from their clinical placements. Participants discussed various situations and events related to noncompliance, including poor hand hygiene, the non-use of personal protective equipment (PPE), and needle recapping situations. Gap between classrooms and fields Participants reported that practices they experienced in clinical settings were quite different from what they had learned in classrooms. Students shared the difficulties of SP compliance in daily basic nursing care activities. Blind spots Some clinical organizations monitored the nursing students’ nursing care activities and gave close attention to the SP compliance. However, most settings did not monitor SP compliance or educate nursing students in SP compliance. Perceived behavioural control Psychological barriers Study participants experienced a variety of psychological barriers such as worry about patient discomfort, their own immaturity and fear, being emotionally uncomfortable, and feeling overwhelmed by tasks. Most participants shared that their SP compliance training while in clinical rotation was limited to following the lead of their nursing supervisors. Nursing students complained about the difficulties of SP compliance when they were with nurses with poor compliance behaviours. Busyness was also another barrier that interfered with SP compliance for students. Physiological barriers Study participants experienced various physical limitations as well as psychological barriers to SP compliance during their clinical training. They complained of difficulties due to limited availability of PPE and accessibility to the equipment. Lack of information Nursing students expressed that a lack of patient information and accessibility to it was another barrier in SP compliance. They had limited information and understanding of patient situations. Participants reported the lack of systematic education and management for students about SP compliance and guidelines in hospitals. Some students shared their experiences with blood and body fluid exposure in practice, but the post-exposure procedures were not performed properly.
Intention Changes in compliance awareness Most participants learned and recognized the importance of SP compliance in schools, but they discussed a cognitive change to an understanding of ’do not need to keep’ when they observed noncompliance of guidelines by HCWs.

Conclusion:

This study explored nursing students’ experiences with SP compliance as a method to avoid occupational exposure to microorganisms within clinical settings. Using the TPB as its theoretical framework, this study has closely focused on the students’ explanations of SP compliance in their clinical rotations. To our knowledge, this is the first study exploring the issues surrounding SP compliance for nursing students at their clinical sites. Interestingly enough, this study found that the general vulnerability of nursing students at their clinical sites and their reliance on mentors for information and guidance led to strikingly different compliance experiences than those reported by HCWs.

Participants reported confusion about the concept of SP and general infection control. Aware that they are at risk for pathogen exposure in clinical practice, students did not have a strong understanding of protection as a core concept of SP. The fact that students are aware of the risk of exposure to pathogens but less familiar with the SP guidelines means that students do not know what to do to protect themselves from the risk of exposure. Nursing students’ experiences of SP compliance are quite different from those of nurses due to their relatively lowly status within the information hierarchy. Students are not able to control resources and barriers during their clinical rotations. In particular, they experienced the absence of subjective norms and the presence of various barriers that need to be removed.

Interestingly, most participants witnessed nurses’ noncompliance in the general ward. Participants said that some nurses admitted their noncompliance and then explained what they should follow as guidelines to the students. Others were not even aware of their noncompliance behaviours. These situations imply that students are in inappropriate or negative educational situations. Nurses’ SP noncompliance models poor practices to students and seriously and directly affects changes in compliance awareness and noncompliance behaviours.

The important cultural characteristic that emerged is that nursing students are aware of ’cues’ from their clinical preceptors regarding SP compliance. The students discussed the ambiguous position of a student nurse within the clinical practice hierarchies and how this led to limited access to patient information and standardized nursing practices. This lowly position also discouraged the students from proactively seeking information around SP compliance; instead, they were expected to simply do as their work superiors did, without question. Disturbingly, following supervisors' non-compliance behaviours was given as the main reason students did not comply with SP. Above all, students perceived their positions as socially indefinite, being not nurse nor student, making it difficult to independently comply with SP during their clinical training.

Furthermore, students experienced limited PPE accessibility. For SP compliance, students should have free access to protective devices and no limitation on their usage. While nurses have limited access because of a supply deficiency, ¹ nursing students’ PPE accessibility is related to a lack of knowledge about PPE location and the perceived indifference nurses have to their charges’ education. Participating students were left in the nursing staff’s blind spot and did not receive proper care and education during clinical training. Therefore, in order to increase the SP compliance of students, detailed and direct education about SP guidelines should be preceded. 

Nursing students are the nurses of the future, so compliance education and an intention to follow compliance in a student are directly related to a nurse’s commitment to compliance. This cognitive change could influence their future SP compliance once they become nurses. Therefore, exploring the factors affecting SP compliance for nurses in charge of student education is needed. In addition, faculty should develop continuing education programs in schools that include discussion on SP compliance, infection control guidelines, and noncompliance cases, then reinforce SP compliance education before clinical placements begin. These focus groups revealed that many nursing student were in vulnerable environments and risked exposure to pathogens. By removing the barriers presented in this study, nursing students would be able to do clinical practice in a safe environment.