Clinical Simulation in Nursing (2014) 10, 395-405

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Featured Article

Development and Evaluation of anInterprofessional Simulation-Based LearningModule on Infection Control Skills for PrelicensureHealth Professional Students

Marian Luctkar-Flude, RN, MScN, PhD(c)a,*, Cynthia Baker, RN, PhDb,Diana Hopkins-Rosseel, DEC, BSc (PT), MSc (Rehab Sci)c, Cheryl Pulling, RN, MSNd,Robert McGraw, BSc, MD, MEd, FRCPCe, Jennifer Medves, RN, PhDf,Ana Krause, RN, BScNg, Cecilia A. Brown, RN, BScNh

aLecturer, School of Nursing, Queen’s University, Kingston, Ontario K7L 3N6, CanadabExecutive Director, Canadian Association of Schools of Nursing, Ottawa, Ontario K1V 0Y3, CanadacProfessor, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario K7L 3N6, CanadadAssociate Professor, School of Nursing, Queen’s University, Kingston, Ontario K7L 3N6, CanadaeAssociate Professor, Department of Emergency Medicine, Queen’s University, Kingston, Ontario K7L 3N6, CanadafDirector, School of Nursing, Queen’s University, Kingston, Ontario K7L 3N6, CanadagEmergency Department, Kingston General Hospital, Kingston, Ontario K7L 2V7, CanadahResearch Assistant, School of Nursing, Queen’s University, Kingston, Ontario K7L 3N6, Canada

KEYWORDSinterprofessionaleducation;

infection control;simulation;nursing students;medical students;physiotherapy students;critical care

pport: Ontario Ministry

tario Ministry of Health

ucation Innovation Fun

ng author: mfl1@queens

e front matter � 2014 Int

/10.1016/j.ecns.2014.03.

AbstractIntroduction: Poor adherence to infection control standards among health care professionals is wide-spread, putting patients at substantial risk. Basic infection control skills are typically learned unipro-fessionally outside the clinical environment. In real clinical settings, the cognitive load associatedwith simultaneously managing challenging clinical problems as part of an interprofessional team com-pounds difficulties in applying infection control standards. This mixed methods study evaluated aninterprofessional education infection control module as part of a larger action research project aimedat developing interprofessional health education using simulation.Methods: Students from medicine, nursing, and physiotherapy (N ¼ 24) participated in a pilot infec-tion control simulation. Participants completed a survey regarding confidence performing infectioncontrol skills, perceptions of interprofessional communication and collaboration, and satisfaction withthe module. Qualitative feedback was obtained from facilitators and participants.Results: Participants reported confidence with all skills except enhanced precautions and found theinterprofessional simulation-based training valuable. Observers identified instances where infectioncontrol practices were not appropriately followed within the clinical context but noted strong team-work and collaboration amongst team members. Several barriers to learning were identified. The ma-jority of participants indicated that the interprofessional infection control module should be

of Training, Colleges and Univer-

and Long-Term Care Interprofes-

d.

u.ca (M. Luctkar-Flude).

ernational Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

003

Key Points� High levels of self-reported learner con-fidence in infectioncontrol skills did nottranslate into highlevels of performancewithin the complexpatient care scenarios.

� Senior health profes-sional students needopportunities to prac-tice infection controlskills within the con-text of complex patientcare situations.

� It is feasible to im-plement a complex,simulation-based IPEmodule to reinforceboth interprofessionalcommunication andteamwork and infec-tion control skills.

Interprofessional Infection Control Module 396

mandatory for health sciences students. Qualitative analysis revealed recommendations on ways tomake this type of session more effective.Conclusions: This pilot project demonstrated the feasibility of using high-fidelity patient simulationto reinforce infection control skills and promote interprofessional communication and teamwork. Studyresults support the need for senior health professional students to learn and practice infection controlskills in an interprofessional manner and to incorporate complex clinical scenarios in the training.

Cite this article:Luctkar-Flude, M., Baker, C., Hopkins-Rosseel, D., Pulling, C., McGraw, R., Medves, J., Krause, A., &Brown, C. A. (2014, August). Development and evaluation of an interprofessional simulation-basedlearning module on infection control skills for prelicensure health professional students. Clinical Simu-lation in Nursing, 10(8), 395-405. http://dx.doi.org/10.1016/j.ecns.2014.03.003.

� 2014 International Nursing Association for Clinical Simulation and Learning. Published by ElsevierInc. All rights reserved.

Prevention of hospital-acquired infections is criticalto patient safety and the re-sponsibility of all healthcare professionals. As preli-censure students prepare totransition to professionalpractice, it is unclear howprepared they are to imple-ment basic infection controlprinciples and practices theyhave learned within realclinical environments andparticularly within complexacute/critical care settings.Although infection controlprinciples and skillsmayhavebeenmastered, applying themappropriately in the contextof multiple clinical demandscan be difficult for even expe-rienced health care profes-sionals. Effective infectioncontrol, however, depends

on every member of the interprofessional team scrupulouslyimplementing the standards while simultaneously respondingto complex clinical problems. Moreover, infection controlskills include the ability to communicate the need to applythe standards to any member of the interprofessional teamwho fails to do so regardless of their respective positions inthe institutional hierarchy. High-fidelity patient simulation isincreasingly being used within educational and clinicalsettings to enhance interprofessional teamwork and patientsafety (Berndt, 2014; Brock et al., 2013; Patterson, Geis,LeMaster, & Wears, 2013). It offers prelicensure health pro-fessionals opportunities to apply specific knowledge andskills being learned to a dynamic, complex, and team-based clinical context.

pp 395-

Background

Poor infection control continues to plague health caredespite major efforts to decrease microbial transmission(Institute of Medicine, 2000). Reports indicate that 5% to10% of hospitalized patients contract one or more infec-tions, which are responsible for lengthened admissionsand increased mortality rates. An estimated 220,000hospital-acquired infections occur in Canadian hospitalseach year, resulting in over 8000 deaths and rates continueto rise (Zoutman et al., 2003), adding an estimated$1 billion annually in direct costs to the Canadian healthcare system (Van Iersel.A., 2007). Estimates of direct med-ical costs to US hospitals range from $28.4 to $45 billion(Scott, 2009). Hand hygiene, by hand washing or alcohol-based hand rubs, is universally considered to be the founda-tion of infection prevention and control (Public HealthAgency of Canada, 2010). Despite increased education,health care worker compliance with hand hygiene is verylow worldwide. Compliance rates in hospital settingshave ranged between 16% and 81% (Pittet, 2001).

Prelicensure students are often exposed to poor infectioncontrol practices early on in clinical training, which hasbeen shown to impact their future practice (Ward, 2010; Ott& French, 2009). Similar to practicing clinicians, prelicen-sure students often overestimate their own compliance withbasic infection control practices (Cole, 2009; Snow, White,Jr., Alder, & Stanford, 2006). This subconscious misjudg-ment of skills is more resistant to behavioral change, add-ing an additional challenge to improving infection controlpractices amongst health care workers (Trunnell & White,Jr., 2005).

Interprofessional education (IPE) informs learners aboutroles of other health professionals and key behaviorsessential for optimal health care team functioning (Cook,2005). High-fidelity clinical simulation has been found tobe an effective method for enhancing clinical knowledge,skills, and team approaches to managing complex care

405 � Clinical Simulation in Nursing � Volume 10 � Issue 8

Interprofessional Infection Control Module 397

amongst prelicensure health professional students (Bakeret al., 2012; Luctkar-Flude et al., 2013; Luctkar-Fludeet al., 2010; Titzer, Swenty, & Hoehn, 2012). Team traininghas been proposed as a strategy to reduce medical errorsand improve patient safety (Institute of Medicine, 2000),and a growing body of evidence supports use of simulationto foster improved collaboration amongst health profes-sionals and students, which ultimately contributes toimproved patient care (Dillon, Noble, & Kaplan, 2009;King, Conrad, & Ahmed, 2013).

The key strategy to improve infection control amongstfuture practitioners has been to educate students unipro-fessionally to develop appropriate infection control practicesearly on in their clinical practice and then to reinforce theseskills throughout their schooling (Swallow & Coates, 2004).However, undergraduate education often places significantemphasis on theoretical components of infection controlsuch as hand hygiene rather than the application of it inclinical areas (Kennedy & Burnett, 2011). A recent studyof infection control practices amongst nursing and medicalstudents demonstrated that routine interprofessional infectioncontrol training is needed (Wagner, Parker, Mavis, & Smith,2011). There is currently no evidence evaluating healthsciences students’ adherence to infection control standardsfollowing high-fidelity interprofessional simulation, a novelapproach to educating prelicensure students.

Studies show that dynamic and contextualized appli-cation of knowledge and skill in high-fidelity simulationenhances students’ abilities to integrate and mobilizecompetencies in clinical settings. Nursing students whocompleted 2 weeks of simulation training in lieu oftraditional training later rated consistently better inclinical settings than colleagues who only receivedclinical training (Meyer, Connors, Hou, & Gajewski,2011). Simulation also boosts self-confidence, allowingstudents to acquire clinical skills in a risk-free environ-ment while learning from potentially harmful errorswithout negative consequences to real patients (Jenkins,Blake, Brandy-Webb, & Ashe, 2011).

High-fidelity interprofessional simulation ensures alllearners receive the same level of infection control educa-tion while observing each other’s practices. Practice in thesimulation laboratory may provide students with greaterawareness of potential sources of contamination, preventa-tive practices, and potential complications. Simulationallows students to develop clinical decision making throughrole-playing and reacting to critical decisions, which mayhelp learners’ transition from student to health care pro-fessional roles (Guhde, 2011).

The aim of this project was to pilot an IPE moduleto teach and evaluate senior prelicensure medical, nursing,and physiotherapy students infection control competenciesin a simulated complex health care environment. Thisfourth and final module of an IPE simulation pilot projectintegrated clinical skills learned in previous modulesincluding suctioning and cardiac resuscitation.

pp 395-

Research objectives consisted of evaluating (a) the needfor learners to practice infection control in a simulatedcomplex health care environment through assessmentof learner performance during the scenario, (b) the modulein terms of learner confidence with infection control skills,perceptions of interprofessional teamwork and collaboration,and satisfaction with the module, and (c) the feasibility ofimplementing such a complex interprofessional simulationscenario within the curricula of three health professions.

Methods

Sample

A convenience sample of 24 students participated volun-tarily in the infection control simulation (nine nursing,seven medical, and eight physiotherapy students). Learnersparticipated in interprofessional teams during the 2½-hourlaboratory.

Design

This mixed-methods study evaluated one component of alarger action research project to develop IPE modulesthrough patient simulation. Congruent with action research,the evaluation is designed to develop knowledge to modifyand improve an innovation as it is implemented (Kemmis &McTaggert, 1990).

A simulation involving three high-fidelity patients in acomplex health care context was offered to senior pre-licensure health sciences students. Three profession-specific instructors facilitated the simulation. Two expertobservers, including an infection control practitioner (ICP)and research associate, were also present.

Although all students had previously been taughtinfection control in their respective programs, participantsviewed a short video on standard infection control practicesreviewing hand hygiene and wearing personal protectiveequipment (PPE) when caring for patients with variousisolation precautions. A prescenario briefing and roleassignments (e.g. primary nurse, charge nurse) followed.Student teams were responsible for care of three ‘‘patients’’with differing infection control precautions in a simulatedintensive care unit: (a) a ventilated patient with acuterespiratory distress syndrome, under routine precautions,requiring suctioning; (b) a patient with cocaine overdoseprogressing to cardiac arrest, requiring airborne precautionsdue to a positive tuberculosis test; and (c) a patient withmeningitis requiring droplet precautions. It is not uncom-mon for health care teams to be required to adapt tochanges in routine patient care in critical care environ-ments. Participants were therefore presented with a varietyof obstacles requiring problem solving and critical thinking,including a lack of appropriate resources, equipmentfailures, a cardiac arrest, and visiting family members.

405 � Clinical Simulation in Nursing � Volume 10 � Issue 8

Table 1 Participant Demographics

CharacteristicsNursing Students,N ¼ 9

PhysiotherapyStudents, N ¼ 8

Medical Students,N ¼ 7

ANOVA

F (df) Significance

Age, mean (SD) 21.4 (0.7) 25.1 (2.4) 26 (2.5) 12.25 (2, 21) 0.001Number of previous IP sessions 4.5 1.4 3 8.04 (2, 21) 0.003Number of previous IP simulations 4 1 1.6 5.17 (2, 20) 0.015

Nursing Students,N ¼ 9

PhysiotherapyStudents, N ¼ 8

Medical Students,N ¼ 7

Chi-Square(df)

Significance

Sex, frequencies 4.86 (2) 0.088Female 9 5 4Male 0 3 3

Note. ANOVA ¼ analysis of variance; df ¼ degrees of freedom; SD ¼ standard deviation.

Bold values indicates statistical significance.

Interprofessional Infection Control Module 398

Twelve students participated in the 25-minute scenariosas clinicians. The remaining 12 students were asked toobserve participant performance of infection control skillsand interprofessional teamwork and collaboration. A sec-ond round of scenarios followed with teams switching rolesof clinicians and observers. As participants in the secondgroup may have benefited from viewing the first group, newproblems were introduced which required further collabo-ration and critical thinking. Faculty and observers invitedreflection and offered feedback during a final semi-structured debriefing session. Following the debriefinglearners completed a written survey and participated in afocus group led by the research assistant.

Instruments

Communication and TeamworkThe Communication and Teamwork Scale of the Universityof the West of England, Bristol Entry Level Interprofes-sional Questionnaire (Pollard, Miers, & Gilchrest, 2004)was used to evaluate self-perceptions of teamwork andcommunication skills. The 9-item, 6-point Likert scaledisplayed good internal consistency (Cronbach’salpha ¼ 0.793).

Confidence Performing Infection Control SkillsA 7-item, 6-point Likert scale was developed to measurelearner confidence performing infection control skills.Internal consistency was very good (Cronbach’salpha ¼ 0.901). Content validity was established throughpeer review by instructors teaching in the course.

Satisfaction with IPE ModuleA 6-item, 6-point Likert scale was developed to measurelearner satisfaction with the interprofessional module.Internal consistency was very good (Cronbach’salpha ¼ 0.890). Content validity was established throughpeer review by instructors teaching in the course.

pp 395-

Observer FeedbackFaculty instructors from the three schools, and two expertobservers, provided qualitative feedback for each scenariorelated to infection control practices and teamwork andcollaboration. Observers also commented on participantperformance of embedded clinical skills and the overallflow of the scenarios.

Ethics

The Queen’s University and Affiliated Teaching Hospi-tals Health Sciences Human Research Ethics Boardapproved this study. Informed consent was obtainedfrom participants.

Data Analysis

Quantitative data were entered into an SPSS database andverified by a second person. Standard univariate measuressuch as frequencies, means, and standard deviations werecalculated to describe the outcomes. Group comparisonswere conducted using chi-square test for nominal data,KruskaleWallis test for ordinal data, and one-wayanalysis of variance for scale data along with post hoctests to explore significant results. Qualitative datacollected from the focus group and participant observa-tions were transcribed. Descriptive thematic analysis wasperformed by an experienced research associate and asenior researcher.

Results

Participants

Questionnaires were completed by all 24 participants fora response rate of 100%. There were a larger proportionof female participants (75%) than male (25%), with

405 � Clinical Simulation in Nursing � Volume 10 � Issue 8

Table 2 Participant Survey Scale Scores

Survey Scale

Mean (SD) ANOVA

Nursing Students,N ¼ 9

PhysiotherapyStudents, N ¼ 8

Medical Students,N ¼ 7 F (df) Significance

Interprofessional communication andteamwork (score out of 54)

38.3 (5.6) 40.3 (3.2) 37.8 (2.9) 0.71 (2, 19) 0.505

Confidence with infection control skills(score out of 42)

33.1 (4.0) 27.6 (6.3) 29.3 (2.1) 3.33 (2, 21) 0.055

Satisfaction with IP Infection ControlSimulation Module (score out of 42)

38.3 (2.7) 35.1 (3.4) 30.0 (6.6) 7.15 (2, 21) 0.004

Note. ANOVA ¼ analysis of variance; df ¼ degrees of freedom; SD ¼ standard deviation.

Bold values indicates statistical significance.

Interprofessional Infection Control Module 399

participants’ ages ranging from 21 to 30 (See Table 1).Before the infection control module, all students hadpreviously attended at least one IPE module on otherclinical skills. Nursing students were significantlyyounger than the physiotherapy and medical studentsand reported the most previous experience with bothIPE and simulation.

Interprofessional Communication and Teamwork

Overall students from all three professions reported similarcomfort levels with interprofessional communication andteamwork (Table 2). However, nursing students reportedsignificantly lower confidence levels when presenting per-sonal opinions in a group (Table 3). The majority of stu-dents also reported feeling uncomfortable taking theleadership role in a group.

Confidence with Infection Control Skills

Overall, students from all three professions reportedfeeling confident with hand hygiene, routine practices,contact precautions, and removing PPE (Table 4). Confi-dence ratings were significantly higher amongst nursingstudents for utilizing contact precautions (77.8%),airborne precautions (55.6%), and droplet precautions(66.7%). Only 12.5% of medical students and 14.3% ofphysiotherapy students reported feeling confident utilizingcontact precautions. Similar ratings were given by medicalstudents and physiotherapy students when utilizingairborne precautions at 25% and 14.3% respectively andutilizing droplet precautions at 25% and 28.6% respec-tively. Confidence ratings were notably lower amongstthe entire group for utilizing enhanced precautions, whichinvolve wearing an N95 respirator in addition to a gown,gloves, and eye protection. Medical students reported be-ing the most confident with enhanced precautions with71.4% as ‘‘somewhat confident,’’ indicating that all stu-dents require additional training with the enhancedprecautions.

pp 395-

Satisfaction with Interprofessional InfectionControl Simulation Module

The majority of students reported that they enjoyed the IPEinfection control session and found simulation-basedtraining and interprofessional learning valuable (Table 5).Many ‘‘agreed’’ (41.7%) or ‘‘strongly agreed’’ (16.7%)the session should be mandatory for all prelicensurestudents. Whereas all nursing students agreed, 14.3% ofmedical students ‘‘disagreed strongly’’ and 28.6% ‘‘dis-agreed’’ and 12.5% of physiotherapy students ‘‘somewhatdisagreed.’’ All physiotherapy and nursing students‘‘agreed’’ they had a ‘‘better understanding of health pro-fessional team members roles as a result of the session’’but 42.9% of the medical students ‘‘disagreed.’’ Overall,nursing students were significantly more satisfied with thesessions than medical students (Table 2).

Participant Feedback

Five main themes emerged from the participant feedback:(a) preparation, (b) role clarification, (c) interprofessional(IP) collaboration, (d) realism, and (e) instructor commu-nication. Many students felt unprepared for the voluntarysession because they had ‘‘never experienced this type ofsimulation before’’ and/or ‘‘had not been in this particularlaboratory’’ before which initially ‘‘caused some stress andconfusion.’’ However, students commented positively onthe opportunity to ‘‘get to share each other’s experiencesand strengths.’’ They felt it was ‘‘good to get multipleperspectives’’ and ‘‘helped to see a problem from theireyes.’’ Many students commented on how the ‘‘communi-cation got better as the scenario progressed.’’ Collaborationwas also evident through comments such as ‘‘it wasinteresting to see how no hierarchy was happening betweenprofessions and we were working together’’ and ‘‘anyonecan be the leader and everyone’s opinion is welcomed.’’Participants reported that the realism of the simulations‘‘helped me to apply what we’ve learned and see whatstressful situations do to your precautions’’ and ‘‘made for a

405 � Clinical Simulation in Nursing � Volume 10 � Issue 8

Table 3 Interprofessional Communication and Teamwork Survey (N ¼ 24)

Please Check the Box ThatIndicates the Extentto Which You Agreeor Disagree Withthe Following Statements:

StronglyDisagree Disagree

SomewhatDisagree

SomewhatAgree Agree

StronglyAgree

KruskaleWallis

Chi-Square(df) Significance

I feel comfortable justifyingrecommendations and/oradvice face-to-face withmore senior people.

0 16.7%Nurs ¼ 1PT ¼ 0Med ¼ 3

8.3%Nurs ¼ 0PT ¼ 2Med ¼ 0

25.0%Nurs ¼ 3PT ¼ 1Med ¼ 2

37.5%Nurs ¼ 4PT ¼ 4Med ¼ 1

12.5%Nurs ¼ 1PT ¼ 1Med ¼ 1

1.93 (2) 0.380

I feel comfortableexplaining an issue topeople who are unfamiliarwith the topic.

0 0 4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

29.2%Nurs ¼ 4PT ¼ 1Med ¼ 2

58.3%Nurs ¼ 4PT ¼ 6Med ¼ 4

8.3%Nurs ¼ 1PT ¼ 1Med ¼ 0

2.40 (2) 0.301

I have difficulty in adaptingmy communication styleto particular situationsand audiences.

0 33.3%Nurs ¼ 3PT ¼ 1Med ¼ 4

12.5%Nurs ¼ 1PT ¼ 2Med ¼ 0

20.8%Nurs ¼ 3PT ¼ 1Med ¼ 1

25.0%Nurs ¼ 2PT ¼ 4Med ¼ 0

4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

2.39 (2) 0.303

I prefer to stay quiet whenother people in a groupexpress opinions that I donot agree with.

4.2%Nurs ¼ 1PT ¼ 0Med ¼ 0

25.0%Nurs ¼ 2PT ¼ 2Med ¼ 2

54.2%Nurs ¼ 4PT ¼ 5Med ¼ 4

8.3%Nurs ¼ 0PT ¼ 1Med ¼ 1

0 4.2%Nurs ¼ 1PT ¼ 0Med ¼ 0

0.26 (2) 0.879

I feel comfortable workingin a group.

0 4.2%Nurs ¼ 1PT ¼ 0Med ¼ 0

0 16.7%Nurs ¼ 2PT ¼ 2Med ¼ 0

50.0%Nurs ¼ 3PT ¼ 5Med ¼ 4

29.2%Nurs ¼ 3PT ¼ 1Med ¼ 3

2.31 (2) 0.315

I feel uncomfortableputting forward mypersonal opinions in agroup.

12.5%Nurs ¼ 0PT ¼ 3Med ¼ 0

41.7%Nurs ¼ 3PT ¼ 3Med ¼ 4

4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

20.8%Nurs ¼ 2PT ¼ 2Med ¼ 1

20.8%Nurs ¼ 4PT ¼ 0Med ¼ 1

0 6.27 (2) 0.044

I feel uncomfortable takingthe lead in a group.

4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

37.5%Nurs ¼ 5PT ¼ 2Med ¼ 2

29.2%Nurs ¼ 2PT ¼ 4Med ¼ 1

16.7%Nurs ¼ 1PT ¼ 0Med ¼ 3

8.3%Nurs ¼ 1PT ¼ 0Med ¼ 1

4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

1.70 (2) 0.429

I am able to become quicklyinvolved in new teamsand groups.

0 0 0 25.0%Nurs ¼ 2PT ¼ 2Med ¼ 2

50.0%Nurs ¼ 4PT ¼ 4Med ¼ 4

25.0%Nurs ¼ 3PT ¼ 2Med ¼ 1

0.49 0.784

I am comfortable expressingmy own opinions in agroup, even when I knowthat other people do notagree with them.

0 0 0 58.3%Nurs ¼ 5PT ¼ 4Med ¼ 5

33.3%Nurs ¼ 4PT ¼ 2Med ¼ 2

8.3%Nurs ¼ 0PT ¼ 2Med ¼ 0

1.27 (2) 0.529

Note. df ¼ degrees of freedom; Med ¼ medical students; Nurs ¼ nursing students; PT ¼ physiotherapy students.

Bold values indicates statistical significance.

Interprofessional Infection Control Module 400

realistic situation in which you have to think about multiplethings including infection control.’’ And finally, studentsfelt that it would have been ‘‘more beneficial if theinstructors could have corrected them throughout thescenario, so they could fix the mistakes’’ rather than‘‘debriefing the mistakes that were made collectively.’’

pp 395-

Observer Feedback

An ICP and research associate provided feedback for eachscenario. As part of their learning, study participants weregiven the opportunity to act as observers during a scenario.All observers identified numerous occasions where

405 � Clinical Simulation in Nursing � Volume 10 � Issue 8

Table 4 Confidence With Infection Control Skills Survey (N ¼ 24)

Please Check the BoxThat Indicates the Extentto Which You Agree orDisagree With theFollowing Statements:

VeryUnconfident Unconfident

SomewhatUnconfident

SomewhatConfident Confident

VeryConfident

KruskaleWallis

Chi-Square(df) Significance

Performing hand hygienein the clinical setting.

0 0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

16.7%Nurs ¼ 1PT ¼ 0Med ¼ 3

54.2%Nurs ¼ 5PT ¼ 5Med ¼ 3

25.0%Nurs ¼ 3PT ¼ 2Med ¼ 1

2.02 (2) 0.364

Performing routinepractices when caringfor patients.

0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

8.3%Nurs ¼ 1PT ¼ 1Med ¼ 0

29.2%Nurs ¼ 1PT ¼ 3Med ¼ 3

50.0%Nurs ¼ 6PT ¼ 2Med ¼ 4

8.3%Nurs ¼ 1PT ¼ 1Med ¼ 0

2.06 (2) 0.358

Utilizing contactprecautions.

0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

50.0%Nurs ¼ 1PT ¼ 5Med ¼ 6

37.5%Nurs ¼ 7PT ¼ 1Med ¼ 1

4.2%Nurs ¼ 1PT ¼ 0Med ¼ 0

12.47 (2) 0.002

Utilizing airborneprecautions.

0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

12.5%Nurs ¼ 0PT ¼ 2Med ¼ 1

45.8%Nurs ¼ 3PT ¼ 3Med ¼ 5

33.3%Nurs ¼ 5PT ¼ 2Med ¼ 1

4.2%Nurs ¼ 1PT ¼ 0Med ¼ 0

6.31 (2) 0.043

Utilizing dropletprecautions.

0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

12.5%Nurs ¼ 0PT ¼ 3Med ¼ 0

37.5%Nurs ¼ 2PT ¼ 2Med ¼ 5

41.7%Nurs ¼ 6PT ¼ 2Med ¼ 2

4.2%Nurs ¼ 1PT ¼ 0Med ¼ 0

7.77 (2) 0.021

Utilizing enhancedprecautions.

8.3%Nurs ¼ 1PT ¼ 0Med ¼ 1

16.7%Nurs ¼ 0PT ¼ 3Med ¼ 1

25.0%Nurs ¼ 4PT ¼ 2Med ¼ 0

37.5%Nurs ¼ 2PT ¼ 2Med ¼ 5

8.3%Nurs ¼ 1PT ¼ 1Med ¼ 0

4.2%Nurs ¼ 1PT ¼ 0Med ¼ 0

0.50 (2) 0.779

Removing personalprotective equipment.

0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

4.2%Nurs ¼ 0PT ¼ 0Med ¼ 0

37.5%Nurs ¼ 3PT ¼ 3Med ¼ 5

45.8%Nurs ¼ 4PT ¼ 4Med ¼ 2

8.3%Nurs ¼ 2PT ¼ 0Med ¼ 0

2.46 (2) 0.293

Note. df ¼ degrees of freedom; Med ¼ medical students; Nurs ¼ nursing students; PT ¼ physiotherapy students.

Bold values indicates statistical significance.

Interprofessional Infection Control Module 401

infection control best practices were not followed includingnot applying or removing PPE correctly, not wearinggloves, and not posting signs when a patient was identifiedas infectious. In contrast, observers noted many examplesof good teamwork and collaboration amongst participantsthat were grouped into three main themes: (a) goodcommunication, (b) assisting each other with infectioncontrol skills (e.g., applying PPE), and (c) collaboratingduring clinical skills (e.g., performing assessments).

Instructor Feedback

Instructors from each discipline noted that senior studentsfrom all disciplines applied infection control principlespoorly and performed other clinical skills poorly,including cardiac resuscitation and suctioning, within thecomplex simulated patient care scenario emphasizing

pp 395-

infection control. Positive observations included instruc-tors noting that interprofessional collaboration amongstparticipants was increasingly evident as the scenariosprogressed, further evidenced by the high level of studentengagement during the final debriefing. In terms offeasibility, some barriers were identified including poorlydefined patient rooms and crowded patient areas, resultingin further confusion for participants. Furthermore, theinstructors agreed the simulated scenarios were toolengthy for the observers.

Discussion

Qualitative participant feedback was particularly valuableindicating most learners appreciated the opportunity to learnwith other professions to gain a better understanding of each

405 � Clinical Simulation in Nursing � Volume 10 � Issue 8

Table 5 Satisfaction with the IP Infection Control Education Module (N ¼ 24)

Please Check the Box ThatIndicates the Extent toWhich You Agree orDisagree With theFollowing Statements:

StronglyDisagree Disagree

SomewhatDisagree

SomewhatAgree Agree

StronglyAgree

KruskaleWallis

Chi-Square(df) Significance

I enjoyed participating inthis session.

0 4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

8.3%Nurs ¼ 0PT ¼ 0Med ¼ 2

12.5%Nurs ¼ 0PT ¼ 3Med ¼ 0

62.5%Nurs ¼ 7PT ¼ 5Med ¼ 3

12.5%Nurs ¼ 2PT ¼ 0Med ¼ 1

4.71 (2) 0.095

The IP component of thissession adds value tomy training.

0 0 4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

12.5%Nurs ¼ 1PT ¼ 0Med ¼ 2

50.0%Nurs ¼ 2PT ¼ 6Med ¼ 4

33.3%Nurs ¼ 6PT ¼ 2Med ¼ 0

8.26 (2) 0.016

I would be interested inadditional IP programsduring my training.

0 0 8.3%Nurs ¼ 0PT ¼ 0Med ¼ 2

8.3%Nurs ¼ 0PT ¼ 0Med ¼ 2

45.8%Nurs ¼ 3PT ¼ 5Med ¼ 3

37.5%Nurs ¼ 6PT ¼ 3Med ¼ 0

11.54 (2) 0.003

Simulation-basededucation adds value tomy training.

0 0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

8.3%Nurs ¼ 0PT ¼ 0Med ¼ 2

33.3%Nurs ¼ 2PT ¼ 4Med ¼ 2

54.2%Nurs ¼ 7PT ¼ 3Med ¼ 3

3.59 (2) 0.166

I would be interested inadditional simulation-based programs duringmy training.

0 0 4.2%Nurs ¼ 0PT ¼ 1Med ¼ 0

4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

41.7%Nurs ¼ 3PT ¼ 5Med ¼ 2

50.0%Nurs ¼ 6PT ¼ 2Med ¼ 4

3.13 (2) 0.209

I have a betterunderstanding of healthprofessional teammember roles as aresult.

0 8.3%Nurs ¼ 0PT ¼ 0Med ¼ 2

4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

20.8%Nurs ¼ 1PT ¼ 2Med ¼ 2

33.3%Nurs ¼ 2PT ¼ 4Med ¼ 2

33.3%Nurs ¼ 6PT ¼ 2Med ¼ 0

10.36 (2) 0.006

This session should bemandatory for allnursing, medicine, andphysiotherapy students.

4.2%Nurs ¼ 0PT ¼ 0Med ¼ 1

8.3%Nurs ¼ 0PT ¼ 0Med ¼ 2

12.5%Nurs ¼ 1PT ¼ 1Med ¼ 1

16.7%Nurs ¼ 1PT ¼ 2Med ¼ 1

41.7%Nurs ¼ 5PT ¼ 3Med ¼ 2

16.7%Nurs ¼ 2PT ¼ 2Med ¼ 0

6.10 (2) 0.047

Note. df ¼ degrees of freedom; Med ¼ medical students; Nurs ¼ nursing students; PT ¼ physiotherapy students.

Bold values indicates statistical significance.

Interprofessional Infection Control Module 402

other’s roles which was one of the main objectives for thesessions. As well, despite the stressfulness of the situation,the complexity of the scenarios provided a realistic contextthat contributed to learning. Observer and instructor feed-back indicated that students performed well in the interpro-fessional component of the module suggesting the clinicalchallenges of the simulation may foster collaboration andteamwork. In contrast, participants’ infection control skillsrequired considerable improvement even though they weresenior students who had all been taught infection control butin isolation from a clinical context. This finding supports theneed to provide prelicensure students with contextualizedlearning opportunities in a safe, high-fidelity simulatedenvironment to integrate infection control in their practice.This is particularly important considering participants in

pp 395-

another study had difficulty changing poor habits andcomplying to standard precautions (Efstathiou,Papastavrou, Raftopoulos, & Merkouris, 2011).

Results from the Confidence with Infection Control Skillssurvey indicate students were confident with the majority ofskills following the module; however, without presessionsurveys, a difference in students’ confidence related to themodule cannot be evaluated. Moreover, as noted earlier, highlevels of self-reported learner confidence in infection controlskills did not translate into high levels of performance withinthe complex patient care scenarios, indicating a need forfurther reinforcement of these skills in a simulated environ-ment before graduation from professional programs. Stu-dents were least confident with the use of enhancedprecautions suggesting further practice opportunities with

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this skill, one that is not encountered as frequently in clinicalsettings, would be valuable. Simulation activities provide anideal opportunity for students to practice rare but high-riskclinical skills and allows for consistency in learningexperiences for all students.

Results from the Interprofessional Communication andTeamwork survey suggest students are accustomed to andcomfortable working within an interprofessional team.However, despite previous IPE experience, results suggestsome participants may be intimidated by more seniorstudents, have difficulty communicating in challengingsituations including communication of opinions, havediscomfort working in groups or taking the lead in groups.In particular, nursing students were significantly moreuncomfortable putting forward personal opinions in a group,which may reflect the younger age of the nursing studentscompared with the medical and physiotherapy students.Such results suggest more IPE exposure would be an assetfor students to gain confidence working among other healthcare professionals before and during clinical experiences, asworking professionals in the clinical environment admit thatfactors such as intimidation will at times deter them fromperforming best practice (Efstathiou et al., 2011). Inter-professional simulation-based teamwork training hasdemonstrated improved attitudes and teamwork behaviorsin educational and clinical settings (Brock et al., 2013;Galbraith, Harder, Macomber, Roe, & Roethlisberger,2014).

Responses to the satisfaction survey suggest studentsvalued this IPE infection control module. Students partici-pated in the simulation scenarios interprofessionally, withlearners having varying degrees of clinical experience andeducation, contributing to the authenticity of the simulations.The interprofessional and simulation components wereevaluated individually, demonstrating students consideredboth aspects to be beneficial to their training. Mostparticipants agreed to some degree that their understandingof roles within the health care team, including their own role,was improved as a result of the module. Most participantsdemonstrated interest in future IPE sessions, which, in thecase of infection control teaching, is necessary for skillretention (Wagner et al., 2011). Nursing students were signif-icantly more satisfied with the sessions than the medical stu-dents. This may be a result of nursing students having moreprevious experience with IP simulations, as well as the factthat the session was held in the nursing simulation laboratorywhich many of the medical students had not previously seen.In the future, a more thorough orientation to an unfamiliarenvironment may reduce stress and confusion and enhancethe experience for all students.

Results of a study of patient safety in health carepreregistration educational curricula indicated safety-related issues are predominantly taught in isolation, withfew opportunities for interprofessional learning or bridgingthe gaps between educational, practice, and policy contextsand suggested patient safety role models were key to student

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learning (Cresswell et al., 2013). Our novel infection controlmodel provided health professional students with opportu-nities for IP learning as well as learning from ICPs whoare patient safety role models. Discussion of observer feed-back during debriefing allowed learners to clarify knowledgegaps related to infection control practices and interprofes-sional roles. The simulation literature suggests debriefing isone of the most important aspects of simulation learning ex-periences (Shinnick, Woo, Horwich, & Steadman, 2011).The activity allows feelings to be resolved and reflectivelearning to take place, and so students may connect theoret-ical concepts with practice and integrate the experience intotheir knowledge base (Cantrell, 2008).

Responses from the majority of participants and observerssuggest the IPE infection control simulations were effectiveand that integration of complex scenarios was successful.Senior students perceived the module presented an effectivemethod to simulate complex patient care, which correspondswith the success of another pilot project designed for seniorstudents to apply knowledge interprofessionally (O’Riordanet al., 2011). The majority of participants indicated that prac-tice in complex interprofessional patient care scenarios wasneeded. Further understanding of the effectiveness of stu-dents’ learning could be evaluated with the use of pre- andpost-surveys in future educational modules.

This pilot demonstrated feasibility of an interprofessionalhigh-fidelity simulation to foster integration of infectioncontrol principles and practices. There were, however,several recommendations from participants and observersfor improving the learning module for future sessions. Theseincluded improving the physical layout of the simulationlaboratory, shortening the scenarios, providing students withopportunities to practice with the equipment and skill setbefore attending the simulation session, creating morescenarios, and having observers in another room with aninstructor. The module design provided only a short video toreview infection control practices; therefore, a more in depthor interactive review could benefit the skills practice andincrease effectiveness of students’ skills performance.

The project represents an innovative application ofsimulation by combining IPE and infection control educa-tion. As the module was new, and our first involving threedisciplines, we collected information about how the studentsfelt about IPE and their confidence with infection controlskills and satisfaction with the module. These data wereuseful in identifying gaps in learner confidence that could bebetter addressed in both the classroom and future simulationsessions. As well, we collected observer data that indicatedour senior students were continuing to struggle with applyingbasic infection control skills within a complex clinicalenvironment, which suggests that providing additionalpractice opportunities is required. As with technical skills,infection control practices may decline and require rein-forcement throughout training (Ott & French, 2009). Thefact that senior students performed well in the interprofes-sional components of the module suggests that previous

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IPE exposure in our program has been effective. As well, ourpilot project demonstrated the feasibility of implementingsuch a complex interprofessional simulation within thecurricula of three health professions.

Conclusion

Seamless interprofessional collaboration and adherence tothe same degree of hygiene practice is crucial in maintain-ing appropriate infection control in modern health caresettings. Contamination occurs easily and can result inhighly detrimental consequences to both patients and healthcare professionals (Institute of Medicine, 2000). Exposureto complex or critical care events and the role of infectioncontrol during clinical rotations may be infrequent amongstprelicensure students. Potential variances in experience canimpact future clinical practice and infection control in acutecare settings (Ward, 2010).

The results of this study support the need for seniorhealth sciences students to practice infection control skillswithin simulated complex patient care scenarios beforetransitioning to postlicensure practice. However, it wasrecognized that students need further reinforcement ofbasic infection control principles and skills earlier in theirprofessional programs, thus an additional module is pro-posed in which intermediate-level students would practicethese skills within simpler IP clinical scenarios, beforeprogressing to complex scenarios in their senior years.

This pilot project demonstrated it is feasible to imple-ment a complex, simulation-based IPE module. Studentsatisfaction with the module was high. However, a revisionof module logistics is required before integration into thehealth sciences curricula. The model used for this educa-tional module, and the feedback obtained through theevaluation will inform the structuring and content of furtherIPE simulation to facilitate the transition from student topractitioner and ideally enhance patient safety.

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