Nurse Education Today 35 (2015) 1175–1180

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Nursing students' knowledge and practices of standard precautions: A Jordanian web-based survey☆ Omar M. AL-Rawajfah ⁎, Ahmad Tubaishat Faculty of Nursing, AL al-Bayt University, Mafraq, Jordan

a r t i c l e

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Article history: Accepted 14 May 2015 Keywords: Infection control compliance Infection control guidelines Standard precautions Infection control practices Standard precautions knowledge Web-based survey

s u m m a r y Background: The main purpose of this web-based survey was to evaluate Jordanian nursing students' knowledge and practice of standard precautions. Methods: A cross-sectional, descriptive design was used. Six public and four private Jordanian universities were invited to participate in the study. Approximately, seventeen hundred nursing students in the participating universities were invited via the students' portal on the university electronic system. For schools without an electronic system, students received invitations sent to their personal commercial email. Results: The final sample size was 594 students; 65.3% were female with mean age of 21.2 years (SD = 2.6). The majority of the sample was 3rd year students (42.8%) who had no previous experience working as nurses (66.8%). The mean total knowledge score was 13.8 (SD = 3.3) out of 18. On average, 79.9% of the knowledge questions were answered correctly. The mean total practice score was 67.4 (SD = 9.9) out of 80. There was no significant statistical relationship between students' total knowledge and total practice scores (r = 0.09, p = 0.032). Conclusion: Jordanian nursing educators are challenged to introduce different teaching modalities to effectively translate theoretical infection control knowledge into safe practices. Published by Elsevier Ltd.

Introduction Nursing and healthcare students are at high risk for blood-borne pathogens and sharp instrument injuries during their clinical placement, which puts them at risk for infection (Smith et al., 2006a,b; Smith and Leggat, 2005; Talas, 2009). The high risk for students may be the result of limited clinical experience in standard precautions (Askarian et al., 2004), a shortage of protective supplies available for students (Askarian et al., 2007), and insufficient training in performing high-risk medical procedures (Askarian et al., 2007). Nursing students may become a source of cross-infection if they do not comply with standard infection control practices (Danzmann et al., 2013; Lin et al., 2007; Loh et al., 2000; Treakle et al., 2009). Standard precautions (SPs) have been established to protect healthcare workers from infection and prevent the transmission of infection (Siegel et al., 2007). The practice of SPs involve application of the basic principle of infection control such as handwashing, using of personal protective equipment (PPE) such as gloves, masks, gowns and eyewear to prevent contact with potentially infectious materials, and safe handling of sharps (WHO, 2004). According to Centers for ☆ The authors report no conflicts of interest relevant to this article. ⁎ Corresponding author at: Faculty of Nursing AL aL-Bayt University, P.O. Box 130040, Mafraq 25113, Jordan. Tel.: +962 2 629 7000x2851; fax: +962 2 629 7025. E-mail address: [email protected] (O.M. AL-Rawajfah).

http://dx.doi.org/10.1016/j.nedt.2015.05.011 0260-6917/Published by Elsevier Ltd.

Disease Control and Prevention [CDC] (2014), PSs are the minimum infection prevention practices that should be applied to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. Healthcare students need to acquire the appropriate knowledge and skills of standard precautions before their initial hospital training (Siegel et al., 2007; Tavolacci et al., 2008). Pre-graduation training plays a crucial role in promoting compliance to SPs practices. Further, undergraduate clinician training serve as a key environment where knowledge acquisition on SPs should occur (Mitchell et al., 2014). Along with staff education and training, the CDC prioritizes the assessment of knowledge and adherence to infection control guidelines to prevent and control healthcare-associated infections (HCAIs) (Siegel et al., 2007). The CDC (2014) asserted that education on the basic principles and practices for preventing the spread of infections should be provided to all heath care professionals. Further, the CDC (2014) stressed that Education and training should be conducted on a regular basis (e.g., annually) to maintain competency. At the same time, new updates on infection control guidelines are to be included in any educational and training programs. Different studies have indicated that high level of knowledge of SPs was a significant predictor of better compliance with SPs practices (Hinkin and Cutter, 2014; Mitchell et al., 2014; Sax et al., 2005). The evaluation of infection control knowledge among healthcare student plays a crucial role in any process aimed to enhance the educational

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strategies and consequently the enhancing the compliance with infection control practices (D'Alessandro et al., 2014). While knowledge and understanding of SPs are important in maintaining high standards of SPs practice, there are other important factors that need to be considered and examined (Hinkin and Cutter, 2014). Although different studies have examined healthcare workers' knowledge and practices of standard precautions (Bryce et al., 2007; Easton et al., 2007; Sax et al., 2005), few studies have targeted nursing students (Al-Hussami and Darawad, 2013; Darawad and Al-Hussami, 2013; Labrague et al., 2012; Tavolacci et al., 2008). Although studies have been conducted in Jordan to evaluate healthcare professionals' and students' infection control knowledge and practices (Al-Dwairi, 2007; Al-Hussami and Darawad, 2013; Al-Rawajfah, 2014; Al-Rawajfah et al., 2013; Qudeimat et al., 2006), none of these studies has used web-based methods for data collection. Therefore, the primary purpose of this web-based survey was to evaluate Jordanian nursing students' knowledge and practice of standard precautions. Method This study utilized a descriptive cross-sectional design. This study used web-based survey as a method of data collection. Web-based surveys are increasingly an acceptable and reliable method of data collection in nursing and health-related research (East et al., 2008; Gordon and McNew, 2008; Jones et al., 2008a,b; Turunen et al., 2013). Research has shown that data collected by web-based surveys are comparable in quality and type with data collected by paper-based surveys (Gordon and McNew, 2008). Furthermore, web-based surveys are associated with several strengths such as speed of data access and decreased data collection and data entry costs (Jones et al., 2008b; Lefever et al., 2006). They are used to target large and geographically scattered populations, collect huge amounts of data in a reasonable amount of time (Fricker and Schonlau, 2002), and can be completed at the participant's convenience (Lefever et al., 2006). Setting and Sampling This was a national, multicenter project. The initial invitation for the study was sent to six public and four private universities in different geographic areas in Jordan. In the invitation, universities were asked to give their permission to use the students' portal on the university electronic system in order to send the survey hyperlink to nursing students. Universities that did not employ a student portal in an electronic system were invited to participate by means of a poster, which was placed in the main entrance of the faculty of nursing. The poster contained invitation cards with space for writing an email address. Students were invited to take an invitation card, provide their email address, and return the card to an appointed faculty member or administrative staff member. This procedure was designed to minimize the possibility of non-nursing students' completing the survey. Students who completed the invitation card received an email message containing the survey hyperlink. The web-based survey was designed to be completed by participants one time only to minimize redundant responses. To maximize the response rate, the survey hyperlink was maintained active for one full semester (4 months). The only inclusion criterion for this study was being a nursing student in one of the participating universities. No exclusion criteria were used in the study. Ethical Considerations The study protocol was approved by the Institutional Review Board of the home university of the authors. Explanation about the research was given to the participants on the survey face page and in the invitation posters. Participation was completely voluntary. Only those who checked the box “I agree to participate” could enter the survey.

Study Instrument The survey utilized a tool developed by Chan et al. (2002); permission to use the tool was obtained from the authors. The tool consisted of three parts: Part I collected demographic data, including age, gender, academic level, and other student-related variables; Part II asked about knowledge of standard precautions; and Part III asked about standard precaution practices during clinical course placements. For Part II, students were asked to respond to 18 items with “True,” “False,” or “I don't know.” The “I don't know” choice was included to decrease the possibility of guessing by students. The total knowledge score ranged from 0 to 18. Correct answers were graded with the number 1; False and “I don't know” responses were graded zero. Out of the 18 items, 4 items were negatively stated to minimize possible biased responses. The answers were validated by one infection control specialist and one infectious disease consultant using the Jordanian Ministry of Health Infection Control Manual (Jordanian Ministry of Health — Department of Communicable Diseases, 2011). Part III, the practice section, consisted of 16 items related to the use of protective devices, disposal of sharps, disposal of waste, decontamination of spills and used instruments, and prevention of crossinfection from person to person. A 5-point Likert scale was used for this section, with scores ranging from 5 (always) to 1 (never), with total scores ranging from 16 to 80. According to Chan et al. (2002), the content validity index of 88.6% for the original tool was achieved with an internal consistency coefficient of 0.72. In our study sample, Cronbach's alpha coefficients were 0.87 for the knowledge subscale and 0.84 for the practice subscale. The original tool was translated into Arabic. The standardized procedure of translation and back translation was followed (Cha et al., 2007). Two independent bilingual Arabic–English healthcare academicians, including the principle investigator, independently translated the original instrument. Back-translation by a bilingual Arabic–English PhD expert was carried out. Each translated versions were evaluated by a meeting of the research team. Any discrepancies between the reviewed versions were discussed by the research team until agreement on final translation was reached. The Arabic version was validated by three doctorally prepared persons whose area of research involved infection control. The final Arabic version was pilot tested and minor modifications were implemented according to recommendation from students' sample. For this study, total knowledge scores were categorized as follows: b50th percentile (range 0 to 10), “poor”; between 50th and 75th percentiles (range 11 to 14), “satisfactory”; and N75th percentile (range 15 to 18), “excellent.” Likewise, total practice scores were categorized as follows: b50th percentile (range 16 to 48), “unsafe practice”; between the 50th and 75th percentiles (range 49 to 64), “weak practice”; and N 75th percentile (range 65 to 80), “competent practice.” Both the knowledge and practices categories were validated by experts in education and infection control and agreed upon according to categorization and corresponding terms. Data Analysis SPSS®-PC Version 20 was used to analyze the data. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were computed to describe students' characteristics and responses. Missing data for the 18 knowledge items ranged from 2.9% to 5.6%; missing data for the 16 practice items ranged from 3.7% to 5.6%. Cases of missing data of 20% or greater in each subscale were excluded from the final analyses; in addition, items missing in more than 10% of the surveys were excluded from the final analyses. Independent t-test was used to compare mean total knowledge and practices scores across different dichotomous variables. Pearson correlation between total knowledge and practices scores was used to test for possible relationships.

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Results Responses from the Participating Universities Ten universities were invited to participate in the study and all agreed to participate. Of these, four public universities sent the survey link to their nursing students using their electronic portal system. Two public and two private universities had no student electronic portal; therefore, the poster invitation was used. Two private universities agreed to put the survey link into their portal system, but no responses were obtained from them. For the four public universities that utilized a student portal system, an electronic invitation message to participate in the study was sent to nursing students. These universities had a total of approximately 1700 nursing students across the four universities; 600 students agreed to participant in the study and entered into the survey webpage, resulting in a response rate of 35.3% across the four universities. Of the 600 student surveys, 11 were excluded from the final analysis because of missing data on more than 50% of the study variables, resulting in a sample of 589 students. For the two public and two private universities that used poster invitations, a total 208 invitation cards were completed by students and returned to the researcher. Surprisingly, only five students (2.4%) responded to the initial invitation message sent to their personal emails and completed the survey. No others responses were received after two reminder messages were sent one and two weeks after the initial invitation. Therefore, the final sample size of the current study was 594 students from 8 universities. Sample Characteristics Out of the total sample, 65.3% were females with a mean age of 21.2 years (SD = 2.6). The majority of participating students were 3rd year students (42.8%). Most participants (66.8%) had no previous clinical experience. The majority of the students (n = 223, 37.5%) reported that they were introduced to standard infection control issues in the first year. At the same time, 116 students (19.5%) reported that infection control issues were not addressed in their teaching courses. Most of the participating students received the hepatitis B virus vaccine (81.0%). About one fifth of the participating students (19.5%) reported that they did not receive formal education regarding infection control during their course work (Table 1). Infection Control Knowledge Total knowledge scores for the students ranged from 4 to 18, with a mean total score of 13.8 (SD = 3.3) representing a score of 76.6% of the highest possible score of the scale. Of the 594 students who entered to the survey, 11 students completed less than 50% of the knowledge questions; their surveys were excluded from the final knowledge analysis. Therefore, the sample size for the knowledge analysis was 583 students. Of the 583 students who completed the knowledge questions, only three students (0.5%) scored 18, the highest possible score; three other students (0.5%) scored 4 out of 18. The quartiles for total students' knowledge score were 13, 15, and 16 for the 25th, 50th, and 75th percentiles, respectively. According to total knowledge scale categories, student knowledge was classified as “weak” (9.1%), “satisfactory” (39.6%), and “excellent” (51.3%). The vast majority (96.0%) of the students correctly answered the first question (needles used for medication preparation or injecting patients should be discarded in the special sharp container). On the other hand, the vast majority (89.6%) falsely answered the fifth question (wearing surgical gloves is necessary in all caring procedures provided to AIDS patients). Table 2 summarizes frequency and percent of correct and false responses for each knowledge question.

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Table 1 Demographic characteristics of the sample.a Characteristic

Number of nurses (%) N = 594

Mean of age (SD) Gender Female Male Type of students' admission Regular program RN to BSN (bridging program) Academic level 2nd year 3rd year 4th year Previous employment as a nurse Yes No Mean of experience in years (SD) Infection control issues have been addressed in the teaching courses Yes No Not sure During your course work, at which academic level infection control issues have been introduced to you 1st year 2nd year 3rd year 4th year No infection control instructions in my study plan Received hepatitis B virus vaccine (HBVV) Yes No

21.20 (2.60) 300 (65.3) 205 (34.5) 517 (87) 76 (12.8) 116 (19.5) 254 (42.8) 223 (37.5) 197 (33.2) 396 (66.8) 0.70 (1.5)

404 (68) 116 (19.5) 73 (12.3)

223 (37.5) 191 (32.2) 90 (15.2) 23 (3.9) 66 (11.1) 481 (81.0) 105 (18.4)

a Missing data were as follows: 1 missing case for gender, type of admission, academic level, previous employment as nurse, infection control issues have been addressed in the teaching courses, and which academic level infection control issues have been introduced to you, and 4 cases for received hepatitis B virus vaccine.

Students who reported that infection control issues were addressed in their courses had a higher mean knowledge score (M = 14.1, SD = 2.9) than students who reported that such issues were not addressed in their courses (M = 13.3, SD = 3.8, p = 0.02). On the other hand, there was no statistical difference between mean total knowledge scores for regular and BSN-bridging students (p = 0.75), nor for students employed as nurse versus never employed (p = 0.42) (Table 3). Similarly, male and female students were not statistically different in their total knowledge score (t = 0.14, p = 0.9). Likewise, One-Way ANOVA analysis revealed no statistical differences in total knowledge score among students' different academic levels (F = 0.74, p = 0.5). Finally, Pearson correlation procedure demonstrated that there was no significant statistical relationship between the total knowledge and the students' clinical experience in years (r = − 0.01, p = 0.80). Infection Control Practice Total practice scores for the students ranged from 16 to 80, with a mean total score of 67.4 (SD = 9.9), representing 84.3% of the highest possible total practice score. Out of the total sample, 28 students (4.8%) completed the practice subscale with missing data of greater than 20%; their surveys were excluded from the final analysis. Of the total sample that completed the practice items, 29 students (4.9%) scored 80, the highest possible practice score. On the other hand, 4 students (0.7%) scored 16, the lowest possible score. The quartiles for total practice scores were 63, 69, and 75 for the 25th, 50th, and 75th percentiles, respectively. According to total practice scale categories, student practice was classified as “unsafe” (4.1%), “weak” (27.1%), and “competent” (68.8%). The majority of students reported that they always wash their hands after providing care to their patients (73.6%) and always wash their

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Table 2 Frequency and percent of correct and false response of the students for each knowledge question (N = 594). No.

Itema

Number of correct answers (%)

1. 2. 3. 4. 5.

Needles used for medication preparation or injecting patients should be discarded in the sharp box. Wearing surgical gloves is necessary in all caring procedures provided to AIDS patients. Standard precautions should be applied to all patients regardless of the presence or absence of a source of infection. Standard precautions should be applied in cases where there is contact with patient's saliva or mouth secretions. Patients with illnesses spread by droplets or spray must wear the face mask through the process of being transferred from one ward to another. Standard precautions should be applied in cases where there is contact with patient's vaginal secretions. It is a must to use/wear the face mask when entering rooms for patients with chickenpox and measles. Standard precautions should be applied in cases where there is contact with patient's urine or stool. Tools of patients who need contact precautions should NOT be used or shared with other patients. It is necessary to use isolation gown when entering rooms of patients who need contact precautions. Spots of blood spilled from the patient must be cleaned using sterilizing agent dedicated for this purpose. Standard Precautions are applied ONLY for AIDS or hepatitis patients. Patients who are in need of using contact precautions should be isolated in private rooms. Double surgical gloving is necessary when performing procedures or nursing care for patients with diseases spread by blood contact such as AIDS or hepatitis-B. Facial mask and eye protection is NOT necessary if the procedure that needs to be done for the patient may cause volatility or spill a patient's blood or body fluids. Patients with diseases spread by droplets or spray should NOT be isolated in private rooms Standard precautions should be applied in cases where there is contact with patient's sweat. Standard precautions should be applied in cases where there is contact with patient's tears.

570 (96) 534 (89.9) 532 (89.6) 532 (89.6) 523 (88.0)

13 (2.2) 49 (8.2) 51 (8.6) 51 (8.6) 43 (7.2)

518 (87.2) 349 (58.8) 509 (85.7) 509 (85.7) 501 (84.3) 497 (83.7) 474 (79.8) 471 (79.3) 470 (79.1)

50 (8.4) 219 (36.9) 59 (9.9) 52 (8.8) 63 (10.6) 86 (14.5) 109 (18.4) 93 (15.7) 91 (15.3)

464 (78.1)

119 (20.0)

424 (71.4) 369 (62.1) 296 (49.8)

140 (23.6) 214 (36.0) 287 (48.3)

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Number of false answers (%)

a Missing data were as follows: 11 (1.9%) cases for items 1–4, 11, 12, 15, 17, & 18, and 26 (4.4%) cases for items 6–8, and 29 (4.7%) cases for item 5, and 30 (5.1%) cases for items 10,13, & 16, and 33 (5.6%) for items 9 and 14.

hands after using gloves (72.6). On the other hand, some students (35.7%) reported that they always perform needle recapping after giving an injection or using needles for drug preparations. Moreover, less than half (47.3%) always wash their hand before performing nondirect patient care (e.g., medication perpetration). Table 4 summarizes frequency and percent of students' actual practice of standard precaution skills. Students who reported that infection control issues were addressed in their courses scored a higher mean practice score (M = 67.9, SD = 9.1) than students who reported that such issues were not addressed (M = 66.40, SD = 11.3, p = 0.48). On the other hand, there was no statistical difference between mean total practice score for regular and BSN-bridging students (p = 0.058), nor for students who were previously employed as nurse versus those who had never been employed (p = 0.40) (Table 3). Similarly, male and female students were not statistically different in their total practice score (t = 0.31, p = 0.8). Likewise, One-Way ANOVA analysis revealed no statistical differences in

Table 3 Comparison of means practice and knowledge scores in relation to different students' factors.

Knowledge mean total score Type of students' admission is regular a Previous employment as a nurse Infection control issues have been addressed in the teaching courses Received hepatitis B virus vaccine (HBVV) Practice mean total score Type of students' admission is regular a Previous employment as a nurse Infection control issues have been addressed in the teaching courses Received hepatitis B virus vaccine (HBVV)

Yes

No

M (SD)

M (SD)

13.8 (3.3)

13.9 (3.1)

0.3 (569) 0.75

13.8 (3.0) 14.1 (2.9)

13.8 (3.3) 13.3 (3.8)

0.8 (569) 0.42 2.3 (503) 0.02

13.8 (3.2)

13.7 (3.4)

0.22 (566) 0.83

70.2 (12.4) 70.1 (8.7)

0.80 (569) 0.72

t (df)

p Value

70.9 (11.0) 70.0 (12.4) 0.50 (569) 0.42 70.9 (12.4) 68.2 (8.7) 2.1 (503) 0.03 70.2 (12.1) 70.1 (11.1) 0.30 (566) 0.80

IC, infection control; SD, standard deviation; dfn, degree of freedom. a Regular admission vs. RN to BSN bridging admission.

total practice score among students' different academic levels (F = 0.8, p = 0.45). Finally Pearson correlation procedure demonstrated that there was no significant statistical relationship between the total practice score and the students' clinical experience in years (r = − 0.02, p = 0.70). In the same context, Pearson correlation procedure demonstrated that there was very weak positive relationship between the total knowledge and total practice scores (r = 0.09, p = 0.032). Discussion Based on our classification system in this study, only about half of the students could be described excellent regarding knowledge of standard precautions. Similar results were reported previously in Jordan (Darawad and Al-Hussami, 2013), with a mean knowledge score of 12.3 out of 25. The researchers commented that the low knowledge score they identified may be the result of not having a special course on infection control issues in nursing curricula in Jordanian universities. From an international perspective, Jordanian students in this study scored relatively higher on total knowledge than students in countries including Australia (Mitchell et al., 2014), Italy (D'Alessandro et al., 2014), Namibia (Ojulong et al., 2013), and Ghana (Bello et al., 2011). The total mean of correctly answered questions in our study was 79.9% compared to Australia, 59.8% (Mitchell et al., 2014), Italy, 74.2% (D'Alessandro et al., 2014), Namibia, 66.6% (Ojulong et al., 2013), and Ghana, 61.3% (Bello et al., 2011). The overall SPs practices among our study sample were congruent with other studies of Jordanian nursing students (Darawad and AlHussami, 2013) and registered nurses (RNs) (Al-Rawajfah, 2014; Al-Rawajfah et al., 2013). In the current study, more than one third of students reported that they always recap needles after use. This result was highly congruent with results from a national study of RNs in Jordan (Al-Rawajfah et al., 2013). In a national Jordanian study, AlRawajfah et al. (2013) reported that 44.5% of RNs stated that they always perform needle recapping. Moreover, a pervious Jordanian study demonstrated that RNs are the healthcare workers most affected by needle sticks because of recapping practices (Khuri-Bulos et al., 1997). It seems that wrong practices by nursing students are reflected in the practices of RNs. Therefore, careful assessment of infection control practices for nursing students is needed by nursing educators in Jordan. Simultaneously, many times students tend to replicate clinical practices performed by the staff without accurate judgment about the safety of

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Table 4 Frequency of infection control practices (N = 594).a Itemb 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. a b

Never or rare n (%)

I wash my hands after providing nursing care to the patient. I wash my hands immediately after removing medical gloves. I change the non-surgical medical gloves when I move from one patient to another. I wear sterile surgical gloves when touching blood or body fluids or internal mucosa or in cases of wounds in the skin. I wash my hands before providing nursing care to patients. I cover my wounds – if any – with a cover that is impermeable to water before providing care to patients. I wear protective apron when there is a likelihood of exposure to patient's blood or body fluids. I wear face mask when there is a possibility of spitting out or spillage of any body fluids from the patient. I put the used needles and surgical blades in the pot allocated for this purpose. I clean surfaces and tools used for patient care after the completion of the care. I get rid of tools and objects contaminated with blood in a medical waste bag, regardless of the presence of source of infection. I wash my hands before doing nursing care even if they were not directly to the patient (for example, preparing the medications). I clean tools which has blood on them with disinfectants. I wear non-surgical gloves when performing nursing care that may result in direct contact with patient's blood or body fluids. I empty the sharp container when it becomes completely full I perform needle recapping for needles after giving injection or using the needle.

Sometime n (%)

Always or most of the time n (%)

17 (2.7) 19 (3.2) 30 (5.1) 31 (5.1)

29 (4.9) 35 (5.9) 53 (8.9) 34 (5.7)

520 (87.5) 511 (86.0) 482 (81.1) 507 (85.4)

32 (5.4) 42 (7.0)

50 (8.4) 51 (8.6)

490 (82.5) 472 (79.5)

43 (7.2)

66 (11.1)

456 (76.8)

45 (7.5)

73 (12.3)

447 (75.3)

45 (7.6) 48 (8.1) 54 (9.1)

19 (3.2) 62 (10.4) 41 (6.9)

508 (85.5) 455 (76.6) 470 (79.1)

56 (9.4)

74 (12.5)

442 (74.4)

60 (10.1) 93 (15.7)

39 (6.5) 56 (9.4)

466 (78.5) 423 (71.2)

252 (42.5) 278 (46.8)

81 (13.6) 37 (6.2)

232 (39.0) 250 (42.1)

Missing data were as follows: 29 (4.9%) cases for items (1, 2, 3, 6,7,8,10,11,13,15, & 16) and 22 (3.7%) cases for items (4,5, 9, 12, & 14). Items 15 & 9 are reverse coded.

these practices. This raises the responsibility of Jordanian nursing educators and clinical instructors to play the role model for their students. At the same time, another learning opportunity is suggested by finding competent staff for preceptorship role. Studies suggested that nursing students identify preceptors as key to their learning in the clinical placement (McClure and Black, 2013). Results from this study revealed that about 70% of the students reported that they were introduced to SPs in the first and second academic year. However, this may be not enough to enforce SP practices in the following clinical courses. Therefore, more specific courses about infection control issues are needed. In the current study, we found very weak positive relationship between overall students' knowledge scores and overall practice scores. Similarly, in a Jordanian conventional survey, Darawad and AlHussami (2013) reported that students' knowledge was not a predictor of compliance with standard precautions. Results from the current study and the Darawad and Al-Hussami study have alarming ramifications for nursing education in Jordan with regard to the connection between theoretical knowledge taught in the nursing classroom and the clinical practice demonstrated during students' clinical courses. The theory–practice gap has been identified as a major challenge that new graduates face regarding infection control practices (Cox et al., 2014; Esmaeili et al., 2014). Jordanian nursing educators are challenged to introduce different teaching modalities and options in order to effectively translate theoretical knowledge into safe practice. The fact that web-based surveys are self-reported represents a different limitation. For example, research has demonstrated that the self-report method overestimates compliance with infection control practices compared to observed practices (Al-Wazzan et al., 2011; Jenner et al., 2006). In the current study, more than one fourth of the students were classified as “weak” in compliance with infection control standard precautions. Conducting direct observational studies will provide better insight regarding levels of compliance with these guidelines. Web-based surveys are not commonly used in nursing and healthrelated research in Jordan. The current study is one of few healthrelated Jordanian electronic surveys (AbuAlRub, 2004; Al Qadire, 2014; Hayajneh et al., 2010). This study revealed that using personal emails as a method of inviting Jordanian nursing students to participate in a web-based survey is not an effective method, at least at the current

time. Only 2.4% of student responded to the email invitation, a very low response rate. A possible explanation concerns the use of personal email as a main method of communication. Nursing students may not check their email regularly for lack of interest in computer and electronic communication. In a Jordanian nursing student sample (Akhu-Zaheya et al., 2011), the researchers reported that only 34.2% of the sample used computers for personal electronic email, but 41.5% of the sample were not interested in computers. Another possible reason for the low response rate is anxiety connected with computer literacy. AkhuZaheya et al. (2011) found a significant negative relationship between computer anxiety and computer literacy rates among undergraduate nursing students. They recommended frequent use of computers in various educational and training activities to reduce computer anxiety and improve computer literacy rates. Research supports that embedding information technology topics in the nursing curriculum has a positive effect on nursing research, education, and practice (Nkosi et al., 2011; Tubaishat, 2014). The issue of low response rate is a prominent limitation in webbased surveys (Chipas and McKenna, 2011; Kern et al., 2014; Parker et al., 2014; Selig et al., 2012; Yuen et al., 2013). In our study, we managed response rates by using students' official accounts where possible. In four of the universities sampled, all students used their official accounts for various reasons, such as registration and viewing exam scores. The initial invitation was sent on the face page of the student's account. By using this method we were successful in achieving a response rate of about 35%. Conclusions Incorporating standard infection control practices in clinical courses is very important. It is not enough to introduce the theoretical component of infection control in the classroom. Rather, both theoretical and clinical practice aspects of infection control should be incorporated in students' clinical courses. With limited resources and infrastructure in many Jordanian hospitals, universities need to take part of the responsibility by providing their students with essential protective equipment during their clinical courses. In Jordan, using personal email accounts to recruit participants for a research study is not an effective method, at least at the current time.

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