INTRODUCTION
Healthcare-associated infections (HAIs) are directly related to patients' lives, and infection control activities to prevent HAIs are important tasks for the safety of patients and healthcare workers (HCWs) [1]. Long-term care hospitals (LTCH) face unique challenges due to lower staffing standards and a higher number of older adults with weakened immune systems, making infection control a top priority [2]. The high infection rates in LTCH are linked to inadequate infection control expertise among caregivers, insufficient infection surveillance systems, and a lack of trained personnel [2]. During the COVID-19 pandemic, LTCHs experienced the highest transmission and mortality rates, further underscoring the need for robust infection control measures [3]. In response, national regulations now mandate hospitals with 100 or more beds to have full-time infection control personnel and in infection control department [4]. However, most LTCH full-time infection control personnel are holding other jobs due to lack of personnel and finances, making it difficult for them to focus on infection control work and sustain systematic infection control activities [5]. Accordingly, the actual implementation of infection prevention is largely dependent on nurses, and identifying their standard precautions and influencing factors can be a key strategy for LTCH infection control.
HCWs are at heightened risk of exposure to infectious agents while caring for patients [6], and these infections can easily spread within healthcare settings [7]. Therefore, infection prevention practices, including hand hygiene, wearing personal protective equipment (PPE), respiratory hygiene/cough etiquette, patient placement, patient transfer, safe injection practices, and environment, medical device, equipment, laundry and linen, waste, hospital dish-ware and visitor management to protect patients, staff, and the environment from infection, are essential to prevent and manage HAIs [8]. Despite the importance of these standard precautions, LTCH nurses often struggle to comply due to environmental factors such as heavy work-loads, limited time, and insufficient resources [9].
Most studies on factors influencing standard precaution adherence have focused on nurses in general hospitals [1,10-12], with little research on LTCH nurses [9,13]. Factors such as perceived barrier, action triggers, standard precaution guideline knowledge and awareness, number of beds, safety environment, and educational experience with standard precautions among LTCH nurses [9,13]. Nurses, being in closest contact with patients, play a vital role in infection prevention and in limiting the spread of infections [10]. Thus, ensuring their adherence to infection control guidelines is crucial for protecting both patients and staff. Previous research indicates that proper adherence to infection control guidelines can reduce HAIs incidence by up to one-third [14]. However, studies show that despite nurses' awareness of the importance of standard precautions, their performance often falls short due to challenges such as inadequate resources, heavy work-loads, and time constraints [11,15].
Hospital environments have been identified as a key factor in standard precaution performance, with inadequate facilities and equipment particularly contributing to lower performance of standard precautions in LTCHs [10,12]. A supportive environment, including necessary resources and administrative backing, is essential to improving infection prevention behaviors among nurses [16]. Additionally, an organizational culture that prioritizes infection control plays a critical role in motivating staff to follow standard precautions, thereby reducing HAIs rates [12]. In LTCHs, nurses' moral sensitivity, which influences ethical decision-making, is also important in ensuring adherence to infection control practices, especially when dealing with vulnerable older adults [17].
Therefore, this study aims to identify personal and environmental factors that affect compliance with standard precautions among LTCH nurses at high risk of infection, and to provide basic data for establishing practical intervention strategies that can be applied even in situations where there is a shortage of infection control personnel. This will contribute to establishing effective infection control measures even within limited resources.
METHODS
1. Study Design
This descriptive study aimed to determine the impact of LTCH nurses' performance compliance with standard precautions.
2. Participants and Setting
The participants were nurses who had been employed for more than 3 months [18] at four LTCH with 300∼500 beds in Daejeon. After the study purpose was fully explained in writing, the participants who understood the content and agreed to participate were selected. The participants were nurses who had worked for more than 3 months [18] at four LTCH in Daejeon with 300∼500 beds, and who voluntarily consented to participate after understanding the purpose of the study. The number of participants was determined to be 208 using G*Power 3.1.9 [19] for multiple linear regression, assuming a medium effect size of .15 [20], a significance level of .05, power of .95, and 17 predictor variables (general characteristics, awareness of standard precautions, protective environment on exposure to infection, infection control organizational culture, and moral sensitivity). Based on a previous study [13] targeting LTCH nurses, questionnaires were distributed to 250 nurses. A total of 250 questionnaires were distributed and all were returned (100% return rate). After excluding 10 questionnaires with insufficient responses, 240 questionnaires were analyzed (response rate 96%).
3. Measurements
The tools used in this study were used after obtaining permission from the authors via email. Participants' general characteristics included the following variables: gender, age, marital status, education level, position, clinical career, hospital bed size, possession of guideline for infection exposure (yes/no), awareness of post-exposure response (yes/no), department of infection control and infection control nurse (ICN) (yes/no), regular infection control education participation (yes/no), and infectious disease exposure experience (yes/no).
1) Performance of standard precautions
A standard precautions performance scale was developed by Askarian et al.[21] and translated by Jeong [15]. It consists of five subdomains (washing hands, wearing PPE, handling sharp tools, environment management, and respiratory hygiene/cough etiquette) comprising 21 items. Each item is scored using a 4-point Likert scale with answers ranging from "definitely not" (1 point) to "definitely would"(4 points). A higher score indicates greater performance of standard precautions. The scale reliability Cronbach's ⍺ values were 0.83 [15] and 0.87 in this study.
2) Awareness of standard precautions
Askarian et al. [21] developed an awareness of standard precautions scale, which was translated by Jeong [15]. It consists of five subdomains (washing hands, wearing PPE, handling sharp tools, environment management, and respiratory hygiene/cough etiquette) comprising 21 items. Each item is scored using a 4-point Likert scale with answers ranging from "definitely not" (1 point) to "definitely would" (4 points). A higher score indicates greater awareness of standard precautions. The scale reliability Cronbach's ⍺ values were 0.83 [15] and 0.86 in this study.
3) Protective environment on exposure to infection
The protective environment on exposure to infection scale, developed by Ahn et al. [16], consists of 11 items. Each item is scored using a 5-point Likert scale with answers ranging from "definitely not" (1 point) to "definitely would" (5 points). A higher the score indicates a greater protective environment on exposure to infection. The scale reliability Cronbach's ⍺ values were 0.85[16] and 0.84 in this study.
4) Infection control organizational culture
The infection control organizational culture scale, developed by Park [22] and modified by Moon [23], consists of 10 items. Each item is scored using a 7-point Likert scale with answers ranging from "definitely not" (1 point) to "definitely would" (7 points). A higher score indicates a greater infection-control organizational culture. The scale reliability Cronbach's ⍺ values were 0.85 [23] and 0.90 in this study.
5) Moral sensitivity
Moral sensitivity was measured using the Korean version of the Moral Sensitivity Questionnaire, which was adapted by Han et al. [24] from the Moral Sensitivity Questionnaire by Lutezen et al. [25], and revised and supplemented to verify its reliability and validity. It consists of five subdomains (patient-oriented care, professional responsibility, conflict, moral meaning, and benevolence) for 27 items. Each item was scored using a 7-point Likert scale, with answers ranging from "not at all" (1 point) to "strongly agree" (7 points). Higher scores indicate greater moral sensitivity. The reliability of the scale Cronbach's ⍺ value was reported as 0.76 [24] and 0.91 in this study.
4. Data Collection
This study collected data from February 18, 2021, to January 20, 2022, using a self-reported survey that takes approximately 20 minutes to complete. Before initiating this study, the researchers explained the purpose of the research to institutional officials and obtained their permission. Subsequently, a recruitment notice was posted on the institutions' bulletin boards and nurses who expressed interest were informed about the research purpose and data collection procedures. To ensure comprehension and voluntary participation, the researchers distributed consent forms and questionnaires to the nurses who voluntarily wanted to participate. The survey included an explanation of the study and a consent form. A total of 240 completed surveys were collected and analyzed. A small gift was provided to the participants.
5. Data Analyses
The collected data were analyzed using SPSS version 24.0. General characteristics, performance of standard precautions, awareness of standard precautions, protective environment on exposure to infection, infection control, organizational culture, and moral sensitivity were analyzed using frequencies, percentages, means, and standard deviations. To analyze the performance of standard precautions according to general characteristics, an independent t-test, one-way analysis of variance, and Scheffé's post hoc test were performed. Pearson's correlation co-efficient was used to examine the relationships between performance of standard precautions, awareness of standard precautions, protective environment on exposure to infection, infection control organizational culture, and moral sensitivity. A stepwise multiple regression analysis was used to identify the factors that influenced performance of standard precautions among the participants.
6. Ethical Considerations
This study was approved by the institutional review board of Konyang University (IRB No. KYU-2020-199-01). Participants included those who were aware of the purpose and content of the study and chose to participate voluntarily after signing a consent form. The participants were informed that they could withdraw from the study at any time without penalty. Forms of consent were sent to the IRB when the final report was submitted. The collected data were anonymized, coded, and encrypted in a secure file before being deleted after 3 years.
RESULTS
1. Participant General Characteristics
Most of the participants were women 92.1% (n=221), and their average age was 43.88±11.09 years. 45.4% (n=109) were associate degree (3-year). 96.3%(n=231) had awareness of post-exposure response, and 46.7% (n=112) had a department of infection control and ICN. 79.6% (n=191) had infection control education experience.
Differences in the performance of standard precautions according to general characteristics showed significant differences in education level (F=5.55, p=.004), awareness of post-exposure response (t=2.73, p=.007), department of infection control and ICN (t=2.56, p=.011), and infection control education experience (t=3.27, p=.002). The post hoc analysis using Scheffé's test determined that participants with a graduate school or above (3.74±0.22) had significantly higher performance than those who were associate degree (3-year) (3.51±0.39) or bachelor's degree (3.65±0.34) (Table 1).
Table 1.
Differences in Performance of Standard Precaution by General Characteristics (N=240)
| Variables | Categories | n (%) or M± SD | Performance of standard precaution | |
|---|---|---|---|---|
| M± SD | t or F (p) Scheffé | |||
| Gender | Women | 221 (92.1) | 3.60±0.36 | −0.60 (.549) |
| Men | 19 (7.9) | 3.55±0.37 | ||
| Age (year) | ≤29 | 38 (15.8) | 3.59±0.40 | 1.17 (.322) |
| 30∼39 | 39 (16.3) | 3.52±0.34 | ||
| ＞40∼49 | 88 (36.7) | 3.59±0.37 | ||
| ≥50 | 75 (31.3) | 3.65±0.34 | ||
| 43.88±11.09 | ||||
| Marital status | Single | 56 (23.3) | 3.55±0.40 | 1.19 (.305) |
| Married | 176 (73.3) | 3.31±0.34 | ||
| Others* | 8 (3.3) | 3.48±0.58 | ||
| Education level | Associate degree (3-year)a | 109 (45.4) | 3.51±0.39 | 5.55 (.004) |
| Bachelor's degreeb | 116 (48.3) | 3.65±0.34 | a＜ b＜ c | |
| Graduate school or abovec | 15 (6.3) | 3.74±0.22 | ||
| Position | Staff nurse | 185 (77.1) | 3.58±0.37 | 1.22 (.297) |
| Head nurse | 32 (13.3) | 3.69±0.31 | ||
| Others† | 23 (9.6) | 3.56±0.32 | ||
| Clinical career (month) | ≤60 | 52 (21.7) | 3.65±0.35 | 0.71 (.548) |
| 61∼120 | 58 (24.2) | 3.55±0.41 | ||
| 121∼240 | 98 (40.8) | 3.59±0.34 | ||
| ≥241 | 32 (13.3) | 3.61±0.36 | ||
| 151.43±103.61 | ||||
| Bed size | ＜400 | 227 (94.6) | 3.59±0.36 | −0.22 (.829) |
| 400∼600 | 13 (5.4) | 3.62±0.34 | ||
| Possession of guideline for infection exposure | Yes | 229 (95.4) | 3.60±0.36 | 1.56 (.120) |
| No | 11 (4.6) | 3.43±0.45 | ||
| Awareness of post-exposure response | Yes | 231 (96.3) | 3.61±0.35 | 2.73 (.007) |
| No | 9 (3.8) | 3.28±0.47 | ||
| Department of infection control and ICN | Yes | 112 (46.7) | 3.66±0.35 | 2.56 (.011) |
| No | 128 (53.3) | 3.54±0.37 | ||
| Infection control education experience | Yes | 191 (79.6) | 3.64±0.33 | 3.27 (.002) |
| No | 49 (20.4) | 3.43±0.42 | ||
| Infectious disease exposure experience | Yes | 106 (44.2) | 3.59±0.34 | 0.20 (.841) |
| No | 134 (55.8) | 3.60±0.38 | ||
| Infectious disease exposure | 0 | 132 (55.0) | 3.60±0.38 | 0.20 (.898) |
| 1 | 78 (32.5) | 3.58±0.34 | ||
| 2 | 19 (7.9) | 3.55±0.35 | ||
| ≥3 | 11 (4.6) | 3.64±0.33 | ||
2. Descriptive Statistics of the Variables
The average awareness of standard precautions was 3.77±0.28 out of 4. The protective environment on exposure to infection average score was 3.93±0.64 out of 5, the infection control organizational culture average score was 5.47±1.03 out of 7, and the moral sensitivity average score was 5.06±0.71 out of 7. The performance of standard precautions average score was 3.59±0.36 out of 4 (Table 2).
Table 2.
Awareness of Standard Precaution, Protective Environment on Exposure to Infection, Infection Control Organizational Culture, Moral Sensitivity, Performance of Standard Precaution (N=240)
3. Correlations among Main Variables
Performance of standard precautions correlated positively with awareness of standard precautions (r=.57, p<.001), protective environment on exposure to infection (r=.45, p<.001), infection control organizational culture (r= .45, p<.001), and moral sensitivity (r=.22, p<.001) (Table 3).
Table 3.
Correlations among Awareness of Standard Precautions, Protective Environment on Exposure to Infection, Infection Control Organizational Culture, Moral Sensitivity, Performance of Standard Precaution (N=240)
4. Factors That Influenced Performance of Standard Precautions
A stepwise multiple regression was performed to identify the factors that influenced performance of standard precautions. Significant predictor (education level, awareness of post-exposure response, department of infection control and ICN and infection control education experience) were converted into dummy variables. Correlated factors (awareness of standard precautions, protective environment on exposure to infection, infection control organizational culture, and moral sensitivity) were included. P-P plot showed a near 45-degree alignment, and scatter-plots indicated uniform residuals. Durbin-Watson index (1.999) indicated no autocorrelation. Tolerance (.48 to .97) and variance inflation factor (1.03 to 2.10) indicated no multicollinearity. Final model included education level (Reference: Graduate school or above), awareness of standard precautions, protective environment on exposure to infection, and infection control organizational culture. Awareness of standard precautions (β=.45, p<.001), protective environment on exposure to infection (β=.19, p= .007), infection control organizational culture (β=.17, p= .017), and education level (associate degree (3-year)) (β=-.12, p=.016) significantly influenced the performance of standard precautions, explaining 43% variance (Table 4).
Table 4.
Factors Influencing Performance of Standard Precautions (N=240)
| Variables | B | SE | β | t | p |
|---|---|---|---|---|---|
| (Constant) | 0.73 | 0.25 | 2.96 | .003 | |
| Awareness of standard precautions | 0.57 | 0.07 | .45 | 8.55 | ＜.001 |
| Protective environment on exposure to infection | 0.11 | 0.04 | .19 | 2.74 | .007 |
| Infection control organizational culture | 0.06 | 0.03 | .17 | 2.39 | .017 |
| Education level (associate degree (3-year))† | −0.09 | 0.04 | −.12 | −2.43 | .016 |
| R2=.44, Adjusted R2=.43, F=46.27, p＜.001 | |||||
DISCUSSION
Present study aimed to identify the factors that influenced the performance of standard precautions and provide data for educational program development. Performance of standard precaution differed significantly by education level, awareness of post-exposure response, department of infection control and ICN, and infection control education experience. Continuous education improves nurses' clinical judgment and problem-solving [12,26]. In present study, performance of standard precautions averaged 3.59 out of 4, similar to Lee and Yang's [27] 3.61 score for small- and medium-sized nurses during COVID-19. Infection control accreditation and ongoing education in LTCH contributed to these results. However, the performance of standard precautions for PPE was low among LTCH nurses, consistent with Sim and Chae [9]. Thus, there is a need to continuously provide training on donning and doffing PPE to increase familiarity with the use of PPE.
In the correlation analysis between the performance of standard precaution and each variable among LTCH nurses, a higher awareness of standard precautions, more positive protective environment on exposure to infection, more favorable infection control organizational culture, and higher moral sensitivity were associated with higher performance of standard precautions. These findings are consistent with previous studies [13,16,17,28].
In present study, the factors that influenced performance of standard precautions among nurses in LTCH were awareness of standard precautions, protective environment on exposure to infection, infection control organizational culture, and education level. Jang and Lee [13] confirmed awareness of standard precaution guidelines among nurses in LTCH was a factor affecting performance of standard precaution guidelines. This suggests the necessity of implementing systematic education programs to ensure that nurses in LTCH recognize and effectively perform essential standard precautions for prevention and management of HAIs.
A protective environment on exposure to infection was identified as an important factor that influenced performance of standard precautions. The study by Ahn, Kim, and Kim [16] also confirmed that a better protective environment on exposure to infection is associated with higher performance of infection exposure prevention behaviors among emergency room nurses. According to the 2022 infection control survey in LTCH, PPE preparation was 90% and the separation of washing areas for contaminated equipment was 61.6% [29]. An adequate environment for standard precautions remains insufficient in LTCH, requiring strong organizational commitment to a systematic protective environment on exposure to infection.
Infection control organizational culture was identified as a factor that influenced performance of standard precautions. Baek et al. [17] determined infection control organizational culture is the most important predictor of infection control performance among LTCH nurses. Infection control organizational culture influences attitudes toward performance of HAIs guidelines, thereby encouraging performance of standard precautions [23]. Institutional efforts like education and staffing support are vital for a strong infection control culture.
Associate degree (3-year) status negatively impacted performance of standard precautions among LTCH nurses. Kim and Kim [26] found that hospital nurses with higher education showed significant differences in clinical performance. This suggests that degree programs improve nurses' understanding of standard precautions, enhancing performance. Institutional support, such as diverse training programs, is essential, along with nurses' individual learning efforts.
Moral sensitivity was not a significant factor that influenced performance of standard precautions. This result differs from the findings of Baek et al. [17], who reported "benevolence," a subcategory of moral sensitivity among LTCH nurses, is an important factor that influences performance of standard precautions. Considering that the data collection period for present study coincided with the COVID-19 pandemic, the LTCH hospital nurses may have experienced challenges in making ethical decisions about providing the best possible care to patients under the unique pandemic circumstances. Therefore, it is necessary to develop and operate continuous ethics education and training programs aimed at enhancing ethical knowledge, firm values, and moral sensitivity among LTCH nurses [17].
This study has several limitations of present study. First, despite no multicollinearity in VIF analysis, high correlation (r=.72) between protective environment on exposure to infection and infection control organizational culture suggests possible interdependence in regression results. Second, during COVID-19 (Feb 2021∼Jan 2022), infection control education (79.6%) and exposure rates (44.2%) were lower than expected, likely due to variations in LTCH policies and education quality. This overlap may result from the conceptual similarity between the two constructs, both representing organizational factors, and therefore warrants cautious interpretation. Future study should develop more robust measurement instruments to distinguish these constructs and reduce shared variance. Longitudinal studies comparing pre and post pandemic contexts are recommended to enhance validity and generalizability. Nevertheless, present study several strengths. First, performance of standard precautions among nurses in LTCH during the pandemic was examined, when infection prevention activities in healthcare institutions were more critical, and provided data that reflected the actual state of infection control. Second, it aimed to comprehensively identify performance of standard precautions among nurses, who are key personnel in LTCH, by analyzing it at the individual (awareness of standard precautions and moral sensitivity) and organizational levels (protective environment on exposure to infection and infection control organizational culture). Finally, present study explored the roles of LTCH nurses and proposed specific improvement strategies to enhance performance of standard precautions when responding to infectious diseases in LTCH.
CONCLUSION
Present study identified factors that influence performance of standard precautions. Therefore, continuous education and organizational support are essential to strengthen performance of standard precautions among nurses.
It is recommended that future studies expand scope of research to improve generalizability, employ longitudinal designs to monitor performance changes over time, and develop educational programs for LTCH nurses.
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