Bringing learning to light: innovative instructional strategies for teaching infection control to nursing students.
Infection control practices are at the forefront of education and compliance monitoring. A university-funded grant allowed faculty and instructional designers to create an experience that increased student awareness, application, and appreciation of infection-control concepts. Computer-based instruction modules are used to provide content, and students participate in a simulation that allows them to apply their newly learned skills in a realistic, immersive environment with a biosphere used to visually depict infectious spread. Student feedback suggests the usefulness of this methodology as a teaching strategy that reinforces evidence-based practice, critical thinking, and clinical judgments.
Experiential Learning--Infection Control--Hand Hygiene
More patients die from infections acquired while hospitalized than die from AIDS, breast cancer, or motor vehicle crashes (Arrowsight Medical, 2014). One out of every 20 hospitalized patients will contract a health-care-associated infection (HAI) (Klevens et al., 2007), incurred while the patient undergoes treatment in a health care setting (Horan, Andrus, & Dudeck, 2008). Emphasis on the reduction of HAIs is a major objective of the Joint Commission's Center for Transforming Healthcare (2012).
Hand hygiene (HH) is the single most effective infection control practice, but multiple studies confirm that it is the most overlooked and poorly executed infection control intervention (Son et al., 2011). In a review of HH compliance studies, Erasmus et al. (2010) found a median compliance rate of 40 percent.
The effective teaching of infection control techniques is challenging, as there is little feedback to show outcomes. This article reports on a learning experience designed with the expectation that simulation of infectious disease spread would reinforce the need for the use of proper precautions for all patients. This approach to learning incorporates Kolb's experiential learning theory (1984) and is expected to leave a more lasting impact than traditional approaches to learning.
Kolb describes a four-staged process by which the learner grasps information and transforms it so that it is meaningful to that individual. The four stages, Concrete Experience, Abstract Conceptualization, Reflective Observation, and Active Experimentation, are listed sequentially, but the learning cycle can be entered at any stage as learning occurs in the fullness of the cycle.
The project began when nurse faculty members were awarded a competitive grant from the university's Center for Learning and Teaching. This project introduces learners to abstract concepts and principles of infection control through computer-based learning modules. Abstract theories and concepts acquired by students include discussion of infection control principles and rationales for the use of personal protective equipment (PPE). The learner actively experiences the learned skill or situation in a concrete or tangible form, for example, by donning sterile gloves or PPE. Transformation of information occurs through reflective observation, that is, organizing and processing, as well as application in a real-world or simulated setting.
The team developed a series of computer-based instruction (CBI) modules that provide content as well as visual and aural events demonstrating infection control principles. The modules are uploaded to the school of nursing's Virtual Hospital. The lessons consist of a foundational module and interactive skills-based HH and PPE modules. The faculty also developed an infection control simulation for students to complete in the clinical lab that allows for the transformation of information. The simulation is followed by faculty-led debriefing sessions for reflective observation. The use of this innovative delivery strategy has resulted in a pedagogy that shifts the instructional delivery from a teacher-centered approach focused on visual and auditory modalities, to a learner-centered, scenario-based simulation that adds a kinesthetic and tactile modality.
THE COURSE CONTENT
To successfully complete the HH CBI module, learners are directed to complete a hand washing exercise that simulates the actions taken at a hand washing station typically found in the health care setting. Following the steps learned via an aural and visual modality in the CBI, the students apply the proper hand washing steps by participating in an interactive, Adobe Flash-based practical application. The application, embedded in the CBI, animates the learner's actions.
In each step, the learner is required to determine the proper sequence while interacting with the virtual hand washing station. If the learner chooses incorrectly, there are aural and visual prompts to try again. When the learner chooses correctly, the step is written on a virtual clipboard to reinforce the correct choice, and the selected actions are animated to simulate the aural and visual feedback found in the actual environment.
The CBI then requires the learner to click and move the mouse to simulate hand rubbing for a minimum of 15 seconds as the clock tracks the elapsed time. The motion of the learner's hand interacting with the mouse closely replicates the physical motion of hand washing, serving as a bridge between a cognitive understanding of the proper hand washing steps and the tactile motor skills required in the clinical environment.
Once learners successfully complete the HH CBIs, they participate in a simulation that allows them to apply their newly learned skills in a realistic, immersive environment. Each lab station contains a mid-or high-level performance simulator headboard with equipment typically found in an inpatient setting. The station also includes a laptop. Students are expected to demonstrate appropriate HH concepts, the use of PPE, and sterile technique.
The patient care simulation includes the use of a biosphere to visually depict infectious spread. The powder is invisible to the naked eye, is easily transferable, and fluoresces under ultraviolet light (UVL). The biosphere, developed for research and educational use for our team after we encountered difficulty cleaning the manikins during pilot testing, is nontoxic and used in everyday household products, for example chewing gum and makeup. Unlike less expensive, commercially available products, this product can be wiped off porous surfaces (e.g., a manikin), and nonporous lab and equipment surfaces by using water and a paper towel.
Prior to the lab session, faculty use makeup brushes to plant the biosphere in the wounds of the manikins. The lab activity requires students to change a surgical or wound dressing for a patient using contact precautions for patients with infectious wounds but not for patients with clean surgical wounds. If students do not apply the infection control/HH knowledge and skills presented in the CBI correctly, the substance spreads as they care for the patient.
At the end of the each lab session, faculty turn off the lights and use hand-held UV lights to demonstrate the spread of the simulated infectious disease. The students are able to visualize the spread of the disease within and between the different lab stations, on PPE, computers, classroom desks, and themselves.
DEBRIEFING AND STUDENT EVALUATIONS
During debriefing, students have reflected upon the ease with which they unknowingly transmitted the SID, not only throughout the lab, but also on their hands and faces and their personal belongings, mainly their cellphones and computers. Several students have expressed concern that they would have the potential to contaminate their own children, through physical contact or through their cellphones, for example. When such comments are made, faculty steer students to also consider the ramifications in the hospital setting. When the conversation focus shifts, the need for vigilance in the health care setting is reinforced. This practical application, followed by the debriefing, completes the final step in the pedagogical design.
After the debriefing session, faculty encourage the students to provide feedback about the new instructional method and application of technology and simulation. In an initial evaluation, 61 of 79 students (77 percent) completed a three-item questionnaire rating their experiences with the CBI and with the UVL practical application. The feedback provided overwhelmingly positive comments about the impact of this project.
Using a five-point Likert scale, students rated the effectiveness of the CBI modules as a teaching method that prepared them for the lab experience with an average score of 4.53 (range 3 to 5). The students rated the UVL lab exercise as being designed for their specific level of knowledge with an average score of 4.48 (range 4 to 5).
Students responded to open-ended questions describing the experience of using UVL to detect the simulated spread of infectious disease. Their responses provided insightful feedback, such as: "I feel so dirty; can I wash my hands?" "This is one of the best ways of learning; this picture was worth more than a thousand words!" Comments included "wow!" "scary!" and "enlightening!" There were no negative comments about the CBIs or the patient care simulation, but two students felt that the 90 minutes of CBI preparation took longer than they would have otherwise spent preparing for class.
The project combined the use of an aural/visual modality in order to stimulate cognitive knowledge of the infection control practices, progressed to an aural/visual/tactile modality during the CBI simulations, and completed the transition with a kinesthetic, practical application in the lab followed by debriefing. This approach represents a pedagogical shift from passive to active learning, acknowledges the Joint Commission's Center for Transforming Healthcare goal of reducing HAIs, and responds to the call by Benner, Sutphen, Leonard and Day (2010) to transform teaching techniques.
Transformation is accomplished by focusing on essential knowledge and skills, incorporating technology, and integrating didactic content with lab and clinical experiences. Student feedback suggests the usefulness of this methodology as a teaching strategy that reinforces evidence-based practice, critical thinking, and clinical judgments.
Arrowsight Medical. (2014). Patient safety: Current statistics. Retrieved from www. patientsafetyfocus.com/patient-safety-current-st.html
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
Erasmus, V., Daha, T., Brug, H., Richardus, J., Behrendt, M., Vos, M., ... van Beeck, E. (2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control and Hospital Epidemiology, 310), 283-294.
Horan, T. C., Andrus, M., & Dudeck, M. A. (2008). CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. American Journal of Infection Control, 360), 309-332.
Joint Commission. (2012). Joint Commission Center for Transforming Healthcare. Retrieved from www.centerfortransforminghealthcare.org
Klevens, R. M., Edwards, J. R., Richards, C. L., Horan, T. C., Gaynes, R. R, Pollock, D. A.,.. . Cardo, D. M. (2007). Estimating health care-associated infections and deaths in U.S. hospitals in 2002. Public Health Reports, 122(2), 160-166.
Kolb, D. A. (1984). Experiential learning. Englewood Cliffs, NJ: Prentice-Hall.
Son, C., Chuck, T., Childers, T., Usiak, S., Dowling, M., Andiel, C., ... Sepkowitz, K. (2011) . Practically speaking: Rethinking hand hygiene improvement in health care settings. American Journal of Infection Control, 39, 716-724.
Lynn L. Wiles, PhD, MSN, RN, CEN, is assistant professor and director of technology and simulation, Old Dominion University School of Nursing, Norfolk, Virginia. Donna Rose, MSN, RN, is senior lecturer, Old Dominion University School of Nursing. Kimberly Curry-Lourenco, PhD, RN, a senior lecturer at Old Dominion University School of Nursing when this project was completed, is coordinator of instruction and technology, Tidewater Community College, Portsmouth, Virginia. Dave Swift, MS, now retired, was an instructional designer, Old Dominion University Center for Learning and Teaching. For more information, write to Dr. Wiles, firstname.lastname@example.org.