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Asian Nursing Research xxx (2014) 1e7
Contents lists available at ScienceDirect
Asian Nursing Research journal homepage: www.asian-nursingresearch.com
Review Article
An Integrative Review of Infection Control Research in Korean Nursing Journals Q17
Kyung Mi Kim, RN, PhD, 1 Jeong Sil Choi, RN, MPH, PhD 2, * 1 2
Department of Nursing, Semyung University, Jecheon, South Korea College of Nursing, Gacheon University, Incheon, South Korea
a r t i c l e i n f o
s u m m a r y
Article history: Received 21 May 2013 Received in revised form 27 December 2013 Accepted 21 January 2014
Purpose: This study was performed to analyze the characteristics and trends of published research papers related to infection control in Korean nursing journals. Methods: A total of 177 studies published between 1970 and 2011 were reviewed using analysis criteria. Subject articles were selected through KoreaMed and journal database searches on the website of subject academic societies using key words related to healthcare-associated infections. Results: Most reports were quantitative studies and the majority of them were descriptive studies. The most common subjects of research were infection control measures for pathogens, followed by disinfection and sterilization, and hand hygiene. Among them, the most descriptive studies were conducted on the knowledge, attitude, and performance of infection control. Theoretical framework, criteria for sample size and ethical consideration were rarely presented in quantitative studies. Conclusions: To enhance the quality of infection control studies and establish infection control studies as a nursing knowledge body, meta-analyses and systematic literature reviews as well as quantitative studies are needed. Moreover, studies employing behavioral science to identify factors influencing the level of knowledge and practice and to change infection control behaviors are also warranted. Copyright Ó 2014, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Keywords: infection control nursing research review
Q1
Introduction Q2
Infection control is a critical issue in clinical settings for patients. health and safety. Infection prevention activities include, but are not limited to surveillance of infections, identifying, controlling and investigating outbreaks in collaboration with appropriate disciplines, infection prevention of healthcare workers (HCWs), ensuring aseptic techniques of procedures as appropriate, education of medical and nonmedical staff for infection prevention, proper disinfection and sterilization procedures of medical equipment and environment in hospitals, environmental management including medical waste management, participation in establishing, implementing, and evaluating proper isolation protocols, departmental infection control procedure, and identifying proper infection control measures for specific pathogens. Infection control activities are closely related to nursing practices in various clinical settings and specialties (Korean Society for Nosocomial Infection Control, 2011). Therefore, understanding the characteristics and trends of infection
* Correspondence to: Jeong Sil Choi, RN, MPH, PhD, College of Nursing, Gacheon University, 191 Hambakmeoro, Yeonsu-gu, Incheon 406-799, South Korea. E-mail address: [email protected]
control is imperative for nursing researchers and nursing disciplines to identify issues related to infection control, and to evaluate if the research focus and approach were appropriate to solve the related problems in clinical practice. Infection control is recognized as a nursing specialty with its activities being performed independently and autonomously by different nursing personnel regardless of if he or she is a direct or nondirect care provider. The full scale infection control in South Korea started with the appointment of a dedicated nurse for infection prevention at Seoul National University Hospital in the early 1990s (Oh & Choi, 1996). Under the amendment of the Medical Act in 2002, infection control has become one of the specialties in nursing. A masters-prepared infection control nurse has become an infection control nurse specialist, thus, resulting in creating a solid foundation for infection control and making it one of the most important nursing specialties in South Korea (Kim, Jeong, & Park, 2010). With the recent increase in the interest in infection control many nursing scholars, researchers, and front-line nurses started publishing research articles on infection control in nursing or nursing-related journals. Recent studies were also conducted to analyze the body of knowledge accumulated in nursing through reviews of articles in specific journals (Choi et al., 2000; Shin et al., 2010), by analyzing articles according to the knowledge classification criteria (Jang,
http://dx.doi.org/10.1016/j.anr.2014.05.002 1976-1317/Copyright Ó 2014, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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2005) or statistical methods (Kang, 2002), and by analyzing the trends of articles with a focus on their key words (Jeong, Ahn, & Cho, 2005). In the past, some nursing researchers focused on analyzing research methods or themes of articles published by the top 10 nursing journals in terms of impact factors based on the quotation index or ranking of the journals (Mantzoukas, 2009). Furthermore, some studies focused on analyzing the international trend of articles published by the top 42 nursing journals registered in the Social Sciences Citation Index (SSCI; Dougherty, Lin, McKenna, & Seers, 2004). Although infection control activities have become more elaborative and its importance has been emphasized since the introduction of infection control in South Korea in the 1990s, studies regarding infection control through literature review and analysis have not yet been conducted thoroughly. To expand the body of knowledge in nursing, literature reviews and analysis of existing published research articles that examine existing types and trends of nursing research are as important as developing a new nursing theory or methodology, which will provide a solid foundation for nursing knowledge and direction for future nursing research (Shin et al.; Suh et al., 2007). Through the comprehensive literature review related to infection control, nursing disciplines will be able to understand the degree and area of researchers’ concerns on infection control. The purpose of this study was to analyze and understand the characteristics and trend of studies regarding infection control through the comprehensive review of studies published in South Korean nursing journals from January 1970 to December 2011 to provide a direction for future studies on infection control. The detailed purposes of the study are to (a) analyze the overall characteristics of studies regarding infection control published in Korean nursing journals by year, (b) analyze quantitative research characteristics of infection control studies published in Korean nursing journals by year, (c) analyze qualitative research characteristics of infection control studies published in Korean nursing journals by year, (d) develop intervention strategies for future infection control in South Korea, and (e) propose a direction for future infection control studies based on the findings. Methods Study design This research was a descriptive study analyzing the characteristics and research trends in infection control studies published in Korean nursing journals using the analysis framework developed by the researcher. Setting and sample In total, 177 articles published between January 1970 and December 2011 were obtained from the various nursing journal databases such as Journal of Korean Academy of Nursing (JKAN), the Journal of Academic Division of Korean Society of Nursing Science, and nursing journals registered in the Korea Citation Index of National Research Foundation. Nursing journals registered in the Korea Citation Index of National Research Foundation are JKAN, The Korean Journal of Fundamentals of Nursing, Korean Journal of Adult Nursing, Korean Journal of Women Health Nursing, Journal of Korean Academy of Psychiatric and Mental Health Nursing, Journal of Biological Nursing Science, Journal of Korean Academy of Community Health Nursing, Journal of Korean Academy of Nursing Administration, Journal of Korean Gerontological Nursing, Journal of Korean Public Health Nursing, The Journal of Korean Academic Society of Nursing Education, Journal of Korean Clinical Nursing Research, Korean Journal of Occupational Health Nursing, and Asian Nursing Research.
Analysis tool An analytical framework, developed by the researchers to analyze the characteristics of infection control studies after reviewing previous studies of article analysis (Choi et al., 2000; Shin et al., 2010; Sohng et al., 2008) was followed. The analytical framework consisted of three parts: (a) general characteristics of the study, (b) quantitative research, and (c) qualitative research. General characteristics included the type of manuscripts, type of research, ethical considerations, and sample sizes by year. To analyze characteristics of infection control studies, author, correspondent author, research theme related to infection control, and research subjects were included. Analysis of quantitative research included research design, conceptual framework, criteria for sample size, reliability and validity of instrument, instrument source, data collection method, and data analysis method. In particular, when the key words were related to knowledge, practice, and attitude of infection control, additional analysis was performed on those key words. Qualitative research included research design, description of philosophical underpinning, training of researchers, data collection methods, and reliability and validity analysis of research findings. Data collection Data collection and analysis was performed from April to June 2012. Inclusion criteria of this study were (a) both English and Korean language publications, (b) research studies identifying issues related to infection control, (c) research articles published in the JKAN, Journals of Academic Division of Korean Society of Nursing Science and nursing journals registered in the Korea Citation Index of National Research Foundation and (d) articles published between January 1970 and December 2011. Subject articles were selected through KoreaMed and journal database searches on the website of subject academic societies by researchers. Search terms included “hospital infection”, “urinary tract infection”, “pneumonia”, “surgical wound infection”, “intravenous catheter infection”, “disinfection and sterilization”, “hand hygiene (hand washing)”, “asepsis”, “standard precautions and isolation”, “infection control by department”, “environmental management”, “HCWs infection control”, and “infection control measures for pathogens: Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE), Acquired Immune Deficiency Syndrome (AIDS), influenza, and human papilloma virus (HPV)”. Search terms were selected based on the table from the APIC textbook of infection control and epidemiology (Carrico et al., 2009), Q3 Textbook of Infection Control (Korean Association for Infection Control, 2012), and Infection control and prevention in healthcare facilities (Korean Society for Nosocomial Infection Control, 2011). Q4 Manual search was conducted with the two researchers to include articles which could have been missed from the initial search with key words and to exclude articles found through the database search that included key words, but not clearly meeting the inclusion criteria. The articles that met the inclusion criteria were again analyzed individually by each researcher. The selected infection control articles were primarily analyzed by each researcher according to the analytical framework developed by the researchers of this research. The results of the primary analysis were cross-reviewed by the researchers and corrections were made for insufficient or unclear parts after rereviewing the original articles (Cohen’s Kappa ¼ .9). Data analysis The collected data was analyzed using SPSS version 20.0 for windows (SPSS Inc., Chicago, IL, USA). General characteristics of subject articles were analyzed using frequency and percentage.
Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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K.M. Kim, J.S. Choi / Asian Nursing Research xxx (2014) 1e7 Table 1 Overall Analysis of Published Papers Related to Infection Control (N ¼ 177).
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66 67 Characteristics Classifications Year n (%) 68 1970e79 1980e89 1990e99 2000e09 2010e11 69 70 Total (%) 3 (1.7) 10 (5.6) 37 (20.9) 92 (52.0) 35 (19.8) 177 (100.0) Manuscript type Research paper 1 1 26 63 17 108 (61.0) 71 Thesis or dissertation 2 2 5 6 5 20 (11.3) 72 Grant 0 7 6 23 13 49 (27.7) 73 Research type Quantitative research 3 10 37 87 34 171 (96.6) 74 Qualitative research 0 0 0 1 1 2 (1.1) 75 Review paper 0 0 0 2 0 2 (1.1) Others 0 0 0 2 0 2 (1.1) 76 First author Professor 0 7 19 52 19 97 (54.8) 77 Nurse 1 2 15 30 9 57 (32.2) 78 Infection control nurse 0 0 0 6 4 10 (5.6) 79 Others 2 1 3 4 3 13 (7.3) Corresponding author Professor 0 9 24 74 29 139 (76.8) 80 Nurse 1 1 9 12 5 28 (15.8) 81 Infection control nurse 0 0 1 2 1 4 (2.3) 82 Others 2 0 3 4 0 9 (5.1) 83 Ethical consideration Verbal consent 0 0 8 39 8 55 (31.1) 84 Written consent 0 0 1 9 12 22 (12.4) Institutional review board 0 0 0 4 6 10 (5.6) 85 Not mentioned 2 6 25 37 6 76 (43.0) 86 Not applicable 1 4 3 4 2 14 (7.9) 87 Sample size < 100 6 21 44 15 2 88 (49.7) 88 100e199 0 2 15 8 0 25 (14.1) 200e299 1 2 12 8 0 23 (13.0) 89 300e399 2 5 7 1 0 15 (8.5) 90 400 1 7 10 3 1 22 (12.4) 91 Unknown 0 0 4 0 0 4 (2.3) 92 Research theme Infection control for pathogen type 0 0 9 30 12 51 (28.8) 93 Disinfection/sterilization 1 2 5 8 7 23 (13.0) Hand hygiene 0 0 4 14 4 22 (12.4) 94 General infection control 0 1 3 11 0 15 (8.5) 95 Urinary tract infections 1 2 4 4 0 11 (6.2) 96 Intravenous catheter associated infections 0 0 3 5 2 10 (5.6) 97 Pneumonia 0 1 1 3 3 8 (4.5) Occupational infection control 0 0 2 5 1 8 (4.5) 98 Surgical site infections 0 1 0 2 1 4 (2.3) 99 Standard precaution/isolation 0 0 0 0 4 4 (2.3) 100 Environmental control 1 1 0 2 0 4 (2.3) 101 Aseptic technique 0 1 2 0 0 3 (1.7) 102 Infection control for unit types 0 0 3 0 0 3 (1.7) Others 0 1 1 8 1 11 (6.2) 103 HIV/AIDS 0 0 9 14 1 24 (47.1) 104 Subclassification of infection control Influenza 0 0 0 2 7 9 (17.6) 105 for pathogen type MRSA 0 0 0 6 0 6 (11.8) 106 HPV 0 0 0 2 3 5 (9.8) VRE 0 0 0 4 0 4 (7.8) 107 Others 0 0 0 2 1 3 (5.9) 108 Subtotal 0 0 9 30 12 51 (100.0) 109 Research subjecta Nurse 0 2 16 38 12 68 (33.2) 110 Patients 2 6 10 24 6 48 (23.4) 111 Well participant 0 0 4 9 10 23 (11.2) Environment 1 4 8 5 2 20 (9.8) 112 Nursing/medical students 0 0 4 10 3 17 (8.3) 113 Physician 1 2 6 6 0 15 (7.3) 114 Other Healthcare workers 0 0 2 6 0 8 (3.9) 115 Microorganisms 0 0 0 1 0 1 (0.5) Others 0 0 0 5 0 5 (2.4) 116 Subtotal 4 14 50 104 33 205 (100.0) 117 118 Note. MRSA ¼ methicillin resistant staphylococcus aureus; VRE ¼ vancomycin resistant enterococci; HIV/AIDS ¼ human immunodeficiency virus/acquired immune deficiency syndrome; HPV ¼ human papilloma virus. 119 a Multiple choice. 120 121 122 123 professors (54.8%). Among the corresponding authors, 139 (76.8%) Results were nursing professors. With regard to ethical consideration, 76 Q5 124 125 (43.0%) studies did “not specifically [mention]” it, and only 10 (5.6%) Analysis of total infection control research articles 126 indicated institutional review board approval. The most common 127 sample sizes were under 100 (49.7%). The most frequent topic of study A total of 177 articles comprising 108 (61.0%) general studies, 20 128 was infection control measures for pathogens, in 51 (28.8%) studies. (11.3%) master’s or doctoral degree theses, and 49 (27.7%) research 129 Among the infection control measures for pathogens, HIV/AIDS was grant studies. Quantitative research was the most frequent type, 130 the most frequently observed, in 24 (47.1%) studies (Table 1). numbered at 171 (96.6%). The most common first author was nursing Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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Table 2 General Characteristics of Quantitative Research (N ¼ 171). Characteristics
Total (%) Study design
Conceptual framework
Criteria for sample size Reliability/validity instrument Instrument sourcea
Data collection methods*
Classifications
Experimental study
True experimental study Quasi-experimental study Pre-experimental study Subtotal
Surveyb Meta analysis Literature analysis Others Presented Not presented Not applicable Presented Not presented Reported Not reported/not applicable Revise Self report Physiological measure Original Clinical records Not applicable Not reported Subtotal Questionnaire Microbiologic culture Chart review Observation Physiological measure Self report Interview Sociopsychological measure Delphi Others Subtotal
Year
n (%)
1970e79
1980e89
1990e99
2000e09
2010e11
3 (1.8) 0 0 0 0 3 0 0 0 0 3 0 0 3 0 3 0 0 3 0 0 0 0 3 0 3 0 0 0 0 0 0 0 0 3
10 (5.8) 0 3 1 4 6 0 0 0 1 4 5 0 10 0 10 1 0 4 3 2 0 1 11 0 7 3 0 0 0 0 0 1 0 11
37 (21.6) 1 9 2 12 25 0 0 0 2 22 13 3 34 13 24 20 10 6 6 4 3 1 50 22 12 2 6 0 0 0 1 0 0 43
87 (50.9) 1 27 9 37 48 0 1 1 4 51 32 17 70 40 47 53 28 31 24 9 3 1 149 54 32 14 5 4 2 1 0 0 1 113
34 (19.9) 3 7 1 11 22 1 0 0 2 26 6 24 10 19 15 19 15 3 7 4 4 1 53 21 7 5 1 0 1 1 0 0 2 38
171 5 46 13 64 104 1 1 1 9 106 56 44 127 72 99 93 53 47 40 19 10 4 266 97 61 24 12 4 3 2 1 1 3 208
(100.0) (2.9) (26.9) (7.6) (37.4) (60.8) (0.6) (0.6) (0.6) (5.3) (62.0) (32.7) (25.7) (74.3) (42.1) (57.9) (35.0) (19.9) (17.7) (15.0) (7.1) (3.8) (1.5) (100.0) (46.6) (29.3) (11,5) (5.8) (1.9) (1.4) (1.0) (0.5) (0.5) (1.4) (100.0)
Q15
Note. aMultiple choice. bSubjects of descriptive research related to knowledge, attitude and performance of infection control: 49 (47.1%).
Analysis of quantitative research General characteristics There were 171 quantitative articles in total, comprising 104 (60.8%) surveys. Among the 104 survey studies, 43 (40.2%) studies were on knowledge, attitude and performance, and 64 studies were experimental studies (37.4%). Of the 64 studies, 46 studies consisted of quasi-experimental studies which were the most frequently used study method. A total of 106 studies (62%) did not include information about theoretical framework. Regarding the provision of criteria for sample size, 127 studies (74.3%) did not provide a rationale related to determining the sample size. Seventy-two studies (42.1%) reported the reliability and validity of tools used, while 99 studies (57.9%) either did not report them or were not applicable. When allowing multiple answers on the source of tools presented in studies, 93 studies (35.0%) were modified and used tools developed by others, while 53 studies (19.9%) developed tools independently for the study, and 17 studies (17.7%) used physiological measurement tools. In data collection methods, 97 studies (46.6%), used questionnaires allowing multiple answers, followed by microorganism culture results in 61 studies (29.3%), and medical record analysis in 24 studies (11.5%; Table 2). Research themes related to knowledge, attitude and performance Among survey studies, 49 studies (47.1%) were on themes related to knowledge, attitude and performance. Among the 49 studies, “infection control measures for pathogens” was the most popular theme found in 24 studies (49.0%) followed by the theme of
“overall infection control” found in 10 studies (20.4%). Among the study of pathogenic organisms, AIDS was the most popular theme examined by 12 studies (24.5%), followed by influenza examined by 5 studies (10.2%). Analysis of qualitative research There were two qualitative researches within the context of the body of existing literature: one using the phenomenological approach (50.0%) and one the focus group method (50.0%). One study provided the philosophical underpinning of the research and a suggestion for training of the researcher (50.0%). Both studies used in-depth interview analysis as the data analysis method. Explanations on the data analysis process were provided in both studies and one (50.0%) study reported reliability and validity of the study findings (Table 3).
Q16
Table 3 Analysis of Qualitative Research (N ¼ 2). Characteristics Design Design Philosophical background Philosophical background Researcher training Researcher training Data collection methods Data analysis process Validity/reliability Validity/reliability
Classifications Phenomenology Focus group Presented Not presented Presented Not presented In-depth interview Presented Reported Not reported
n (%) 1 1 1 1 1 1 2 2 1 1
(50.0) (50.0) (50.0) (50.0) (50.0) (50.0) (100.0) (100.0) (50.0) (50.0)
Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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Discussion
Q6
Q7
This study was the first comprehensive literature review undertaken to analyze characteristics and trend of the infection control research studies published in nursing journals in South Korea. A total of 177 studies published between 1970 and 2011 were reviewed. They were selected through journal database searches on the website of subject academic societies. The strength of this study was that it was meaningful in identifying common themes and types of infection control related to nursing disciplines, and understanding the changes and trends of infection control studies over the past 40 years in South Korea. The study results showed that there have been an increasing number of infection control studies published in Korean nursing journals. Based on the increase in the number of published studies, one can conclude that researchers’ interest in infection control was also increased. By study type, quantitative studies were dominant, comprising 96.6% of the total research studies, and review and meta-analysis of the literature related to infection control research were rarely done. Studies in infection control with emphasis on evidence-based practice, although Centers for Disease Control and Prevention and World Health Organization have prepared and provided infection control guidelines based on various research, are not enough to answer the problems related to infection control. To provide evidence-based practice to the front line practitioners, researchers needed to perform systematic literature reviews and meta-analysis, and provide a summary of the existing body of literature on intervention effects (Jeong, Jeon, Whang, Kim, & Ha, 2008). In the 2000s, subsidized research on infection control had increased. However, for the 2 years after 2010, publication of both research grant studies and general research studies on infection control have increased as well. Based on the current trend of the research on infection control, one can conclude more research grant studies are expected in the future. More than 50% of the total number of studies conducted before the year 2000 did not mention whether the researchers had ethical considerations or followed proper processes to protect research participants. After 2000, more and more studies mentioned obtaining verbal agreement, written agreement, or IRB approval for the study. According to a study by Choi et al. (2011), which analyzed trends of articles published in journals mainly by nurses working in the clinical setting, the results found were similar with those of this study. In that study, there were only two studies that received IRB approval from 1995 to 2008. This shows that the emphasis on research ethics is recent and it was not the main matter to consider in the previous period. As a result of diverse efforts on nursing ethics, in 2006, the Korean Society of Nursing Science enacted the ethics charter and code of research ethics for Korean nursing researchers. Articles about infection control submitted to nursing journals were influenced because many of these journals recently required IRB approval before submission. In the past 2 years, most researchers obtained IRB approval for research and conducted research within the ethical and moral considerations during the research processes. Because infection control research deals with sensitive issues related to the safety of clients, there should be systematic efforts, by various nursing disciplines and organizations, to provide proper education by developing, implementing, and sustaining educational programs on ethics for future nursing research. The frequently used subject of infection control studies were “infection control measures for pathogens”, followed by “disinfection and sterilization”, while “hand hygiene” was the least frequent subject. Among the infection control measures for pathogens, the most frequently studied pathogen was HIV/AIDS between the 1990s and 2000s, which strongly related to the AIDS epidemics in
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South Korea which started in 1999 (Korean Alliance to Defeat AIDS, 2011). Studies on the most common cause of healthcare-associated infections, such as MRSA and VRE were mainly conducted after the year 2000 in South Korea. For the past 2 years, studies on influenza have increased significantly as new strains of influenza became more prevalent in 2009 (Kim, 2011). In controlling the epidemical outbreak of influenza, many studies on infection control measures specific for pathogens were not conducted in hospitals or communities at the time of influenza outbreaks to find intervention strategies that were specific for specific causes. This phenomenon can be explained by the fact that most researchers were nursing professors or nurses, not infection preventionists. No research analyzed trends of nationwide infection control related articles. However, according to a study which analyzed the articles focused on education in infection control in the US and Europe to identify the effect of infection control education, 41.0% of the research were about application of various educational methods, 28.2% for hand hygiene, 12.8% for bacteremia, and 7.7% for MRSA (Ward, 2011). The American Association of Nurse Anesthetists reports, through the research to revise evidence-based infection control guideline, that multidrug resistant organism is settling in the main research of infection control, while the matter of interest in 1980s was HIV, the life-threatening blood infection (Griffis, 2013). Also, in the UK, research was conducted in order to provide national evidencebased guidelines for preventing HAIs executed multiple systematic review about hospital environmental hygiene, hand hygiene, use of personal protective equipment, safe use and disposal of sharps, principles of asepsis, short-term indwelling catheters, and intravascular access devices (Loveday et al., 2014). Hand hygiene was the most frequently referenced one among the above subjects. Based on results from previous research, it turned out that it is similar that research about hand hygiene and multidrug resistant organism were performed in the main theme. Within the body of literature collected for analysis, most studies used quantitative research as the research method, comprising 60.8% of the surveys. Among the survey studies, 47.1% of research was conducted on the knowledge, practice, and attitude related to infection control. However, Pittet (2004) suggested that the level of knowledge on infection control cannot be regarded as an appropriate index indicating practice behaviors. Pittet also stated that the practices of infection control guidelines were affected by many other factors. Therefore, it is desirable to identify the factors that influence the low level of knowledge and practice, develop and apply concrete programs to enhance the levels and then measure the effects of the programs rather than repeating survey research on infection control knowledge, practice and attitudes of nurses and nursing students. Only 2.2% of the research was a true experimental study. We assumed that the reason for this low percentage was due to the difficulty or impossibility of conducting true experimental research on human subjects ethically. The current trend of infection control activity is the use of clinical guidelines developed based on evidence-based research. Therefore, further systematic review of the literature or quasi-experimental studies related to unresolved issues are needed to verify the appropriateness of the infection control guidelines. Most quantitative research did not provide a theoretical framework for their study because these studies did not apply nursing interventions and the subjects of the research were not humans. Many researchers modified and supplemented existing tools developed by other researchers rather than developing new tools for the study. Microorganism cultures were the most frequently used data collection methods because of the nature of the study: infection control. Most of the quantitative studies conducted before the year 2000, did not provide the criteria for sample
Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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size, rationales for sampling strategies, or the validity of the study with theoretical framework. However, the studies providing information on sampling strategies using specific statistical analysis including G-Power have increased since 2000, thus, enhancing the quality of the research. There were only two qualitative studies, which did not provide sufficient information on addressing successful infection control strategies, based on the understanding in the spread of infectious diseases or pathogenicity in South Korea. In other countries, many studies (Efstathiou, Papastavrou, Raftopoulos, & Merkouris, 2011; Seto, 1995 ; Trunnell, & White, 2005; Whitby, McLaws, & Ross, 2006) have been conducted to improve the compliance of hand hygiene, standard precautions, and infection control guidelines by applying various behavioral change strategies based on the behavioral science (Seto, 1995), as most healthcare associated infections are related to improper procedures or behaviors of HCWs. From this perspective, conducting qualitative research is strongly encouraged for understanding the phenomena between infection control related reactions and environment on HCWs, which will lead to constructing a new body of knowledge. Nurses take the most important role in infection control as they are the front-line workers in the healthcare arena and provide direct care to patients on a daily basis. Nurses should be aware of the current issues related to infection control in the clinical settings, be able to identify the controversial issues of infection control, and formulate solutions for effective infection control through research. This evidence-based clinical practice, based on nursing research, will truly advance nursing practice, resulting in better patient outcomes. In this study, research studies on infection control conducted between January 1970 and December 2011 were reviewed. This study is meaningful as it was the first integrated review on infection control research studies published over the past 40 years in South Korea. This study is limited by the fact that the study samples were those published in the South Korean nursing journals. Thus, we were unable to generalize the study findings. In addition, 20% of the research was conducted after 2010, and due to the shorter time frame, it is not feasible to conduct a 10-year-span comparison, which poses as a study limitation as well. Further, continuous efforts should be made in studying current trend of infection control to develop and implement effective infection control strategies. This study results could provide South Korean and foreign nursing researchers some directions for future nursing research on infection control. Conclusion Most reports were quantitative studies and the majority of them were descriptive studies. Most descriptive studies were conducted on the knowledge, attitude, and performance of infection control. The most common subjects of research were infection control measures for pathogens. To enhance the quality of infection control studies and establish infection control studies as a nursing knowledge body, meta-analyses and systematic literature reviews as well as quantitative studies are needed. Moreover, studies employing behavioral science to identify factors influencing the level of knowledge and practice and to change. Understanding the characteristics and trends of infection control research will enable us to identify whether they have the right directions to solve the infection control related problems in clinical practice. Further research is needed to identify factors influencing effective infection control and to develop intervention strategies. Conflict of interest The authors declare no conflict or interest.
Uncited reference Choe et al., 2010. Acknowledgment The authors would like to thank assistant professor Leesuk Ferencsik of the Adventist University of Health Sciences Department of Nursing, for editorial help. This study was supported by the Korean Association of Infection Control Nurses Grant. References Carrico, R., Adam, L., Aureden, K., Fauerbach, L., & Friedman, C. (Eds.). (2009). APIC text of infection control and epidemiology (3rd ed.). Washington: Association for Professionals in Infection Control and Epidemiology. Q13 Choe, M. A., Jeong, J. S., Lim, K. C., Kim, J. H., Kim, K. S., Kwon, J. S., et al. (2010). Research trend of studies published in Journal of Korean Clinical Nursing Research, 1995e2008. Journal of Korean Clinical Nursing Research, 16(2), 95e105. Q14 Choi, K. S., Song, M. S., Hwang, A. R., Kim, K. H., Chung, M. S., Shin, S. R., et al. (2000). The trends of nursing research in the Journal of the Korean Academy of Nursing. Journal of Korean Academy of Nursing, 30(5), 1207e1218. Dougherty, M. C., Lin, S. Y., McKenna, H. P., & Seers, K. (2004). International content of high ranking nursing journals in the year 2000. Journal of Nursing Scholarship, 36(2), 173e179. http://dx.doi.org/10.1111/j.1547-5069.2004.04031.x Efstathiou, G., Papastavrou, E., Raftopoulos, V., & Merkouris, A. (2011). Factors influencing nurses’ compliance with standard precautions in order to avoid occupational exposure to microorganisms: a focus group study. BMC Nursing, 10(1), 1e12. http://dx.doi.org/10.1186/1472-6955-10-1 Griffis, C. A. (2013). AANA introduces an evidence-based infection control guide. Journal of the American Association of Nurse Anesthetists, 81(3), 174e176. Jang, S. O. (2005). Analysis of research papers published in the Journal of Korean Academy of Nursing by the classification of knowing in nursing. Journal of Korean Academy of Nursing, 35(1), 206e212. Jeong, G. H., Ahn, Y. M., & Cho, D. S. (2005). Coincidence analysis of key words of the Journal of Korean Academy of Nursing with MeSH. Journal of Korean Academy of Nursing, 35(7), 1420e1425. Jeong, I. S., Jeon, S. S., Whang, S. K., Kim, D. H., & Ha, J. Y. (2008). Systematic reviews and meta-analysis. Seoul, Korea: Soomoonsa. Kang, H. C. (2002). Analysis of statistical method applied in the Journal of Korean Academy of Nursing. Journal of Korean Academy of Nursing, 32(6), 929e935. Kim, K. M., Jeong, J. S., & Park, H. R. (2010). Infection control nurse specialist education in Korea. American Journal of Infection Control, 38(5), 413e415. http://dx. doi.org/10.1016/j.ajic.2009.08.018 Kim, O. S. (2011). Status of and influencing vaccination against the pandemic (H1N1) 2009 virus among university students from the fields of nursing and allied health. Journal of Korean Academy of Nursing, 41(3), 403e410. http://dx. doi.org/10.4040/jkan.2011.41.3.403 Korean Alliance to Defeat AIDS. (2011, December). Number of increasing new HIV infected person. Retrieved May 16, 2012, from http://aids2.likeweb.co.kr/library/ ?p_url¼library_4_1 Korean Association for Infection Control. (2012). Text of infection control (2nd ed.). Seoul, Korea: Hyunmoonsa. Korean Society for Nosocomial Infection Control. (2011). Infection control and prevention in healthcare facilities (1st ed.). Seoul, Korea: Hanmibook. Loveday, H. P., Wilson, J. A., Pratt, R. J., Golsorkhi, M., Tingle, A., Bak, A., et al. (2014). Epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection, 86(Suppl. 1), S1eS70. http://dx.doi.org/10.1016/S0195-6701(13)60012-2 Mantzoukas, S. (2009). The research evidence published in high impact nursing journals between 2000 and 2006: a quantitative content analysis. International Journal of Nursing Studies, 46(1), 479e489. http://dx.doi.org/10.1016/j.ijnurstu. 2008.12.016 Oh, H. S., & Choi, K. W. (1996). History and activity of infection control in Seoul National University Hospital. Korean Journal of Nosocomial Infection Control, 1(1), 95e121. Pittet, D. (2004). The Lowbury lecture: behaviour in infection control. Journal of Hospital Infection, 58(1), 1e13. http://dx.doi.org/10.1016/j.jhin.2004.06.002 Seto, W. H. (1995). Staff compliance with infection control practices: application of behavioural science. Journal of Hospital Infection, 30(Suppl. 1), 107e115. http:// dx.doi.org/10.1016/0195-6701(95)90011-X Shin, H. S., Hyun, M. S., Ku, M. O., Cho, M. O., Kim, S. Y., Jeong, J. S., et al. (2010). Analysis of research papers published in the Journal of the Korean Academy of Nursing-focused on research trends, intervention studies, and level of evidence in the research. Journal of Korean Academy of Nursing, 40(1), 139e149. http://dx. doi.org/10.4040/jkan.2010.40.1.139 Sohng, K. Y., Kim, J. I., Choi, D. W., Kim, A. K., Chung, S. K., Kim, K. H., et al. (2008). Research trends in the Journal of Korean Academy of Fundamental
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Ward, D. J. (2011). The role of education in the prevention and control of infection: a review of the literature. Nurse Education Today, 3(1), 9e17. http://dx.doi.org/10. 1016/j.nedt.2010.03.007 Whitby, M., McLaws, M. L., & Ross, M. W. (2006). Why healthcare workers don’t wash their hands: a behavioral explanation. Infection Control and Hospital Epidemiology, 27(5), 485e491. http://dx.doi.org/10.1086/503335
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Asian Nursing Research xxx (2014) 1e7
Contents lists available at ScienceDirect
Asian Nursing Research journal homepage: www.asian-nursingresearch.com
Review Article
An Integrative Review of Infection Control Research in Korean Nursing Journals Q17
Kyung Mi Kim, RN, PhD, 1 Jeong Sil Choi, RN, MPH, PhD 2, * 1 2
Department of Nursing, Semyung University, Jecheon, South Korea College of Nursing, Gacheon University, Incheon, South Korea
a r t i c l e i n f o
s u m m a r y
Article history: Received 21 May 2013 Received in revised form 27 December 2013 Accepted 21 January 2014
Purpose: This study was performed to analyze the characteristics and trends of published research papers related to infection control in Korean nursing journals. Methods: A total of 177 studies published between 1970 and 2011 were reviewed using analysis criteria. Subject articles were selected through KoreaMed and journal database searches on the website of subject academic societies using key words related to healthcare-associated infections. Results: Most reports were quantitative studies and the majority of them were descriptive studies. The most common subjects of research were infection control measures for pathogens, followed by disinfection and sterilization, and hand hygiene. Among them, the most descriptive studies were conducted on the knowledge, attitude, and performance of infection control. Theoretical framework, criteria for sample size and ethical consideration were rarely presented in quantitative studies. Conclusions: To enhance the quality of infection control studies and establish infection control studies as a nursing knowledge body, meta-analyses and systematic literature reviews as well as quantitative studies are needed. Moreover, studies employing behavioral science to identify factors influencing the level of knowledge and practice and to change infection control behaviors are also warranted. Copyright Ó 2014, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Keywords: infection control nursing research review
Q1
Introduction Q2
Infection control is a critical issue in clinical settings for patients. health and safety. Infection prevention activities include, but are not limited to surveillance of infections, identifying, controlling and investigating outbreaks in collaboration with appropriate disciplines, infection prevention of healthcare workers (HCWs), ensuring aseptic techniques of procedures as appropriate, education of medical and nonmedical staff for infection prevention, proper disinfection and sterilization procedures of medical equipment and environment in hospitals, environmental management including medical waste management, participation in establishing, implementing, and evaluating proper isolation protocols, departmental infection control procedure, and identifying proper infection control measures for specific pathogens. Infection control activities are closely related to nursing practices in various clinical settings and specialties (Korean Society for Nosocomial Infection Control, 2011). Therefore, understanding the characteristics and trends of infection
* Correspondence to: Jeong Sil Choi, RN, MPH, PhD, College of Nursing, Gacheon University, 191 Hambakmeoro, Yeonsu-gu, Incheon 406-799, South Korea. E-mail address: [email protected]
control is imperative for nursing researchers and nursing disciplines to identify issues related to infection control, and to evaluate if the research focus and approach were appropriate to solve the related problems in clinical practice. Infection control is recognized as a nursing specialty with its activities being performed independently and autonomously by different nursing personnel regardless of if he or she is a direct or nondirect care provider. The full scale infection control in South Korea started with the appointment of a dedicated nurse for infection prevention at Seoul National University Hospital in the early 1990s (Oh & Choi, 1996). Under the amendment of the Medical Act in 2002, infection control has become one of the specialties in nursing. A masters-prepared infection control nurse has become an infection control nurse specialist, thus, resulting in creating a solid foundation for infection control and making it one of the most important nursing specialties in South Korea (Kim, Jeong, & Park, 2010). With the recent increase in the interest in infection control many nursing scholars, researchers, and front-line nurses started publishing research articles on infection control in nursing or nursing-related journals. Recent studies were also conducted to analyze the body of knowledge accumulated in nursing through reviews of articles in specific journals (Choi et al., 2000; Shin et al., 2010), by analyzing articles according to the knowledge classification criteria (Jang,
http://dx.doi.org/10.1016/j.anr.2014.05.002 1976-1317/Copyright Ó 2014, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
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2005) or statistical methods (Kang, 2002), and by analyzing the trends of articles with a focus on their key words (Jeong, Ahn, & Cho, 2005). In the past, some nursing researchers focused on analyzing research methods or themes of articles published by the top 10 nursing journals in terms of impact factors based on the quotation index or ranking of the journals (Mantzoukas, 2009). Furthermore, some studies focused on analyzing the international trend of articles published by the top 42 nursing journals registered in the Social Sciences Citation Index (SSCI; Dougherty, Lin, McKenna, & Seers, 2004). Although infection control activities have become more elaborative and its importance has been emphasized since the introduction of infection control in South Korea in the 1990s, studies regarding infection control through literature review and analysis have not yet been conducted thoroughly. To expand the body of knowledge in nursing, literature reviews and analysis of existing published research articles that examine existing types and trends of nursing research are as important as developing a new nursing theory or methodology, which will provide a solid foundation for nursing knowledge and direction for future nursing research (Shin et al.; Suh et al., 2007). Through the comprehensive literature review related to infection control, nursing disciplines will be able to understand the degree and area of researchers’ concerns on infection control. The purpose of this study was to analyze and understand the characteristics and trend of studies regarding infection control through the comprehensive review of studies published in South Korean nursing journals from January 1970 to December 2011 to provide a direction for future studies on infection control. The detailed purposes of the study are to (a) analyze the overall characteristics of studies regarding infection control published in Korean nursing journals by year, (b) analyze quantitative research characteristics of infection control studies published in Korean nursing journals by year, (c) analyze qualitative research characteristics of infection control studies published in Korean nursing journals by year, (d) develop intervention strategies for future infection control in South Korea, and (e) propose a direction for future infection control studies based on the findings. Methods Study design This research was a descriptive study analyzing the characteristics and research trends in infection control studies published in Korean nursing journals using the analysis framework developed by the researcher. Setting and sample In total, 177 articles published between January 1970 and December 2011 were obtained from the various nursing journal databases such as Journal of Korean Academy of Nursing (JKAN), the Journal of Academic Division of Korean Society of Nursing Science, and nursing journals registered in the Korea Citation Index of National Research Foundation. Nursing journals registered in the Korea Citation Index of National Research Foundation are JKAN, The Korean Journal of Fundamentals of Nursing, Korean Journal of Adult Nursing, Korean Journal of Women Health Nursing, Journal of Korean Academy of Psychiatric and Mental Health Nursing, Journal of Biological Nursing Science, Journal of Korean Academy of Community Health Nursing, Journal of Korean Academy of Nursing Administration, Journal of Korean Gerontological Nursing, Journal of Korean Public Health Nursing, The Journal of Korean Academic Society of Nursing Education, Journal of Korean Clinical Nursing Research, Korean Journal of Occupational Health Nursing, and Asian Nursing Research.
Analysis tool An analytical framework, developed by the researchers to analyze the characteristics of infection control studies after reviewing previous studies of article analysis (Choi et al., 2000; Shin et al., 2010; Sohng et al., 2008) was followed. The analytical framework consisted of three parts: (a) general characteristics of the study, (b) quantitative research, and (c) qualitative research. General characteristics included the type of manuscripts, type of research, ethical considerations, and sample sizes by year. To analyze characteristics of infection control studies, author, correspondent author, research theme related to infection control, and research subjects were included. Analysis of quantitative research included research design, conceptual framework, criteria for sample size, reliability and validity of instrument, instrument source, data collection method, and data analysis method. In particular, when the key words were related to knowledge, practice, and attitude of infection control, additional analysis was performed on those key words. Qualitative research included research design, description of philosophical underpinning, training of researchers, data collection methods, and reliability and validity analysis of research findings. Data collection Data collection and analysis was performed from April to June 2012. Inclusion criteria of this study were (a) both English and Korean language publications, (b) research studies identifying issues related to infection control, (c) research articles published in the JKAN, Journals of Academic Division of Korean Society of Nursing Science and nursing journals registered in the Korea Citation Index of National Research Foundation and (d) articles published between January 1970 and December 2011. Subject articles were selected through KoreaMed and journal database searches on the website of subject academic societies by researchers. Search terms included “hospital infection”, “urinary tract infection”, “pneumonia”, “surgical wound infection”, “intravenous catheter infection”, “disinfection and sterilization”, “hand hygiene (hand washing)”, “asepsis”, “standard precautions and isolation”, “infection control by department”, “environmental management”, “HCWs infection control”, and “infection control measures for pathogens: Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE), Acquired Immune Deficiency Syndrome (AIDS), influenza, and human papilloma virus (HPV)”. Search terms were selected based on the table from the APIC textbook of infection control and epidemiology (Carrico et al., 2009), Q3 Textbook of Infection Control (Korean Association for Infection Control, 2012), and Infection control and prevention in healthcare facilities (Korean Society for Nosocomial Infection Control, 2011). Q4 Manual search was conducted with the two researchers to include articles which could have been missed from the initial search with key words and to exclude articles found through the database search that included key words, but not clearly meeting the inclusion criteria. The articles that met the inclusion criteria were again analyzed individually by each researcher. The selected infection control articles were primarily analyzed by each researcher according to the analytical framework developed by the researchers of this research. The results of the primary analysis were cross-reviewed by the researchers and corrections were made for insufficient or unclear parts after rereviewing the original articles (Cohen’s Kappa ¼ .9). Data analysis The collected data was analyzed using SPSS version 20.0 for windows (SPSS Inc., Chicago, IL, USA). General characteristics of subject articles were analyzed using frequency and percentage.
Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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K.M. Kim, J.S. Choi / Asian Nursing Research xxx (2014) 1e7 Table 1 Overall Analysis of Published Papers Related to Infection Control (N ¼ 177).
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66 67 Characteristics Classifications Year n (%) 68 1970e79 1980e89 1990e99 2000e09 2010e11 69 70 Total (%) 3 (1.7) 10 (5.6) 37 (20.9) 92 (52.0) 35 (19.8) 177 (100.0) Manuscript type Research paper 1 1 26 63 17 108 (61.0) 71 Thesis or dissertation 2 2 5 6 5 20 (11.3) 72 Grant 0 7 6 23 13 49 (27.7) 73 Research type Quantitative research 3 10 37 87 34 171 (96.6) 74 Qualitative research 0 0 0 1 1 2 (1.1) 75 Review paper 0 0 0 2 0 2 (1.1) Others 0 0 0 2 0 2 (1.1) 76 First author Professor 0 7 19 52 19 97 (54.8) 77 Nurse 1 2 15 30 9 57 (32.2) 78 Infection control nurse 0 0 0 6 4 10 (5.6) 79 Others 2 1 3 4 3 13 (7.3) Corresponding author Professor 0 9 24 74 29 139 (76.8) 80 Nurse 1 1 9 12 5 28 (15.8) 81 Infection control nurse 0 0 1 2 1 4 (2.3) 82 Others 2 0 3 4 0 9 (5.1) 83 Ethical consideration Verbal consent 0 0 8 39 8 55 (31.1) 84 Written consent 0 0 1 9 12 22 (12.4) Institutional review board 0 0 0 4 6 10 (5.6) 85 Not mentioned 2 6 25 37 6 76 (43.0) 86 Not applicable 1 4 3 4 2 14 (7.9) 87 Sample size < 100 6 21 44 15 2 88 (49.7) 88 100e199 0 2 15 8 0 25 (14.1) 200e299 1 2 12 8 0 23 (13.0) 89 300e399 2 5 7 1 0 15 (8.5) 90 400 1 7 10 3 1 22 (12.4) 91 Unknown 0 0 4 0 0 4 (2.3) 92 Research theme Infection control for pathogen type 0 0 9 30 12 51 (28.8) 93 Disinfection/sterilization 1 2 5 8 7 23 (13.0) Hand hygiene 0 0 4 14 4 22 (12.4) 94 General infection control 0 1 3 11 0 15 (8.5) 95 Urinary tract infections 1 2 4 4 0 11 (6.2) 96 Intravenous catheter associated infections 0 0 3 5 2 10 (5.6) 97 Pneumonia 0 1 1 3 3 8 (4.5) Occupational infection control 0 0 2 5 1 8 (4.5) 98 Surgical site infections 0 1 0 2 1 4 (2.3) 99 Standard precaution/isolation 0 0 0 0 4 4 (2.3) 100 Environmental control 1 1 0 2 0 4 (2.3) 101 Aseptic technique 0 1 2 0 0 3 (1.7) 102 Infection control for unit types 0 0 3 0 0 3 (1.7) Others 0 1 1 8 1 11 (6.2) 103 HIV/AIDS 0 0 9 14 1 24 (47.1) 104 Subclassification of infection control Influenza 0 0 0 2 7 9 (17.6) 105 for pathogen type MRSA 0 0 0 6 0 6 (11.8) 106 HPV 0 0 0 2 3 5 (9.8) VRE 0 0 0 4 0 4 (7.8) 107 Others 0 0 0 2 1 3 (5.9) 108 Subtotal 0 0 9 30 12 51 (100.0) 109 Research subjecta Nurse 0 2 16 38 12 68 (33.2) 110 Patients 2 6 10 24 6 48 (23.4) 111 Well participant 0 0 4 9 10 23 (11.2) Environment 1 4 8 5 2 20 (9.8) 112 Nursing/medical students 0 0 4 10 3 17 (8.3) 113 Physician 1 2 6 6 0 15 (7.3) 114 Other Healthcare workers 0 0 2 6 0 8 (3.9) 115 Microorganisms 0 0 0 1 0 1 (0.5) Others 0 0 0 5 0 5 (2.4) 116 Subtotal 4 14 50 104 33 205 (100.0) 117 118 Note. MRSA ¼ methicillin resistant staphylococcus aureus; VRE ¼ vancomycin resistant enterococci; HIV/AIDS ¼ human immunodeficiency virus/acquired immune deficiency syndrome; HPV ¼ human papilloma virus. 119 a Multiple choice. 120 121 122 123 professors (54.8%). Among the corresponding authors, 139 (76.8%) Results were nursing professors. With regard to ethical consideration, 76 Q5 124 125 (43.0%) studies did “not specifically [mention]” it, and only 10 (5.6%) Analysis of total infection control research articles 126 indicated institutional review board approval. The most common 127 sample sizes were under 100 (49.7%). The most frequent topic of study A total of 177 articles comprising 108 (61.0%) general studies, 20 128 was infection control measures for pathogens, in 51 (28.8%) studies. (11.3%) master’s or doctoral degree theses, and 49 (27.7%) research 129 Among the infection control measures for pathogens, HIV/AIDS was grant studies. Quantitative research was the most frequent type, 130 the most frequently observed, in 24 (47.1%) studies (Table 1). numbered at 171 (96.6%). The most common first author was nursing Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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Table 2 General Characteristics of Quantitative Research (N ¼ 171). Characteristics
Total (%) Study design
Conceptual framework
Criteria for sample size Reliability/validity instrument Instrument sourcea
Data collection methods*
Classifications
Experimental study
True experimental study Quasi-experimental study Pre-experimental study Subtotal
Surveyb Meta analysis Literature analysis Others Presented Not presented Not applicable Presented Not presented Reported Not reported/not applicable Revise Self report Physiological measure Original Clinical records Not applicable Not reported Subtotal Questionnaire Microbiologic culture Chart review Observation Physiological measure Self report Interview Sociopsychological measure Delphi Others Subtotal
Year
n (%)
1970e79
1980e89
1990e99
2000e09
2010e11
3 (1.8) 0 0 0 0 3 0 0 0 0 3 0 0 3 0 3 0 0 3 0 0 0 0 3 0 3 0 0 0 0 0 0 0 0 3
10 (5.8) 0 3 1 4 6 0 0 0 1 4 5 0 10 0 10 1 0 4 3 2 0 1 11 0 7 3 0 0 0 0 0 1 0 11
37 (21.6) 1 9 2 12 25 0 0 0 2 22 13 3 34 13 24 20 10 6 6 4 3 1 50 22 12 2 6 0 0 0 1 0 0 43
87 (50.9) 1 27 9 37 48 0 1 1 4 51 32 17 70 40 47 53 28 31 24 9 3 1 149 54 32 14 5 4 2 1 0 0 1 113
34 (19.9) 3 7 1 11 22 1 0 0 2 26 6 24 10 19 15 19 15 3 7 4 4 1 53 21 7 5 1 0 1 1 0 0 2 38
171 5 46 13 64 104 1 1 1 9 106 56 44 127 72 99 93 53 47 40 19 10 4 266 97 61 24 12 4 3 2 1 1 3 208
(100.0) (2.9) (26.9) (7.6) (37.4) (60.8) (0.6) (0.6) (0.6) (5.3) (62.0) (32.7) (25.7) (74.3) (42.1) (57.9) (35.0) (19.9) (17.7) (15.0) (7.1) (3.8) (1.5) (100.0) (46.6) (29.3) (11,5) (5.8) (1.9) (1.4) (1.0) (0.5) (0.5) (1.4) (100.0)
Q15
Note. aMultiple choice. bSubjects of descriptive research related to knowledge, attitude and performance of infection control: 49 (47.1%).
Analysis of quantitative research General characteristics There were 171 quantitative articles in total, comprising 104 (60.8%) surveys. Among the 104 survey studies, 43 (40.2%) studies were on knowledge, attitude and performance, and 64 studies were experimental studies (37.4%). Of the 64 studies, 46 studies consisted of quasi-experimental studies which were the most frequently used study method. A total of 106 studies (62%) did not include information about theoretical framework. Regarding the provision of criteria for sample size, 127 studies (74.3%) did not provide a rationale related to determining the sample size. Seventy-two studies (42.1%) reported the reliability and validity of tools used, while 99 studies (57.9%) either did not report them or were not applicable. When allowing multiple answers on the source of tools presented in studies, 93 studies (35.0%) were modified and used tools developed by others, while 53 studies (19.9%) developed tools independently for the study, and 17 studies (17.7%) used physiological measurement tools. In data collection methods, 97 studies (46.6%), used questionnaires allowing multiple answers, followed by microorganism culture results in 61 studies (29.3%), and medical record analysis in 24 studies (11.5%; Table 2). Research themes related to knowledge, attitude and performance Among survey studies, 49 studies (47.1%) were on themes related to knowledge, attitude and performance. Among the 49 studies, “infection control measures for pathogens” was the most popular theme found in 24 studies (49.0%) followed by the theme of
“overall infection control” found in 10 studies (20.4%). Among the study of pathogenic organisms, AIDS was the most popular theme examined by 12 studies (24.5%), followed by influenza examined by 5 studies (10.2%). Analysis of qualitative research There were two qualitative researches within the context of the body of existing literature: one using the phenomenological approach (50.0%) and one the focus group method (50.0%). One study provided the philosophical underpinning of the research and a suggestion for training of the researcher (50.0%). Both studies used in-depth interview analysis as the data analysis method. Explanations on the data analysis process were provided in both studies and one (50.0%) study reported reliability and validity of the study findings (Table 3).
Q16
Table 3 Analysis of Qualitative Research (N ¼ 2). Characteristics Design Design Philosophical background Philosophical background Researcher training Researcher training Data collection methods Data analysis process Validity/reliability Validity/reliability
Classifications Phenomenology Focus group Presented Not presented Presented Not presented In-depth interview Presented Reported Not reported
n (%) 1 1 1 1 1 1 2 2 1 1
(50.0) (50.0) (50.0) (50.0) (50.0) (50.0) (100.0) (100.0) (50.0) (50.0)
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Discussion
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This study was the first comprehensive literature review undertaken to analyze characteristics and trend of the infection control research studies published in nursing journals in South Korea. A total of 177 studies published between 1970 and 2011 were reviewed. They were selected through journal database searches on the website of subject academic societies. The strength of this study was that it was meaningful in identifying common themes and types of infection control related to nursing disciplines, and understanding the changes and trends of infection control studies over the past 40 years in South Korea. The study results showed that there have been an increasing number of infection control studies published in Korean nursing journals. Based on the increase in the number of published studies, one can conclude that researchers’ interest in infection control was also increased. By study type, quantitative studies were dominant, comprising 96.6% of the total research studies, and review and meta-analysis of the literature related to infection control research were rarely done. Studies in infection control with emphasis on evidence-based practice, although Centers for Disease Control and Prevention and World Health Organization have prepared and provided infection control guidelines based on various research, are not enough to answer the problems related to infection control. To provide evidence-based practice to the front line practitioners, researchers needed to perform systematic literature reviews and meta-analysis, and provide a summary of the existing body of literature on intervention effects (Jeong, Jeon, Whang, Kim, & Ha, 2008). In the 2000s, subsidized research on infection control had increased. However, for the 2 years after 2010, publication of both research grant studies and general research studies on infection control have increased as well. Based on the current trend of the research on infection control, one can conclude more research grant studies are expected in the future. More than 50% of the total number of studies conducted before the year 2000 did not mention whether the researchers had ethical considerations or followed proper processes to protect research participants. After 2000, more and more studies mentioned obtaining verbal agreement, written agreement, or IRB approval for the study. According to a study by Choi et al. (2011), which analyzed trends of articles published in journals mainly by nurses working in the clinical setting, the results found were similar with those of this study. In that study, there were only two studies that received IRB approval from 1995 to 2008. This shows that the emphasis on research ethics is recent and it was not the main matter to consider in the previous period. As a result of diverse efforts on nursing ethics, in 2006, the Korean Society of Nursing Science enacted the ethics charter and code of research ethics for Korean nursing researchers. Articles about infection control submitted to nursing journals were influenced because many of these journals recently required IRB approval before submission. In the past 2 years, most researchers obtained IRB approval for research and conducted research within the ethical and moral considerations during the research processes. Because infection control research deals with sensitive issues related to the safety of clients, there should be systematic efforts, by various nursing disciplines and organizations, to provide proper education by developing, implementing, and sustaining educational programs on ethics for future nursing research. The frequently used subject of infection control studies were “infection control measures for pathogens”, followed by “disinfection and sterilization”, while “hand hygiene” was the least frequent subject. Among the infection control measures for pathogens, the most frequently studied pathogen was HIV/AIDS between the 1990s and 2000s, which strongly related to the AIDS epidemics in
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South Korea which started in 1999 (Korean Alliance to Defeat AIDS, 2011). Studies on the most common cause of healthcare-associated infections, such as MRSA and VRE were mainly conducted after the year 2000 in South Korea. For the past 2 years, studies on influenza have increased significantly as new strains of influenza became more prevalent in 2009 (Kim, 2011). In controlling the epidemical outbreak of influenza, many studies on infection control measures specific for pathogens were not conducted in hospitals or communities at the time of influenza outbreaks to find intervention strategies that were specific for specific causes. This phenomenon can be explained by the fact that most researchers were nursing professors or nurses, not infection preventionists. No research analyzed trends of nationwide infection control related articles. However, according to a study which analyzed the articles focused on education in infection control in the US and Europe to identify the effect of infection control education, 41.0% of the research were about application of various educational methods, 28.2% for hand hygiene, 12.8% for bacteremia, and 7.7% for MRSA (Ward, 2011). The American Association of Nurse Anesthetists reports, through the research to revise evidence-based infection control guideline, that multidrug resistant organism is settling in the main research of infection control, while the matter of interest in 1980s was HIV, the life-threatening blood infection (Griffis, 2013). Also, in the UK, research was conducted in order to provide national evidencebased guidelines for preventing HAIs executed multiple systematic review about hospital environmental hygiene, hand hygiene, use of personal protective equipment, safe use and disposal of sharps, principles of asepsis, short-term indwelling catheters, and intravascular access devices (Loveday et al., 2014). Hand hygiene was the most frequently referenced one among the above subjects. Based on results from previous research, it turned out that it is similar that research about hand hygiene and multidrug resistant organism were performed in the main theme. Within the body of literature collected for analysis, most studies used quantitative research as the research method, comprising 60.8% of the surveys. Among the survey studies, 47.1% of research was conducted on the knowledge, practice, and attitude related to infection control. However, Pittet (2004) suggested that the level of knowledge on infection control cannot be regarded as an appropriate index indicating practice behaviors. Pittet also stated that the practices of infection control guidelines were affected by many other factors. Therefore, it is desirable to identify the factors that influence the low level of knowledge and practice, develop and apply concrete programs to enhance the levels and then measure the effects of the programs rather than repeating survey research on infection control knowledge, practice and attitudes of nurses and nursing students. Only 2.2% of the research was a true experimental study. We assumed that the reason for this low percentage was due to the difficulty or impossibility of conducting true experimental research on human subjects ethically. The current trend of infection control activity is the use of clinical guidelines developed based on evidence-based research. Therefore, further systematic review of the literature or quasi-experimental studies related to unresolved issues are needed to verify the appropriateness of the infection control guidelines. Most quantitative research did not provide a theoretical framework for their study because these studies did not apply nursing interventions and the subjects of the research were not humans. Many researchers modified and supplemented existing tools developed by other researchers rather than developing new tools for the study. Microorganism cultures were the most frequently used data collection methods because of the nature of the study: infection control. Most of the quantitative studies conducted before the year 2000, did not provide the criteria for sample
Please cite this article in press as: Kim, K. M., & Choi, J. S., An Integrative Review of Infection Control Research in Korean Nursing Journals, Asian Nursing Research (2014), http://dx.doi.org/10.1016/j.anr.2014.05.002
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size, rationales for sampling strategies, or the validity of the study with theoretical framework. However, the studies providing information on sampling strategies using specific statistical analysis including G-Power have increased since 2000, thus, enhancing the quality of the research. There were only two qualitative studies, which did not provide sufficient information on addressing successful infection control strategies, based on the understanding in the spread of infectious diseases or pathogenicity in South Korea. In other countries, many studies (Efstathiou, Papastavrou, Raftopoulos, & Merkouris, 2011; Seto, 1995 ; Trunnell, & White, 2005; Whitby, McLaws, & Ross, 2006) have been conducted to improve the compliance of hand hygiene, standard precautions, and infection control guidelines by applying various behavioral change strategies based on the behavioral science (Seto, 1995), as most healthcare associated infections are related to improper procedures or behaviors of HCWs. From this perspective, conducting qualitative research is strongly encouraged for understanding the phenomena between infection control related reactions and environment on HCWs, which will lead to constructing a new body of knowledge. Nurses take the most important role in infection control as they are the front-line workers in the healthcare arena and provide direct care to patients on a daily basis. Nurses should be aware of the current issues related to infection control in the clinical settings, be able to identify the controversial issues of infection control, and formulate solutions for effective infection control through research. This evidence-based clinical practice, based on nursing research, will truly advance nursing practice, resulting in better patient outcomes. In this study, research studies on infection control conducted between January 1970 and December 2011 were reviewed. This study is meaningful as it was the first integrated review on infection control research studies published over the past 40 years in South Korea. This study is limited by the fact that the study samples were those published in the South Korean nursing journals. Thus, we were unable to generalize the study findings. In addition, 20% of the research was conducted after 2010, and due to the shorter time frame, it is not feasible to conduct a 10-year-span comparison, which poses as a study limitation as well. Further, continuous efforts should be made in studying current trend of infection control to develop and implement effective infection control strategies. This study results could provide South Korean and foreign nursing researchers some directions for future nursing research on infection control. Conclusion Most reports were quantitative studies and the majority of them were descriptive studies. Most descriptive studies were conducted on the knowledge, attitude, and performance of infection control. The most common subjects of research were infection control measures for pathogens. To enhance the quality of infection control studies and establish infection control studies as a nursing knowledge body, meta-analyses and systematic literature reviews as well as quantitative studies are needed. Moreover, studies employing behavioral science to identify factors influencing the level of knowledge and practice and to change. Understanding the characteristics and trends of infection control research will enable us to identify whether they have the right directions to solve the infection control related problems in clinical practice. Further research is needed to identify factors influencing effective infection control and to develop intervention strategies. Conflict of interest The authors declare no conflict or interest.
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