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Improving infection control competency through an online learning course

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This study explores whether online learning can improve nurses' infection control knowledge

Lynda Atack, PhD, RN,
is professor, School of Community and Health Studies, Centennial College; Robert Luke, PhD, is director, Office of Applied Research and Innovation, George Brown College; both in Toronto, Canada.

Atack, L., Luke, R
. (2009) Improving infection control competency through an online learning course. Nursing Times; 105: 4, 30-32.

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Background: While most staff are aware of the basics of infection prevention and control, this can be eroded over time. In addition, it is difficult to keep up with emerging best practices.

Aim: To develop an online course to improve infection prevention and control competency and access to training.

Method: Surveys were conducted with 76 healthcare professionals, most of whom were nurses, before and after the course.

Results: Participants made significant increases in competency scores, and satisfaction with the course was high.

Discussion: A number of barriers to online learning in the workplace were identified. Organisational support in terms of protected training time, computers and internet access are essential.

Conclusion: Online learning can be an effective way for nurses to learn or refresh their skills and knowledge but needs employer support to be successful.

Implications for practice

  • This study demonstrates that online courses can contribute to nursing education in the area of infection prevention and control.

  • It has also identified some barriers to this method of learning, and it is essential that trusts overcome these obstacles if staff are to benefit from e-learning.

  • Online courses should be integrated into existing staff education programmes to achieve maximum benefit.


The outbreaks of severe acute respiratory syndrome (SARS) in Toronto, Hong Kong and Singapore exposed infection control gaps in global healthcare systems.

While many factors influence infection control - including staffing (Sujijantararat et al, 2005) and resources (Lymer et al, 2004) - basic activities such as staff handwashing practices can have a tremendous impact in reducing infection (Gould, 2005; Trampuz and Widmer, 2004; Pittet, 2003).

While most staff are aware of the importance of basic infection prevention and control (IPC), they are often not aware of emerging best practices (RCN, 2005), and attention to basics often erodes over time.

The Healthcare Commission recently reported that 11 out of 51 trusts did not comply with standards for handwashing and antibacterial handrubs (Staines, 2008).

One factor contributing to poor practice is the limited number of programmes available to train and retrain health workers (Murphy, 2006; Loutfy et al, 2004; Walker, 2004; Naylor, 2003). Another is making programmes accessible to large numbers of staff when there are limited IPC experts available to provide training and the majority of care providers work shifts. The ideal educational approach is providing courses that are interactive, readily accessible, time-efficient and support 'on-the-job' learning.

To improve competency and access to training, a project was launched to develop an online course in IPC. Partners included educational institutions, hospitals, a Canadian provincial government health ministry and the Community Hospital Infection Control Association of Canada (CHICA). This association developed course competencies and content.

The Ontario Ministry of Health and Long-Term Care (2008) sponsored the IPC materials as part of its Just Clean Your Hands campaign. It used material from the World Health Organization's World Alliance for Patient Safety's Clean Care is Safer Care project and the UK National Patient Safety Agency's cleanyourhands campaign as guides (see and


The study's goals were to determine if an online programme improved professionals' perceptions of their IPC competence and clinical practice. We were also interested in identifying components of the online course that were most effective in promoting learning. The findings reported here form part of a larger study (Atack and Luke, 2008).


The online course

Participants enrolled in an online course with three modules: hand hygiene; routine practices; and the chain of transmission (Box 1). These modules are the core of a proposed eight-module programme. IPC experts from CHICA provided course content, under the scientific direction of the Ontario Provincial Infectious Diseases Advisory Council. The course was developed for self-study workplace training and learners took it at any time convenient for them. Each module takes 20-30 minutes to complete.

BOX 1. IPC online course

  • Content is provided through text, photographs and graphics.

  • Skills such as handwashing and donning personal protective equipment are demonstrated through video clips.

  • Learning is an active process - each module includes pre- and post-module knowledge tests and activities such as case situations, multiple-choice quizzes and games, for example matching quizzes.


The study used internet-based surveys to collect data. Participants were directed to e-learning readiness and IPC competency surveys before starting the course, then to the three IPC modules. After completing the modules, they took part in post-course competency and satisfaction surveys (the results of four surveys are reported here).

We developed the e-learning readiness survey - which provides information on participants' experience and identified barriers to online learning - and the IPC competency and course satisfaction surveys, based on a model by Ryan et al (1999), who gave permission to use the surveys in this study.

Results from reliability tests for the surveys in this study were all greater than 0.84, a result considered more than satisfactory.


Seventy-six staff from four hospitals took part. Thirty-five (46%) were nurses, and 27 (36%) were other health professionals including pharmacists, physiotherapists, respiratory technicians and occupational therapists. Fourteen (18%) included nurse educators, nurse practitioners, clinical nurse coordinators, informatics specialists, student nurses and discharge planners. One-third (n=25) had over 20 years' healthcare experience and one-third (n=24) had less than five. Almost half (49%) had experience with online learning and most (97%; n=74) described themselves as 'intermediate or advanced' in IT/internet skills.

Participants were asked to identify any barriers to online workplace learning. The most common was lack of time (88%), followed by no reserved place to work on the course (32%), the organisation's firewall blocking access (32%) and slow internet connections (17%). Twenty-six per cent said it was not seen as acceptable for employees to take online training while at work.

Data collection

IPC competency survey: This asks respondents to rate their ability using a five-point Likert scale ranging from novice to expert. Competencies include: safely cleaning equipment; demonstrating IPC procedures to patients, staff and visitors; knowing when to contact an IPC expert for help; and using personal protective equipment. The post-course survey includes three open-ended questions that ask staff to identify ways (if any) in which the online course influenced their practice regarding IPC with patients, other staff and visitors.

Course satisfaction survey: The 14 items in this measure: clarity of course objectives; level of course organisation; quality of learning materials and activities; convenience of mode of course delivery; and time demands. A high score means the learner was satisfied with the course.

Ethical considerations

Ethics committees at the participating clinical and educational institutions approved the study. All participants received an information letter and gave informed consent.

Data analysis

Descriptive statistics were used to provide a profile of participants and analyse the satisfaction survey. A paired-samples T-test was used to examine change in competency before and after the course. Open-ended questions were grouped and analysed for themes using a content-analysis approach.


Infection control competency

Eighty-eight per cent (n=67) of the sample completed both the pre- and post-course competency survey.

Participants made significant increases in IPC competency scores (p<0.001). the="" average="" pre-course="" score="" was="" 64="" out="" of="" 100;="" the="" post-course="" average="" was="">

Eighty per cent of those who took the course completed the satisfaction survey. The average score was 91 out of 100, meaning most were highly satisfied. Scores ranged from 71-100. All participants indicated the course was extremely useful; the learning activities were helpful and creative. All noted they would recommend online learning as a way to learn about infection control. Twenty-seven per cent (n=14) said the video clips were very effective for learning and 21% commented on the interactive activities.

While most feedback was positive, there were some problems such as wanting more feedback on quiz results, the course taking longer than expected and hospital firewalls making video uploading slow or impossible.

The open-ended items on the post-course competency survey asked participants how useful the course had been and, if possible, to give an example of a change in practice. The course raised some participants' awareness of their current practice and fostered reflection on workplace practice.

One participant commented: 'I need to change my ways of thinking- I often do not pay too much attention to how much time is required to use the handgel sanitiser. Most of us use it and right away go to the next patient without scrubbing it and waiting for the 15 seconds. I need to take time to think properly to get the maximum benefit out of it, rather than doing things because I was told to do so and not putting too much thought behind it.'

Another said: 'Sad to say, in real situations many of us have good intentions but a hectic environment, and a lack of equipment and cleaning agents prevent most staff from doing their jobs properly. But maybe instead of being busy [and] blaming others for not doing their job properly, each of us should proactively take steps to prevent infection and raise awareness of fundamental handwashing as a primary precaution.'

New knowledge and skills gave some participants more confidence when teaching patients, visitors and other staff. One said: 'The videos about how to properly put on protective equipment were very informative, and now I'm more confident in teaching somebody else (patients, visitors, staff) about how to put on protective equipment.'

Nearly three-quarters (72%; n=55) gave an example of something new or different they were doing. Three major themes were identified: improved hand-hygiene practices; improved teaching of patients, visitors and staff about using protective equipment; and improved personal IPC techniques.

Some participants had examined the workplace environment and processes, and asked for changes and better access to hand-hygiene products and equipment. One said: 'As nurses, we were always taught to focus on infection prevention in the actual patient care area- We often forgot other hidden areas of the hospital such as offices, computers etc, which also require attention.'


We were not surprised to find an increase in learners' perception of competency. We were, however, surprised to see such a significant change after completion of just three of a proposed eight-module course.

The rise in pre and post average scores from 64 to 77 suggests online learning can be effective in enhancing IPC knowledge and skills. However, the score of 77 shows that learners still need access to the remaining modules that address certain competencies in greater depth.

It is important to note that the online course was never intended to replace hands-on practice. These courses will be most effective when integrated with hospitals' professional development sessions.

The overall satisfaction score of 91 indicates that learners were highly satisfied, and supports the claim that highly interactive online learning can deliver quality while being convenient. This finding is similar to earlier studies (Chaffin and Maddux, 2004; Desai et al, 2000). Online IPC courses provide ongoing access to standardised, up-to-date information and may reduce pressure on strained training resources.

The study identified a number of barriers to online learning in the workplace. While these do not seem to have reduced course satisfaction, it is important to acknowledge them if organisations are committed to online learning for competency training. The government and employers are responsible for providing the resources to support workplace learning in terms of protected training time, computers and internet access.

Results from this study were used to guide the implementation of a province-wide hand-hygiene programme in Ontario, in which an initial evaluation of the materials, assessment instruments and review metrics was conducted at 10 Ontario hospitals. These include information and technical guides, educational resources (such as the e-learning modules discussed here), promotional materials and evaluation instruments.

Importantly, the Just Clean Your Hands campaign recommends using e-learning as part of a comprehensive implementation strategy with in-service supports designed to encourage staff uptake and implementation of skills learnt online.

Study limitations

Change in practice was not directly observed. In a study to determine the impact of an education programme on doctors' prescribing practices, Wakefield et al (2003) found that self-reported change was significantly associated with an objective measure of change. We would recommend study of the impact of the online course using objective measures.

Study of knowledge retention and activity to align the course with existing training will help identify best practices for integrating online learning within organisational IPC training. It should also be noted that study participants were volunteers and most had intermediate or advanced internet skills.


The study's results indicate that online learning can be a satisfactory and effective way for nurses to learn or refresh their IPC skills. However, for online learning to succeed, employers need to support it, address barriers and integrate courses into existing staff education programmes.


Atack, L., Luke, R. (2008) Impact of an online course on infection control and prevention competencies. Journal of Advanced Nursing; 63: 2, 175-180.

Chaffin, A.J., Maddux, C.D. (2004) Internet teaching methods for use in baccalaureate nursing education. Computers in Nursing; 22, 132-142.

Desai, N. et al (2000) Infection control training: evaluation of a computer-assisted learning package. Journal of Hospital Infection; 44: 3, 193-199.

Gould, D. (2005) The fall and rise of cleanliness in British healthcare and the nursing contribution. Journal of Research in Nursing; 10: 5, 495-509.

Loutfy, M.R. et al (2004) Hospital preparedness and SARS. Emerging Infectious Diseases; 10: 5, 771-776.

Lymer, U.B. et al (2004) Blood exposure: factors promoting healthcare workers' compliance with guidelines in connection with risk. Journal of Clinical Nursing; 13, 547-554.

Murphy, C. (2006) The 2003 SARS Outbreak: Global challenges and innovative infection control measures. Online Journal of Issues in Nursing; 11: 1, 6.

Naylor, D. (2003) Learning from SARS: Renewal of Public Health in Canada.

Ontario Ministry of Health and Long-Term Care (2008) Just Clean Your Hands Implementation Guide: Ontario's Step-by-Step Guide to Implementing a Multifaceted Hand Hygiene Program in Your Hospital.

Pittet, D. (2003) Hand hygiene: improved standards and practice for hospital care. Current Opinion in Infectious Diseases; 16: 327-335.

RCN (2005) Good Practice in Infection Prevention and Control: Guidance for Nursing Staff. London: RCN.

Ryan, M. et al (1999) Continuing professional education and interacting variables affecting behavioral change in practice: instrument development and administration. The Journal of Continuing Education in Nursing; 30: 4, 168-175.

Staines, R. (2008) Coming clean on infection control. Nursing Times; 104: 48, 8-9.

Sujijantararat, R. et al (2005) Nosocomial urinary tract infection: nursing sensitive quality indicator in a Thai hospital. Journal of Nursing Care Quality; 20: 2, 134-139.

Trampuz, A., Widmer, A.F. (2004) Hand hygiene: a frequently missed lifesaving opportunity during patient care. Mayo Clinic Proceedings; 79, 109-116.

Wakefield, J. et al (2003) Commitment to change statements can predict actual change in practice. Journal of Continuing Education in the Health Professions; 23: 81-93.

Walker, D. (2004) For The Public's Health: A Plan of Action. Final Report of the Ontario Expert Panel on SARS and Infectious Disease Control. Ontario, ON: Ministry of Health and Long-term Care.

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