Abstract
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Purpose
This study aimed to examine the factors affecting the performance of standard precautions among third- and fourth-year nursing students. Focusing on the health belief model, it included individual factors such as knowledge of standard precautions, health beliefs, and self-efficacy, along with patient safety culture factor—conceptualized as an environmental factor of the performance of standard precautions.
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Methods
This study included 160 third- and fourth-year nursing students in South Korea. Participants completed self-report questionnaires assessing factors influencing the performance of standard precautions during clinical practice.
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Results
The hierarchical multiple regression analysis revealed that self-efficacy (β=.58, p<.001), experience with healthcare-associated infections (HAIs) (β=–.15, p=.01), age (β=.12, p=.02), and knowledge of standard precautions (β=.14, p=.04) were significant predictors of the performance of standard precautions. Explanatory power of the model was 64.7%.
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Conclusion
To enhance the performance of standard precautions among third- and fourth-year nursing students, ongoing education and strategies to improve their self-efficacy for health behaviors are essential. Tailored programs should be developed to prevent HAIs based on the specific self-efficacy levels of these students.
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Key words: Health belief model; Knowledge; Nursing; Self-efficacy; Universal precaution
INTRODUCTION
According to the United states (US) Centers for Disease Control and Prevention, major healthcare-associated infections (HAIs), such as central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated events, increased during the coronavirus disease 2019 (COVID-19), with reported increases ranging from approximately 19% to 47% in 2021 compared with 2019 [
1]. An HAI is an infection acquired during hospitalization that was not present upon admission. HAIs occur in 5%–10% of hospitalized patients, affecting both patients and healthcare workers. HAIs during medical procedures prolong recovery and increase healthcare costs owing to extended hospital stays, organ damage, and higher mortality rates [
1,
2].
The prevention and management of HAIs have become increasingly crucial owing to the rising number of elderly patients, immunocompromised individuals, and those at higher infection risk. Previous study has shown that following performance of standard precautions can reduce HAIs [
1,
2]. Preventive measures, including hand hygiene, aseptic practices, environmental management, and staff infection prevention are vital, with adherence to standard precautions crucial for reducing HAIs [
2,
3].
Within this context, nurses play a pivotal role, as they constitute the largest segment of the healthcare workforce and are in frequent direct contact with patients. They are particularly vulnerable to infection because of their direct contact with patients and performance of various invasive procedures. Therefore, regular education and training on these precautions are recommended for healthcare workers, patients, visitors, and nursing students [
4].
In accordance with the Korean Accreditation Board of Nursing Education [
5], future nurses (i.e., nursing students) must complete over 22 credits of clinical practice during their undergraduate curriculum. During clinical practice, they interact with patients with various diseases, similar to practicing nurses. However, nursing students often lack familiarity with clinical situations, increasing their susceptibility to infections due to inexperience, inadequate practice transfer, and personal anxiety, leading to significant challenges in implementation. Jeong [
6] found that 71.5% of nursing students are exposed to infections, 41.7% experience needlestick injuries, 9.4% are injured by sharp instruments, and 58.9% come in direct contact with blood or body fluids. These findings underscore the significant occupational risks nursing students face due to their limited expertise and experience.
Therefore, nursing students must practice standard precautions to protect themselves and prevent the transmission of infections to patients. As key personnel in clinical patient care after graduation, prospective nurses should develop competency in performance of standard precautions for HAIs even before performing clinical practice [
7].
To explain the performance of standard precautions, the health belief model (HBM) can be applicable to promote infection-control behaviors in nursing students and help prevent infections during clinical practice. Developed by American social psychologists in the 1950s, the model serves as a framework for predicting and explaining health-related behaviors [
8]. It posits that individuals develop behaviors when they believe those behaviors can prevent or reduce the risk of diseases. The original HBM included perceived susceptibility, perceived severity, perceived benefits, and perceived barriers; and self-efficacy was added later [
8]. Therefore, a theory-based approach is essential to understand and improve adherence to standard precautions. The HBM can provide a powerful framework for explaining infection control behaviors by emphasizing perceived vulnerability, perceived severity, perceived benefits, perceived barriers, and self-efficacy.
This study indicates that individual factors, including beliefs about health and self-efficacy, can enhance the performance of standard precautions among third- and fourth-year nursing students. In addition, as a modifying factor, knowledge of standard precautions refers to awareness of the Centers for Disease Control and Prevention (CDC) guidelines for standard care [
9]. Although some studies have found no significant effect of such knowledge on performance of standard precautions [
7], more recent research has reported a significant positive correlation [
3]. Therefore, it is necessary to investigate whether nursing students’ knowledge of standard precautions influences their actual practice of those precautions.
For individual beliefs, health beliefs influence the performance of standard precautions. Healthcare professionals widely use these beliefs to predict and explain specific behaviors derived from health beliefs. According to the HBM, higher perceived susceptibility (risk of contracting a disease), higher perceived severity (seriousness of the condition), higher perceived benefits (advantages of the behavior), and lower perceived barriers (obstacles to the behavior) increase the likelihood of engaging in recommended health behaviors when appropriate cues to action are present [
10]. Empirical studies have demonstrated positive correlations between the performance of standard precautions and perceived susceptibility, severity, and benefits, and a negative correlation with perceived barriers [
4]. Thus, health beliefs may play a crucial role in shaping nursing students’ adherence to standard precautions.
Self-efficacy, which was added to the HBM in 1988, is defined as an individual’s confidence in their ability to perform a specific behavior successfully [
8]. Successful or unsuccessful experiences with a given behavior influence self-efficacy; higher self-efficacy leads to positive coping behaviors and better performance of challenging tasks [
11]. Health beliefs and self-efficacy influence motivation to adopt health behaviors and the probability of taking action. Self-efficacy plays a crucial role in facilitating and sustaining achievement, potentially influencing behavior change more significantly than the other 4 variables in the HBM [
11]. Previous studies have reported a significant positive correlation between nursing students’ self-efficacy and the performance of standard precautions [
4]. Therefore, self-efficacy is an important predictor of nursing students’ implementation of standard precautions during clinical practice.
In addition to individual factors, patient safety culture is an environmental factor, which encompasses the collective values, attitudes, perceptions, abilities, and behaviors that determine an organization’s commitment to patient safety [
12]. An organization that values safety fosters individuals’ motivation to engage in safety behaviors, thereby enhancing infection-prevention activities. The clinical practice environment also influences nursing students’ performance of standard precautions [
3]. Additionally, a hospital’s patient safety culture affects nurses’ safety behaviors, leading to better adherence to standard precautions [
13].
Individual factors such as knowledge, self-efficacy, nursing professionalism have been studied as variables affecting nursing students’ performance of standard precautions [
3,
7]. Furthermore, recent research suggests that environmental influences, particularly the patient safety culture within clinical settings, significantly influence safety-related behaviors. However, research on environmental factors—particularly the relationship between patient safety culture and performance of standard precautions grounded in the HBM—remains limited. Moreover, earlier research, especially concerning the influence of knowledge, shows inconsistencies, indicating that individual cognition by itself cannot completely account for preventive behaviors [
3,
7,
14].
A comprehensive study that integrates individual factors and environmental influences based on the HBM is essential to identify the mechanisms by which nursing students implement standard preventive measures and to provide information necessary for developing effective educational and organizational interventions to prevent HAIs. Therefore, this study aimed to identify the factors affecting nursing students’ performance of standard precautions, focusing on HBM, thereby providing foundational data for developing a standard precaution program to prevent HAIs.
1. Research Questions
• What differences exist in nursing students’ performance of standard precautions across their general characteristics?
• What is the level of nursing students’ performance of standard precautions during clinical practicum?
• What are the relationships between nursing students’ performance of standard precautions and knowledge of standard precautions, health beliefs, self-efficacy, and patient safety culture?
• Which individual and environmental factors significantly affect performance of standard precautions among nursing students during clinical practicum?
2. Conceptual Framework
Drawing upon the HBM and a comprehensive literature review, we established a conceptual framework to identify the individual and environmental factors affecting the performance of standard precautions during clinical practice among third- and fourth-year nursing students. We constructed a conceptual framework that includes individual factors, such as modifying factors and personal belief factors, which influence an individual’s standard-based performance behavior, as well as environmental factors including patient safety culture.
Modifying factors, including individual knowledge of standard precautions, were conceptualized as variables that influence health behavior by shaping individuals’ perceptions within the HBM. Individual belief factors, such as perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action, which are the core components of the model, were categorized as individual factors influencing health behaviors [
8]. In addition, patient safety culture within hospitals was identified as an environmental factor affecting the performance of standard precautions based on insights from prior studies [
3,
13]. Patient safety culture, which reflects organizational norms and practices regarding safety, was included as an external determinant of health behavior in the modified HBM. The resulting conceptual framework, based on the HBM, is depicted in
Figure 1.
METHODS
Ethical statements: This study was approved by the Institutional Review Board (IRB) of Chonnam National University in South Korea (IRB No. 1040198-240529-HR-087-02). All procedures involving human participants followed ethical standards established by the institutional and national research committee following the 1964 Helsinki Declaration and its amendments. Informed consent was obtained from all participants.
1. Study Design
This cross-sectional study identified factors affecting the performance of standard precautions during clinical practicum in third- and fourth-year nursing students. Reporting followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [
15].
The study population comprised third- and fourth-year nursing students in South Korea. Inclusion criteria were as follows: (1) students who understood the purpose of the study and completed the questionnaire and (2) students who had clinical practice experience in the nursing curriculum. Participants who confirmed understanding of the study voluntarily agreed to participate.
We used the G Power ver. 3.1.9.7 program to calculate the minimum required sample size [
16]. Based on the 13 predictor variables, a significance level of .05, a medium effect size of .15 and a power of .80 for regression analysis, the minimum required number of participants was estimated to be 135. We distributed questionnaires to 161 students via online platform (Google Forms; Google LLC), accounting for an anticipated 15% dropout rate. After excluding one incomplete response, our final sample included 160 participants.
1) Knowledge of standard precautions
To assess students’ knowledge of standard precautions, we employed a measurement tool developed by Cho [
17] and subsequently modified by Suh and Oh [
18] and Baek [
19]. It consists of 29 items across 7 areas (conception of standard precautions, hand hygiene, personal protective equipment (PPE), care of the environment, safe injection practices, respiratory etiquette, and patient placement) with possible responses of “yes,” “no,” or “unknown.” “Yes” is given 1 point, and “no” or “unknown” is given 0 points; the maximum possible score is 29. Measurements include items such as “Gown should be worn when blood or body fluids are likely to contaminate skin and clothing.” Lee et al. [
20] used the version employed by Baek [
19] and reported a Kuder-Richardson formula 20 of 0.81, whereas it was 0.90 in the present study.
2) Health belief
We employed the Health Belief Scale developed by Erkin and Özsoy [
21] and subsequently modified by Kim and Cha [
22] and Rhew [
23] to align with standard precautions guidelines. This tool comprises 29 items across 5 domains (perceived susceptibility, perceived benefits, perceived severity, perceived barriers, and cues to action). This measurement is a 5-point Likert scale, ranging from 1 (not at all) to 5 (very much). Sample items include statements such as “I can be exposed to HAIs at any time.” A higher score reflects a stronger health belief. Rhew [
23] calculated a Cronbach’s α of .81, whereas in this study, it was .73.
3) Self-efficacy
We used the Self-Efficacy Scale developed by Sherer et al. [
24] and subsequently modified by Jung [
25]. This tool is composed of 17 items encompassing 5 areas (conviction, achievement, putting into practice, effort-making, and ordeal). Each item was rated on a 5-point Likert scale, ranging from 1 (not at all) to 5 (very much). The scale includes items such as “When I plan something, I am confident that I can do it.” A higher score indicates greater self-efficacy. Jung [
25] found Cronbach’s α to be .86; it was .94 in this study.
4) Patient safety culture
To assess nursing students’ awareness of patient safety culture, we used a tool based on the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality in 2004. This survey was translated by Kim et al. [
26] and revised by Han [
27] and Yoo et al. [
12]. The tool comprises 39 items across several areas: hospital/ward practice environment, manager, communication and procedures, and hospital area. Each item was rated on a 5-point Likert scale, ranging from 1 (not at all) to 5 (very much). Sample items include statements such as “The ward has enough staff to handle the assigned workload.” A higher score indicates a greater awareness of patient safety culture. Yoo et al. [
12] reported Cronbach’s α as .86, whereas it was .70 in this study.
5) Performance of standard precautions
We employed a tool based on the CDC standard precautions guidelines revised in 2007. This instrument was translated into Korean by Jeong [
28] and modified by Hong et al. [
29]. The tool is composed of 36 items measured on a 5-point Likert scale, ranging from 1 (not at all) to 5 (very much). The scale includes items such as “If there are visible contaminants such as blood or body fluids, I wash my hands with soap and water.” A higher score indicates better adherence to standard precautions. Hong et al. [
29] determined a Cronbach’s α of .95; herein, it was .97.
Data collection occurred between July and August 2024. Data were collected online after obtaining permission from the administrators of a nationwide nursing student community and its social networking platform. Subsequently, participation announcement and online survey, which included an explanation and consent form was posted. Furthermore, participants received a brochure describing the study’s objectives, methods, provisions for confidentiality and anonymity, the voluntary nature of participation and right to withdraw, as well as the risks and benefits of participation. Only those who voluntarily signed the written consent form completed a 15-minute online self-report questionnaire. Participants were offered a small present as a token of appreciation.
5. Data Analyses
The data was analyzed using IBM SPSS Statistics ver. 29.0 (IBM Corp., Armonk, NY, USA). The level of statistical significance was set at .05. We identified differences in the performance of standard precautions based on the general characteristics using independent t-tests and one-way analysis of variance. Additionally, we explored correlations among main variables using Pearson’s correlation coefficient. Hierarchical regression analysis was conducted to identify factors affecting nursing students’ performance of standard precautions based on theoretical considerations. Before hierarchical regression analysis, assumptions of normality, homoscedasticity, and multicollinearity were examined. In Model 1, general characteristics that showed significant differences in the univariate analyses were entered. In Model 2, individual factors among the main independent variables were added to examine their effects on the dependent variable. Finally, in Model 3, environmental factors were additionally entered to assess their incremental explanatory power.
RESULTS
1. Performance of Standard Precautions according to General Characteristics
Table 1 presents the general characteristics of participants. The average age of the nursing students was 23.2 years (standard deviation=2.6), with the majority (n=147; 91.9%) being women. Among them, 89 (55.6%) attended nursing colleges in Seoul or the metropolitan area. There were 88 (55.0%) participants in their fourth year and 72 (45.0%) in their third year. Overall, 99 participants (61.8%) were satisfied with their major. The most frequently reported clinical practice setting was university hospital (137 of 197 responses, 69.5%), followed by general hospitals (47 of 197 responses, 23.9%) and clinics (13 of 197 responses, 6.6%). The most common clinical practice duration was between 6 and 12 weeks (n=68, 42.5%). Almost all participants (n=151; 94.4%) had received education on standard precautions (
Table 1).
We observed significant differences in nursing students’ performance of standard precautions based on participants’ age (F=3.39,
p=.036), school year (t=3.44,
p<.001), satisfaction with their major area of study (F=15.55,
p<.001), clinical practice period (F=5.19,
p=.002), and experience of HAI (F=17.23,
p<.001). Participants satisfied with their major, those with 18 weeks or more of clinical practice, and those without HAI experience demonstrated higher adherence to standard precautions. However, no significant differences were observed for other characteristics (
Table 1).
Participants’ performance level in adhering to standard precautions was 3.98±0.95 (5-point Likert scale). Their health-beliefs scores averaged 3.46±0.36, whereas self-efficacy and patient safety culture were rated at 4.17±0.68 and 3.24±0.32, respectively (5-point Likert scale) (
Table 2).
Knowledge of standard precautions was 22.44±5.80, with “yes” responses assigned 1 point and “no” or “unknown” responses assigned 0 points (maximum possible score=29). The average correct-response rate among participants was 77.4%. The items with the highest correct-response rate (90.6%) were: “Gown should be worn when blood or body fluids are likely to contaminate skin and clothing,” and “Be careful not to contaminate clothing, skin, or mucous membranes with contaminated linens, and care should be taken not to contaminate other items.” The items with the lowest correct-response rates were: “Personal protective equipment (gloves, gowns, etc.) should always be worn during work” (41.3%) and “After the patient has been treated, perform hand hygiene before removing the gown before leaving the room”, “Disposable or reusable gloves may be used when cleaning the environment and medical equipment” (42.5%), as presented in
Supplement 1.
A positive correlation was found between the performance of standard precautions and self-efficacy (r=.78,
p<.001) and knowledge of standard precautions (r=.62,
p<.001), health beliefs (r=.42,
p<.001) and patient safety culture (r=.26,
p<.001). In addition, age was not significantly correlated with performance of standard precautions (r=–.04,
p=.631) as presented in
Table 3.
Using hierarchical multiple regression analysis, we found that nursing students’ knowledge of standard precautions and self-efficacy significantly influenced their performance of standard precautions after controlling for general characteristics. After univariate analysis, we conducted multiple regression using variables that showed a significant relationship with performance (p<.05) as independent variables. We examined multicollinearity and residual independence in the regression model; no predictor correlation coefficients exceeded .80.
The regression model (Model 1), which included age, school year, satisfaction with major area of study, clinical practice period, and experience of HAI, was statistically significant (F=8.61,
p<.001) and explained 30.1% of the variance in performance (adjusted R²=.301). According to Model 1, high satisfaction with major (β=.37,
p=.013), indirect (β=–.29,
p<.001), and direct HAI (β=–.31,
p<.001) experience was a significant predictor. The tolerance values for Model 1 ranged from .21 to .91, and the variance inflation factor (VIF) ranged from 1.10 to 5.03 (
Table 4).
Model 2 introduced individual variables of this study, including knowledge of standard precautions, health beliefs, and self-efficacy. Model 3 added the environmental variable (patient safety culture) to the previous main variables. The tolerance values for Model 3 ranged from .19 to .88, and the VIF values ranged from 1.10 to 5.24. Additionally, no evidence of multicollinearity was noted, and the residuals met assumptions of normality and homoscedasticity.
After verifying the basic assumptions of the error term, the Durbin-Watson statistic indicated no autocorrelation (value=2.107). The tolerance values for multicollinearity were ≥.10, and the VIF values were less than 10.0 for both models. The residuals also satisfied the assumptions of normality and homoscedasticity. Influence was interpreted using the standardized coefficients. Model 3 showed that the following variables exhibited the strongest influence on performance, in descending order of effect: self-efficacy (β=.58,
p<.001), experience with HAI (β=–.15,
p=.008), age (β=.12,
p=.019), and knowledge of standard precautions (β=.14,
p=.043). The model’s explanatory power was 64.7% (adjusted R²=.647, F=23.42,
p<.001) (
Table 4).
DISCUSSION
We analyzed factors affecting the performance of standard precautions of nursing students applying the HBM as a conceptual framework. This study analyzed factors influencing nursing students’ performance of standard precaution using the HBM as a theoretical framework. The results showed that the performance of standard precaution knowledge and self-efficacy significantly influenced the performance, while health beliefs and patient safety culture did not directly influence the performance. However, from the perspective of the HBM, health beliefs such as perceived susceptibility, severity, benefits, and barriers do not directly predict health behaviors, but rather shape motivational readiness to perform the behavior [
10]. Furthermore, organizational environmental factors, such as patient safety culture, may act as modifiers, influencing health belief formation and the perception of the likelihood of performing behaviors, rather than directly influencing individual health behaviors.
The mean performance score for standard precautions among participants was 3.98±0.95 out of 5, lower than the scores of 4.19 reported by Kang et al. [
30]. The study by Kang et al. [
30] included both nursing students and nurses, whereas this study involved nursing students with clinical practice experience. These differences in inclusion criteria may explain the discrepancy. Additionally, Kim and Kim [
13] found that nurses had higher performance scores of 4.47. Nursing students’ lower scores are understandable due to their limited familiarity and experience with standard precautions. Infection control education must be provided prior to clinical practice, along with simulation-based training that covers diverse clinical scenarios.
To improve nursing students’ performance of standard precautions, we need an approach that goes beyond knowledge transfer and strengthens their self-efficacy for actual practice. Therefore, scenario-based simulations and repetitive practice reflecting the procedural nature of performance of standard precautions should be used to provide successful experiences. Furthermore, the practical application of knowledge should be enhanced by ensuring a clear understanding of the application criteria for performance of standard precautions and their transmission pathways.
This study found that the mean knowledge score for standard precautions was 22.44±5.80 out of 29, indicating a 77.4% correct-response rate. This score is lower than those reported in previous studies by Baek [
19]. This result suggests that nursing students have had fewer opportunities to gain knowledge about performance of standard precautions compared to nurses with diverse experience in clinical settings.
The highest correct-response rate (90.6%) was seen for the questions: “Be careful not to contaminate clothing, skin, or mucous membranes with contaminated linens, and care should be taken not to contaminate other items” and “A gown should be worn when blood or body fluids are likely to contaminate skin and clothing.” The lowest correct-response rate (41.3%) was seen for the question: “Personal protective equipment (gloves, gowns, etc.) should always be worn during work.” These findings indicate a gap in understanding the difference between route-specific and standard precautions. Therefore, future nursing curricula should integrate theory-based instruction with experiential learning strategies that explicitly address the situational application of PPE to enhance students’ understanding of infection prevention principles and promote safe, evidence-based clinical practice.
Performance of standard precautions varied significantly based on satisfaction with their major, clinical practice duration, school year, age, and experience with HAI. This aligns with the studies by Hwang and Lim [
31], which reported that higher satisfaction during clinical practice correlated with better adherence to standard precautions. It is hypothesized that satisfaction with their major helps nursing students focus on coursework, ultimately enhancing their performance in clinical training. Additionally, Lee and Yang [
32] indicated that confidence in basic nursing skills with scenario-based simulation training boosts satisfaction with their major, leading to better adherence to safety protocols.
Moreover, the performance of standard precautions improved with longer clinical practice periods, with students who practiced for 18 weeks or more performing best. This finding is similar to the findings reported by Lee [
33], which can be inferred that prolonged exposure to clinical practice experiences may influence students’ adherence to standard precautions for infection control. Therefore, continuous education on infection control before clinical practice each semester, along with the accumulation of experience in core basic nursing skills as their grade level increases, may have influenced their performance of standard precautions.
In this study, self-efficacy and knowledge of standard precautions, age, and experience with HAI were identified as key factors influencing performance, with an explanatory power of 64.7%. Self-efficacy had the strongest effect on third- and fourth-year nursing students’ adherence to standard precautions. This supports the findings of Jang et al. [
4] and Park and Byun [
11]. Nursing students’ self-efficacy can significantly affect their motivation and likelihood of performing standard precautions [
11]. Self-efficacy is not simply an attitude or perception but rather a crucial factor that enables actual behavioral execution. While health beliefs provide cognitive judgments about “Why something should be done,” self-efficacy provides behavioral confidence about “Whether it can actually be done.” These results support the HBM [
8].
Third- and fourth-year nursing students experience situations through clinical practice where the performance of standard precautions by nurses and other nursing students is necessary. These experiences have allowed third- and fourth-year students to gain successes and failures in performing standard precautions, potentially impacting their self-efficacy and adherence to these practices [
11]. As nursing students gain confidence in performing standard precautions independently based on these experiences, improving nursing students’ self-efficacy is essential for enhancing their performance of standard precautions.
Accordingly, observing clinical nurses or upper-level students performing standard precautions can help students recognize this behavior as a feasible nursing competency. In addition, specific and positive feedback from instructors and clinical supervisors can clarify performance and enhance confidence. An emotionally safe learning environment and debriefing can alleviate performance anxiety and sustain self-efficacy. Additionally, developing various infection scenario-based simulation exercises related to infection control is essential for improving the self-efficacy of nursing students, who represent the future nursing workforce.
HAI with indirect experience was also found to be a factor influencing the performance of standard precautions. In other words, hospital-related indirect experience negatively affected the performance of standard precautions suggests that learning effects in clinical settings may be difficult to achieve through indirect exposure alone. In simpler terms, watching others go through infection experiences might cause students to view infection control situations as easier than they really are or to downplay the risks, which can result in a lack of compliance with standard practices. For nursing students, indirect experiences such as news reports, cases of infection in others, or witnessing HAIs during clinical practice, rather than direct management or control of HAIs, may lead to an excessive recognition of the severity of the infection, which may increase anxiety or fear. It is necessary to educationally reconstruct this indirect experience to enhance self-efficacy and a sense of control. Therefore, infection control education should incorporate simulation training or hands-on approaches that prepare students to effectively handle infections in real-world scenarios.
In addition, nursing students’ knowledge of standard precautions was also an influential factor in their performance of standard precautions. This outcome supports the findings of previous studies by Ayele et al. [
3]. However, it contradicts the findings reported by Jang et al. [
4]. Continuous education is necessary, especially in relation to the hospital care environment, as nursing students’ knowledge of standard precautions leads to improved performance. Therefore, it is important for nursing students to acquire sufficient knowledge on infection prevention measures and standard precautions through basic nursing and nursing management before going to clinical practice. Rather than directly inducing health behaviors, knowledge of standard precautions can act as a modifying factor that shapes awareness of the need for infection prevention, thereby strengthening beliefs about the possibility of performing the behaviors, which can then lead to actual performance through self-efficacy.
However, health beliefs did not affect third- and fourth-year nursing students’ performance of standard precautions. While health beliefs mainly reflect an individual’s cognitive factors regarding the risk of infection, the performance of standard precautions is a procedural and behavioral practice area that requires situational judgment, skill performance, and repetitive application, and it may be difficult to directly translate simple perceptions or attitudes into actual clinical practice [
3,
8]. These results indicate that health beliefs likely influence performance of standard precautions indirectly through self-efficacy or actual performance ability.
Meanwhile, previous studies by Ahn [
7] found health beliefs to be a significant factor. Nurses may be more aware of HAIs’ severity in clinical settings than nursing students. To improve nursing students’ adherence to standard practices, it is necessary to go beyond simply promoting health beliefs through education. Instead, we should implement practical experiences, and positive role models to create a solid educational and environmental foundation that transforms health beliefs into actual practice. In the HBM, health beliefs are viewed as cognitive factors that shape motivational readiness to perform a behavior, rather than directly predicting behavior. Further research is required to assess if health beliefs influence performance via self-efficacy or cues to action.
Patient safety culture did not influence nursing students’ performance of standard precautions. This finding contrasts with those reported by Kim and Kim [
13], who found that patient safety culture was significantly associated with nursing students’ performance of standard precautions. Few studies have examined patient safety culture among third- and fourth-year nursing students, making comparisons difficult. The finding that patient safety culture did not independently influence standard precautions in this study can be interpreted as suggesting that environmental factors may influence behavioral performance through cognitive or motivational processes rather than directly affecting health behaviors.
Patient safety culture refers to the values, beliefs, and behavioral norms regarding patient safety shared by organizational members and is considered an important environmental factor promoting safe nursing practice in clinical settings [
12,
13,
26]. In particular, nursing students have limited direct decision-making authority and responsibility for independent nursing practice within the clinical practice environment, making it difficult for their perception of the organization’s patient safety culture to immediately translate into actual standard precautions. Furthermore, because nursing students often engage in observation-based learning within a limited role scope during clinical practice, their perception of organizational safety culture may remain at a cognitive level, such as assessing individual performance potential or building confidence, rather than influencing individual performance behavior.
Therefore, infection control education for nursing students should go beyond simply conveying awareness of organizational patient safety culture. It is necessary to provide an environment where students can actually practice safety-related behaviors through experiential learning opportunities, such as simulation-based training or role-based practice. This educational approach can contribute to linking patient safety awareness to action. Furthermore, further research is needed to more clearly elucidate the relationship between patient safety culture and cognitive or behavioral factors in the performance of standard precautions by nursing students. The results of this study suggest that cognitive awareness of the need for infection control and organizational environmental factors may indirectly influence performance behaviors through self-efficacy, rather than directly affecting performance of standard precautions.
In light of the study’s limitations, we propose the following recommendations to enhance third- and fourth-year nursing students’ adherence to standard precautions during clinical practice. First, the measure of standard-precaution performance in this study was based on a self-report survey, which involves subjectivity and may differ from actual performance. Self-reported surveys are inherently susceptible to response bias. Future research should include larger samples and conduct long-term surveys across multiple research sites. Second, although the HBM was used as a theoretical framework, some of the factor such as health beliefs (perceived susceptibility, severity, benefit, and barrier) didn't show a significant effect on performance of standard precaution. Therefore, further research is needed to identify the detailed pathways for this.
As this study used a cross-sectional design, it is limited in clearly establishing causal relationships between variables. A longitudinal study is needed to determine whether nursing students’ performance of standard precautions changes over the course of their internship. Nevertheless, the significance of this study is the fact that it identified the standard performance factors of nursing students in a nation-wide population, including a large domestic region, based on the HBM.
The results of this study highlight the need for clinically applicable practice strategies to help nursing students better implement standard precautions in clinical settings. Since self-efficacy was identified as the strongest predictor of standard precaution implementation, nursing education programs should enhance self-efficacy through various case-based simulation training and repetitive practice, enabling students to apply standard precautions in realistic clinical situations. Additionally, educational content should focus on the practical application of PPE, the differences between standard and route-based precautions, and the nurse’s role in environmental management in real-world nursing settings.
Furthermore, considering the limitations and variability of clinical practice periods, clinical training institutions should provide consistent guidance on standard precautions, support active supervision, and encourage clinical instructors and nurses to serve as positive role models. These practice-oriented strategies will enhance nursing student adherence to standard precautions and help prevent HAIs in clinical settings.
CONCLUSION
This study identified third- and fourth-year nursing students’ knowledge of standard precautions, health beliefs, self-efficacy, and patient safety culture, as well as their correlation with adherence to standard precautions during clinical practice. The results indicated that self-efficacy, indirect HAI experience, age and knowledge of standard Precautions significantly influenced performance. To enhance adherence to standard precautions among third- and fourth-year nursing students, continuous education and interventions aimed at improving self-efficacy are essential. Multifaceted educational interventions that enhance self-efficacy, experiential learning, and practical skill development are crucial for preparing nursing students to effectively practice standard precautions in clinical settings and help prevent HAIs.
ARTICLE INFORMATION
Supplementary material
Figure 1.
Table 1.Performance of standard precautions according to general characteristics (N=160)
|
Characteristic |
No. (%) |
Mean±SD |
t/F |
p
|
|
Age (yr) |
|
23.23±2.58 |
|
|
|
Age group (yr) |
|
|
3.39 |
.036 |
|
20–22 |
76 (47.5) |
4.07±0.80 |
|
|
|
23–24 |
53 (33.1) |
4.09±0.99 |
|
|
|
≥25 |
31 (19.4) |
3.60±1.14 |
|
|
|
Sex |
|
|
1.01 |
.316 |
|
Female |
147 (91.9) |
3.96±0.97 |
|
|
|
Male |
13 (8.1) |
4.24±0.68 |
|
|
|
Nursing college area |
|
|
1.05 |
.372 |
|
Seoul/metropolitan area |
89 (55.6) |
3.89±1.05 |
|
|
|
Hoseo/Gwandong Province |
14 (8.8) |
4.28±0.62 |
|
|
|
Yeungnam Province |
11 (6.9) |
4.26±0.59 |
|
|
|
Honam/Jeju Province |
46 (28.7) |
4.00±0.89 |
|
|
|
School year |
|
|
3.44 |
<.001 |
|
Third year |
72 (45.0) |
3.70±1.04 |
|
|
|
Fourth year |
88 (55.0) |
4.21±0.80 |
|
|
|
Satisfaction with major |
|
|
15.55 |
<.001 |
|
Satisfieda
|
99 (61.8) |
4.28±0.72 |
|
a>b, a>c |
|
Neutralb
|
51 (31.9) |
3.54±1.07 |
|
|
|
Dissatisfiedc
|
10 (6.3) |
3.28±1.10 |
|
|
|
Clinical practice period (wk) |
|
|
5.19 |
.002 |
|
<6a
|
9 (5.6) |
3.52±0.71 |
|
c<d |
|
6–11b
|
68 (42.5) |
3.87±0.98 |
|
|
|
12–17c
|
35 (21.9) |
3.76±1.09 |
|
|
|
≥18d
|
48 (30.0) |
4.40±0.66 |
|
|
|
Type of hospitala)
|
|
|
0.77 |
.482 |
|
University hospital |
137 (69.5) |
4.02±0.98 |
|
|
|
General hospital |
47 (23.9) |
3.81±0.78 |
|
|
|
Clinic |
13 (6.6) |
3.46±0.53 |
|
|
|
Experience in standard precautions education |
|
|
0.39 |
.533 |
|
Yes |
151 (94.4) |
4.01±0.95 |
|
|
|
No |
9 (5.6) |
3.60±0.81 |
|
|
|
HAI experience |
|
|
17.23 |
<.001 |
|
Indirect experiencea
|
75 (46.9) |
3.80±0.97 |
|
a<c, b<c |
|
Direct experienceb
|
21 (13.1) |
3.30±1.02 |
|
|
|
No experiencec
|
64 (40.0) |
4.44±0.66 |
|
|
Table 2.Descriptive statistics for measured variables (N=160)
|
Variable |
Mean±SD |
|
Knowledge of standard precautions |
22.44±5.80 |
|
Health beliefs |
3.46±0.36 |
|
Self-efficacy |
4.17±0.68 |
|
Patient safety culture |
3.24±0.32 |
|
Performance of standard precautions |
3.98±0.95 |
Table 3.Correlations among measured variables (N=160)
|
Performance of standard precautions |
Knowledge of standard precautions |
Health beliefs |
Self-efficacy |
Patient safety culture |
Age |
|
|
Performance of standard precautions |
1 |
|
|
|
|
|
|
|
Knowledge of standard precautions |
.62 (<.001) |
1 |
|
|
|
|
|
|
Health beliefs |
.42 (<.001) |
.47 (<.001) |
1 |
|
|
|
|
|
Self-efficacy |
.78 (<.001) |
.69 (<.001) |
.46 (<.001) |
1 |
|
|
|
|
Patient safety culture |
.26 (<.001) |
.18 (.024) |
.49 (<.001) |
.26 (<.001) |
1 |
|
|
|
Age |
–.04 (.631) |
–.18 (.022) |
–.14 (.089) |
–.21 (.009) |
–.12 (.145) |
1 |
|
Table 4.Summary of hierarchical multiple regression analysis (N=160)
|
Variable |
Model I |
Model II |
Model Ⅲ |
|
B |
SE |
β |
t |
p
|
B |
SE |
β |
t |
p
|
B |
SE |
β |
t |
p
|
|
(Constant) |
3.91 |
0.65 |
|
5.99 |
<.001 |
−1.82 |
0.72 |
|
−2.54 |
.012 |
–2.12 |
0.77 |
|
–2.85 |
.005 |
|
Age |
0.01 |
0.03 |
.03 |
0.41 |
.682 |
0.04 |
0.02 |
.12 |
2.31 |
.022 |
0.04 |
0.02 |
.12 |
2.37 |
.019 |
|
School year |
–0.31 |
0.17 |
–.16 |
–1.86 |
.065 |
−0.15 |
0.12 |
−.08 |
−1.27 |
.205 |
–0.14 |
0.12 |
–.07 |
–1.19 |
.237 |
|
Satisfaction with majora)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Satisfied |
0.73 |
0.29 |
.37 |
2.51 |
.013 |
0.28 |
0.21 |
.14 |
1.32 |
.188 |
0.25 |
0.21 |
.13 |
1.18 |
.242 |
|
Neutral |
0.17 |
0.29 |
.08 |
0.59 |
.558 |
0.13 |
0.21 |
.07 |
0.64 |
.523 |
0.12 |
0.21 |
.06 |
0.56 |
.579 |
|
Clinical practice period (wk)b)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
<6 |
–0.21 |
0.20 |
–.09 |
–1.05 |
.296 |
0.01 |
0.14 |
.04 |
0.69 |
.491 |
0.12 |
0.14 |
.05 |
0.81 |
.422 |
|
6–11 |
–0.25 |
0.19 |
–.13 |
–1.31 |
.191 |
0.05 |
0.14 |
.03 |
0.36 |
.717 |
0.02 |
0.14 |
.01 |
0.17 |
.869 |
|
12–17 |
–0.29 |
0.32 |
–.07 |
–0.90 |
.367 |
–0.16 |
0.23 |
–.04 |
–0.67 |
.506 |
–0.18 |
0.23 |
–.04 |
–0.78 |
.436 |
|
HAI experiencec)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Indirect experience |
–0.54 |
0.14 |
–.29 |
–3.95 |
<.001 |
–0.26 |
0.10 |
–.14 |
–2.57 |
.011 |
–0.28 |
0.10 |
–.15 |
–2.70 |
.008 |
|
Direct experience |
–0.87 |
0.23 |
–.31 |
–3.85 |
<.001 |
–0.12 |
0.17 |
–.04 |
–0.70 |
.488 |
–0.16 |
0.18 |
–.06 |
–0.89 |
.374 |
|
Knowledge |
|
|
|
|
|
0.02 |
0.01 |
.14 |
1.96 |
.052 |
0.02 |
0.01 |
.14 |
2.05 |
.043 |
|
Health belief |
|
|
|
|
|
0.25 |
0.15 |
.09 |
1.65 |
.101 |
0.16 |
0.16 |
.06 |
0.95 |
.345 |
|
Self-efficacy |
|
|
|
|
|
0.82 |
0.10 |
.59 |
7.86 |
<.001 |
0.81 |
0.10 |
.58 |
7.73 |
<.001 |
|
Patient safety culture |
|
|
|
|
|
|
|
|
|
|
0.23 |
0.17 |
.08 |
1.32 |
.190 |
|
R2
|
.341 |
.672 |
.676 |
|
Adjusted R2
|
.307 (F=8.61, p<.001) |
.645 (F=25.10, p<.001) |
.647 (F=23.42, p<.001) |
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