Current challenges in teaching healthcare-associated infections prevention and control in nursing education in Vietnam and Cambodia: a qualitative study

Introduction

Healthcare-associated infections (HAIs) are infections people get while receiving health care in any healthcare facility, including hospitals, ambulatory surgical centers, and long-term care facilities.¹ Bacteria, fungi, viruses or other, less common pathogens can cause HAIs. HAIs are often acquired from hospitals after 48 hours or more of admission or within 30 days after having received health care. The World Health Organization (WHO) report shows a high rate of Antimicrobial Resistance and estimates 10 million deaths per year due to HAIs in 2050.² The various consequences of HAIs for patients and the health system are included e.g., the increased morbidity and mortality of patients, prolonged average hospital stay from 7 to 15 days, and increased use of antibiotics leading to a resistance of microorganisms.

The incidence of HAIs is higher in developing countries compared to developed countries.^2,3 Therefore, the increasing prevalence of HAIs in Asian countries increases the costs of healthcare organizations and the morbidity and mortality of patients in already low-income countries.⁴ The overall prevalence of HAIs in developing countries is around 17.0%, in which the rate of infections acquired in intensive care units is at least two to three times higher than in high-income countries.⁵

In Vietnam, previous findings indicated that the rate of hospital infections was around 6%, of which respiratory tract infections accounted for the highest rate at 56%. The risk factors associated with HAIs such as age (18-30 years old), gender (male), length of hospital stay (9 days), and invasive procedures.⁶ The prevalence of HAIs in the adult ICU accounted for around 23-30%.^7,8 In addition, the rate of antibiotic resistance in Vietnam is a significant concern. Tran and colleagues (2019) indicated that the rate of gram-negative bacteria infection in inpatients is high. Infectious diseases accounted for 25% of hospitalizations and had a high rate of mortality (12%).⁹

On the other hand, in Cambodia, the most-reported ones were respiratory tract infections accounting for 53%.¹⁰ The study conducted at the National Hospital for Children indicated that HAIs incidence was around 14%, and the incidence of HAIs in ICU was 50%.¹⁰ The various rates of HAIs in different Asian countries and hospitals could be due to different morbidity patterns, treatment protocols, level of development of health systems, or HAIs prevention and control (HAIs-PC). Moreover, the different operational definitions of HAIs adopted in the studies and the low notification and monitoring of these events can also be the reason for the variation in HAIs rates across countries.¹¹

Even though prevalence statistics regarding HAIs are not sufficiently reported, there are many problems, which hinder systematic HAIs-PC work in developing countries.¹² The awareness of the healthcare workers is not adequate, and at the same time, the lack of support resources such as education and medical equipment leads to a high percentage of HAIs. In Vietnam, according to Ngo (2018), healthcare workers reported challenges related to HAIs including poor resources, awareness, and patient overload.⁶ In 2015, WHO emphasized the importance of strengthening HAIs-PC by improving awareness among healthcare workers and patients.¹³ Governments of different countries indicated that it is necessary to promote healthcare, thereby consolidating and perfecting the system of surveillance, warning, and proactive disease prevention; establishing units of disease control and prevention.¹³

The provision of quality education is essential for the training and development of the appropriate competencies, knowledge, and skills of healthcare workers, which enables them to provide safe and quality healthcare. In Asian countries, healthcare universities gradually introduced HAIs-PC education programs for students at all levels.¹⁴ These programs demonstrated certain effectiveness of education in raising awareness and reducing the rate of HAIs. In Cambodia, following the WHO’s global action plan, efforts have been made to enhance the quality of Cambodia’s health institutions’ conditions, including infection prevention and control practices.¹³ Moreover, the research evidence recommended that hospitals and healthcare universities should provide appropriate HAIs-PC education to students, patients, and healthcare providers, especially, nursing students at the very beginning of their bachelor program.^15,16

In Asian countries, the HAIs-PC education program currently differs between universities and countries in contents and form of practice training, as well as in assessment and recognition.²⁷ These disparities have led to difficulties in evaluating the effectiveness of the education program in improving nursing students’ knowledge and competence in this field. Moreover, there is insufficient scientific research to evaluate the perception of lecturers and learners about HAIs-PC education in developing countries. The research aim thus was to explore current challenges in HAIs-PC education in nursing curriculum in two Vietnamese and two Cambodian universities.

Methods

Results

The participants were asked questions pertaining to the focus of the implementation of HAIs-PC education, the challenges of the faculty on teaching and students’ learning, facilities, and students’ competency perceptions. The results indicated that there were challenges in HAIs-PC education in Vietnamese and Cambodian institutions. The challenges come from the curriculum, students’ and teachers’ characteristics, and universities. The diagnostic indicator results provided primary information on the designed curriculum regarding each academic year for the HAIs-PC module, contents, and credit hours for theory and practice. The interview and group discussion results showed that the challenges came from the implementation of the curriculum, an inactive learning environment, and unsupportive facilities at the university.

Most HEIs have been providing nursing education programs for bachelor students for more than ten years. These universities integrated HAIs-PC contents into the nursing curriculum during various study years. Mostly, nursing teachers provided lectures and lab practice of HAIs-PC to the nursing students in the second year of the study program. The students practiced providing care for patients in the hospitals in the third year of study, under the supervision of the clinical lecturers and nurses.

The total participants in the study were 49 managers, nursing faculty teachers, and clinical tutors. Vietnam (V) had 28 participants, with university 1 (U1) (16 participants), University 2 (U2) (12 participants), and Cambodia (C) had 21 participants, with university 3 (U3) (12 participants) and University 4 (U4) (9 participants). The detail is shown in Table 1.

The diagnostic indicators of the curriculum

The four universities offered a wide range of nursing degree levels. Universities in Vietnam had bachelor’s degrees in nursing with large numbers of students, especially U1 currently has 1,733 nursing bachelor’s students studying at the university. All universities in the countries lectured one to two credits for the HAIs-PC module, which, distributed time equally between theory and skill practice. In Asian countries, each credit corresponds to 15 hours of theory or 30 hours of skill practice. The institutions provided lecture and skill practice hours for HAIs-PC variously, U1 with 45 hours and U4 with 15 hours for the whole course. Clinical practice at the hospital for HAIs-PC was integrated into the other modules. All four universities provided students with knowledge and lab practice related to HAIs-PC. The contents were transmission routes and HAIs prevention measures; sterilization for and management of medical equipment; Sanitization of the hospital environment; Medical waste management; Prevention and control of blood and body fluid exposure and Infection surveillance. There was a slight difference in the program structure. A university in Vietnam arranged an HAIs-PC course with 3 credits, including a credit in microbiology and parasites HAIs-PC theory and clinical practice. The other universities provided the program with a different structure. The total hours of theory and practice ranged from 15 to 45 hours, in which, the practice hours were double compared to theory hours. Details are presented in Table 2.

Results of current challenges of HAIs-PC education in the nursing curriculum in Asian countries

The research findings were structured into three generic themes, which were the Implementation of HAIs-PC education into nursing curriculum, Positive aspects fostering IPC learning, and Negative aspects hindering HAIs-PC learning (Figure 1).

Figure 1. The challenges in HAIs-PC education in Vietnamese and Cambodian Universities.

Implementation of HAIs-PC education into the nursing curriculum

The generic theme was composed of sub-themes including Curricula’s structure and content and Used teaching methods. The HAIs-PC education in the four institutions was recognized as an important aspect of nursing education. However, the Curricula’s structure and content in the institutions were different depending on the perception of the role of HAIs-PC in clinical settings. The participants indicated various perceptions regarding the current nursing curriculum in their universities. In both countries, the nursing curriculum contents, teaching materials, and teaching methods met the objectives related to the HAIs-PC course. The HEI regularly updated the structure and contents of HAIs-PC contents to meet the rapidly changing situation of the countries’ healthcare system and the needs for healthcare services. The participants indicated that continuous updating of the contents of the course always ensured a scientific and evidence-based curriculum before integrated teaching to students. Moreover, it seemed that the students gained the needed basic knowledge and skills on HAIs-PC during their learning process.

A difficulty in the implementation of HAIs-PC education in the curricula was that the countries did not have clear enough guidelines from the Ministry of Health (MOH) and there was no common agreement between the academic and the hospital settings on HAIs-PC curriculum. Therefore, the Universities were not able to prioritize the corresponding HAIs-PC practical skills before students practiced in the hospital settings.

However, the Covid-19 pandemic brought more consistency into the regular updating of teaching content met the need of healthcare service systems under the direction of MOH and WHO.

The used teaching methods were based on an assumption that nursing bachelor’s students need to gain enough knowledge and skills related to HAIs-PC while they study in classes and skill practice before they enter the clinical settings. Therefore, the universities designed a curriculum that provided bachelor students the lectures on basic knowledge and skill practice, in which the strategies and methods in teaching HAIs-PC were used to meet the requirements.

The lecturers have precepted the role of simulation in clinical teaching, especially in training students in positive thinking and decision-making skills for HAIs-PC. However, their capacity was insufficient to apply the method. In clinical settings, awareness of the exited inherent gap between the academic and clinical settings, the wards tried to create the best possible conditions to guide students while practicing HAIs-PC in the hospital.

Discussion

This study explored the challenges of HAIs-PC education in nursing curriculum in two Vietnamese and two Cambodian HEIs. The exploratory study was conducted in two Vietnam and two Cambodia HEIs with 49 participants who were leaders, nursing teachers, and clinical tutors. There was diversity in the ratio of students to faculty between universities and between countries, specifically, the ratio in a Vietnam university was 22.7 while that at Cambodia university was 12.0. The research results indicated that there were various hours in theory and laboratory practice from university to university. Furthermore, there were differences in the hours per credit requirement between the two countries, particularly with regard to the number of hours per credit for practical courses. The results correspond to the results of previous studies on the diversity in the regulation system of nursing professional training of two countries.^18,19 The qualitative results emerged the main theme challenges in HAIs-PC education with generic themes of Implementation of HAIs-PC education into nursing curriculum, Positive aspects fostering HAIs-PC learning, and Negative aspects hindering HAIs-PC learning.

Research results on the positive aspects of HAIs-PC education at the HEIs included motivating students’ learning and enhancing students’ ability to practice. HEIs strived to apply active teaching methods to enhance student engagement in learning. The addition of an extra-curricular skill practice for students was also a positive method to be applied. In addition, the case-based pedagogy had begun to improve students’ practical capacity on HAIs-PC. The research results were similar to previous studies to enhance the learning and practice of HAIs-PC of nursing students.^20,21 Kim and colleagues (2020) indicated that simulation pedagogy improved HAIs-PC competence by increasing knowledge, compliance, and practical quality and outcomes in patients.²²

The negative aspects hindering HAIs-PC learning were revealed by the managers, lecturers, and clinical tutors. The participants admitted that they used active teaching methods in delivering HAIs-PC lectures, but it was not effective. These perceptions were consistent with nursing instructors in some Asian countries because they were familiar with traditional teaching methods, along with a large number of students in study groups.^23,24 The connection, application of knowledge, and practice between the University and the clinical environment was also a challenge to the teaching capacity of lecturers. Therefore, improvements are urgently needed in HAIs-PC education for nursing bachelors at Asian universities. To create a positive learning environment, specifically related to HAIs-PC education, efforts need to come from teachers, students, and especially from educational institutions. Therefore, in order to improve the challenges in HAIs-PC education for nursing students, HEIs of Vietnam and Cambodia should pay attention to the following changes and improvements. Firstly, the universities should build an active learning model in which increased content knowledge, critical thinking, problem-solving abilities, and positive attitudes toward learning and make a fluency between theory and clinical practice.²⁵ Although leaders and teachers claimed that they regularly updated the books, however, updating should focus on making the books more appealing to learners. Instead of simply providing content, the books should include images and interesting real-life cases related to HAIs-PC. This may make an interesting first impression of HAIs-PC learning. Moreover, the orientation session is equally important to help students understand the significance of HAIs-PC learning in their professional practice. In theory, the teachers should use active teaching methods, create two-way interaction and initiative in learning, and provide timely two-way feedback. For practice, the simulation pedagogy would provide students with the opportunity to familiarize themselves with and experience HAIs-PC before practicing in real clinical settings.²⁶

Unsupported facilities for HAIs-PC learning included the lack of equipment, teaching materials, and clinical facilities. This result corresponds to some previous studies.^27,28 Through the nursing education system, lecturers and instructors should be empowered and encouraged to provide an enhanced nursing education approach that applies local facilities and resources, as well as enhance awareness of local resources. Developing countries’ universities should adopt and adapt active teaching methods to improve nursing education by utilizing available resources.^29,30 The use of different active learning methods, especially, simulation pedagogy may improve communication and critical thinking skills and enhance safety in healthcare for the patients and nursing students themselves.³¹

The research results indicated that one of the challenges was the lack of knowledgeable and skilful lecturers in the field of HAIs-PC education. Many nursing teachers were not confident in teaching theory and practice on HAIs-PC because they have not been regularly trained on the module. The results were congruent with previous studies that the teachers need to be more competent by attending regular training or workshops on HAIs-PC education.³² The InovSafeCare Pedagogical Model for HAIs-PC education was implemented and presented the effectiveness of student HAIs-PC outcomes in Europe.³³ The model focuses on the comprehensive application of active teaching pedagogies to theoretical, practical, and clinical learning environments. In particular, the simulation method with well-designed scenarios based on clinical reality enhanced students’ ability to critically thinking and problem-solving HAIs-PC problems.³⁴ A similar culturally adapted model should be piloted to evaluate the model on HAIs-PC students’ outcomes. Moreover, the universities should have regular training on HAIs-PC for the teachers, as well as assign them as clinical instructors in the HAIs-PC department at the hospital for their updating knowledge and skills. Besides supplementing competency related to HAIs-PC, lecturers also need to be trained to improve their pedagogical skills as well as how to deploy active teaching methods, especially simulation teaching. In addition, the capacity building of evidence-based research and practice in the field of HAIs-PC should also be considered to enhance students’ and lecturers’ competency in HAIs-PC.^35,26

The present study used a qualitative design with in-depth interviews and focus group discussions on diverse participants and a quantitative design to ensure various perspectives were obtained from the participants. In addition, the number of focus groups and in-depth interviews was continuously conducted until the final interview and discussion, although the researcher found the data were saturated, which made the research results identified rich and reliable. The combined data provided a comprehensive insight into the prevailing challenges of HAIs-PC education in nursing curricula across Asian countries. By analyzing these diverse data sources, researchers could gain a nuanced understanding of the multifaceted issues surrounding HAIs-PC education, including curriculum effectiveness, educational strategies, and barriers to learning. The quantitative data offered statistical evidence regarding the prevalence and impact of HAIs, while deep interviews and focus group discussions facilitated the exploration of nuanced perspectives and experiences of educators and students. This integrated approach not only elucidated the current state of HAIs-PC education but also enables researchers to address the research question by identifying key areas for improvement and informing evidence-based interventions to enhance IPC learning outcomes in nursing education within Asian contexts.

The results obtained from both methods of data collection, namely deep interviews conducted with The University Board and focus group discussions with lecturers and tutors regarding their perceptions of the Healthcare-Associated Infections Prevention and Control (HAIs-PC) program in their nursing curriculum, offered complementary insights into the effectiveness and challenges of the program implementation. Deep interviews with The University Board members provided a high-level perspective on the overarching goals, strategic planning, and institutional support for the HAIs-PC program. These interviews may yield insights into the alignment of the program with broader educational objectives and institutional priorities. On the other hand, focus group discussions with lecturers and tutors delved into the frontline experiences, perceptions, and challenges faced in the delivery of the HAIs-PC program. These discussions overall offered a granular understanding of the practical implementation issues, pedagogical strategies, and student engagement within the program. By combining the results of both methods, researchers can triangulate findings, identify converging themes, and gain a comprehensive understanding of the HAIs-PC program’s strengths and weaknesses from both strategic and operational perspectives.

However, the study has some limitations. Firstly, only data from leader boards, teachers, and tutors were collected, without perceptions from students. Future research should be explored these challenges from the student’s perspective for a holistic perspective on the issue.

Secondly, the research results identified that challenges in HAIs-PC education were considered sensitive topics for their HEIs. However, face-to-face interviews and focus group discussions with participants may create the impression that participants could be trying to “hide” real challenges or overemphasize the positive aspects of their HEIs. During the interviews and focus group discussions, the researcher emphasized that the research purpose was to identify common challenges, not problems with the participants themselves, therefore, reducing concealment. In addition, interviews and focus group discussions conducted in universities had various characteristics and cultures, the research results may be generalized to the other HEIs in Asian countries.

Conclusions

The study may provide evidence of the challenges to the current HAIs-PC education in the nursing curriculum in Vietnam and Cambodia. The negative aspects hindering HAIs-PC education of inappropriate pedagogy, equipment and materials, and university and hospital cooperation were the challenges. The evidence may suggest useful solutions for future nursing education on HAIs-PC practice, consequently reducing the prevalence of HAIs in Vietnam and Cambodia.

Providing a robust, updated HAIs-PC education curriculum that is culturally consistent and contextually relevant is an important first step in improving nursing education outcomes and quality care. The faculty and clinical instructors, who provide direct education to nursing students, are ideally positioned to develop students’ HAIs-PC skills for future nurses with safe and effective care competency. Regularly updating content, applying active teaching methods in skills training, and utilizing existing local resources may improve the effectiveness of HAIs-PC education for nursing students.

Disclaimer

The European Commission’s support for the production of this publication does not constitute an endorsement of the contents, which reflect the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.