Assessing Student Nurses' Knowledge of Microbiology for Course Content Improvement

Tonie Victoria Akpata Correspondence: Tonie Victoria Akpata, Ph.D College of Nursing, The Public Authority for Applied Education and Training (PAAET) Al- Shuwaikh, Kuwait Telephone: 0096567670598 Fax number: 00965 22315702 Email: vicakpata@hotmail.com

Abstract Background: Microbiology curriculum in pre-registration nursing programs varies in different countries and institutions. Thus, making a decision on the course content can be a challenge, especially in a new institution. Objective: To assess students' knowledge of microbiology with a view to improving the course content for nursing programs. Methods: An anonymous questionnaire was administered to 330 nursing students and 14 faculty members. The questionnaire contained 10 questions on each subject area of microbiology - infection control, immunity, epidemiology and pathogenicity, with answers on a three-point Likert scale. Descriptive statistics, t-test and ANOVA were used to determine the significance of the differences between scores by different programs, levels of enrollment and gender. Results: Students in Bachelor of Science in Nursing (BSN) program generally had higher mean scores than those in Associate Degree in Nursing (ADN). Students' mean scores increased with level of enrollment. Female students had significantly higher mean scores in pathogenicity than males (p= 0.018). For all respondents, knowledge of microbiology was highest in immunity and infection control and least in pathogenicity and epidemiology. Conclusion: Areas of pathogenicity and epidemiology require more emphasis in the nursing microbiology curriculum. Keywords: Nursing, knowledge, microbiology course content, curriculum

INTRODUCTION
Microbiology is one of the biological science courses required by nursing institutions; however, the microbiology course content varies from one institution to another (Goetz et al., 1992; Choe & Shin, 1999). Goetz (1992) reported that 49 percent of nursing institutions in the USA required students to take a microbiology course before clinical experience; some institutions offered only infection control and immunization as their microbiology course content. However, Reynolds (2006) felt that infection control, transmission of diseases and epidemiology are areas that should be included in the microbiology course for nurses. Knowledge of these areas could reduce occupational risk of nursing students, as was reported by Atulomah & Oladepo (2002). In a study by Davis (2010) in the UK, nursing students reported that the bioscience content of their pre-registration nursing education was inadequate.

The present study assessed students' knowledge of four subject areas of microbiology- infection control, immunity, epidemiology and pathogenicity. The results will be helpful in determining the areas requiring improvement so as to enhance nursing students' knowledge of microbiology.

Review of Literature
Biosciences taught in pre-registration nursing programs include anatomy, physiology, biochemistry and microbiology. Henderson (2000) reported that the Georgia Board of Nursing in the USA, mandated that nursing curricula should contain natural sciences, including microbiology. Reynolds (2006) reported the importance of microbiology to nursing students. Literature indicates poor performance of students in biosciences, including microbiology (Jordan et al., 1999; Davis, 2010). Wong &Wong (1999) observed that performance in biosciences together with grade point average of nursing courses in years 3 and 4 contributed significantly to student success in the nursing program (p<0.001). Furthermore, Campbell & Dickson (1996) reported that grade point averages in nursing and science courses were the greatest cognitive predictors of NCLEX-RN examination success. In addition, performance in microbiology was associated with the score in the final examination as well as the professional licensure examinations.

Knowledge of microbiology is essential for the understanding of the pathogenesis of infectious diseases and infection control. Atulomah & Oladepo (2002) in Nigeria attributed occupational risks from HIV/AIDS among nursing and midwifery students to poor knowledge of microbiology. Similarly, Denny-Smith et al. (2006) reported that female nursing students' inadequate knowledge of microbiology put them at risk of human papillomavirus and cervical cancer. Thus, Trnobranski (1993) stressed the need for nurses to understand disease processes sufficiently to practice safely. Kyriacos et al. (2005) suggested that the curriculum content of microbiology must equip nurses in developing countries, such as South Africa, to meet their expanding roles as leaders in health care clinics. In fact, doctors and service users expect of nurses a higher level of knowledge of biosciences than they actually have (Davis, 2010). Staff nurses have been reported to express lack of confidence in articulating their knowledge to patients and other health professionals (Courtenay, 1991; Clancy et al., 2000).

As the knowledge of the various areas of microbiology impact differently on clinical practice, it is of interest to evaluate students' performance in the various areas of the subject.

Aim
The aim of this study was to assess students' knowledge of microbiology with a view to improving the course content for pre- registration nursing programs.

Definition of terms
Course content in this study refers to four subject areas of microbiology, namely: infection control, immunity, epidemiology and pathogenicity.

Study setting
The College of Nursing is the only institution, in Kuwait, admitting high school graduates for nursing training (Al-Kandari et al., 2009). Established by decree in November, 2002, the College offers two programs: Bachelor of Science in Nursing (BSN) which runs for four years and Associate Degree in Nursing (ADN) that has five levels each being one semester of four months. Microbiology is compulsory for the nursing programs so, there is need for enhancement of students' knowledge.

Previous reports have focused on the relevance of basic sciences to nursing practice, or as a predictor of success in nursing programs. There appears to be few studies on nursing students' knowledge of microbiology as a basis for evaluation of microbiology course content.
The aim of this study was, therefore, to assess the knowledge of microbiology among nursing students in the ADN and BSN programs against a standard score by registered nurses who were clinical teachers in the College of Nursing.

METHODS
Ethical approval
Approval for this research project was given by the Research Committees of the College of Nursing and the Public Authority for Applied Education and Training (PAAET), Kuwait. Ethical considerations were given in the use of human subjects and their informed consent. The purpose of the study was described in writing and also explained to all the students before distribution of the questionnaire to those willing to participate. Their consent was expressed by their responding to the questionnaire.

Questionnaire
The instrument for the research study was an anonymous questionnaire.
The first section of the questionnaire dealt with demographic information on nationality, gender, college program, level of enrollment, and if respondent had previously studied microbiology. The second section comprised ten questions on each of four subject areas of microbiology namely; infection control, immunity, epidemiology and pathogenicity. Answers were on a three -point Likert scale of: I agree, I do not know, and I disagree.

Procedure
An anonymous self-administered questionnaire was distributed to nursing students in a classroom setting, under the supervision of a faculty member who explained the objectives of the research study and the anonymity of the questionnaire. Participation meant consent. The supervisor ensured that individual responses were given to the questionnaire.

Validity
The content validity of the questionnaire was assessed by four faculty members - two registered nurses and two biomedical scientists.

Pilot study
Twenty-five students were given the questionnaire before the main research study. Their responses were used to test the suitability of the questions and feasibility of the research methods.

Reliability
To test the reliability of the responses, one week after completion of the questionnaire, 10 of the students were given new copies of the questionnaire to repeat. The test retest responses given to the questionnaire were compared, giving a result of 0.86.

Statistical analysis
Descriptive statistics were carried out to determine the percentages, means, and standard deviations of the scores. T-test and ANOVA were used to determine significance of the differences between mean scores by different groups at 95 percent confidence interval.
Knowledge was assessed as the correct responses to the questions.

RESULTS
Demographic data
There were 330 students and 14 teachers who responded to the questionnaire. Of the students, 97 percent were Arabs, and the remainder non-Arabs. Altogether, 278 students (84 percent) were in the Associate Degree in Nursing (ADN) program, while 52 students (16 percent) were in the Bachelor of Science in Nursing (BSN) program. The number of students who had not studied microbiology previously, decreased as the level of enrollment increased. Only 10 percent of students in BSN program had not studied microbiology before their enrollment.

The response rate to the questionnaire was 95.1 percent for students, 93.3 percent for teachers and 95 percent overall.

Mean scores by male and female students at different levels of enrollment (Table 1).


Table1. Mean scores (SD) for male and female students in 10 questions of each subject area according to levels of enrollment (L) in ADN

Table 1 shows the mean scores of male and female respondents in each subject area according to their level of enrollment. Generally, mean scores increased with level. However, in ADN at level 2, females had lower mean scores than level 1. Overall, female students had higher mean scores than their male counterparts but the difference was not significant. Nevertheless, female students (ADN) had significantly higher mean scores in pathogenicity than male students in level 1 (p<0.018) and level 4 (p<0.001).

Mean scores by students in different programs as well as teachers (Table 2)

Click here for Table 2: Mean scores (SD) for ADN (males & females), BSN and Teachers according to the Subject Area

Results in Table 2 show the highest mean scores in this order: teachers, BSN, ADN. Among the ADN students, females had higher scores than males in each subject area. All groups of respondents had the highest mean scores in immunity followed by infection control. The area with lowest mean scores was pathogenicity followed by epidemiology. Teachers had significantly higher scores than ADN male (p<0.004) and female (p<0.038) students, irrespective of subject area. Analysis of variance (ANOVA) showed that there was a significant difference between the scores by teachers, when compared to mean scores by ADN and BSN students, notably in epidemiology (p<0.001). Students in BSN obtained significantly higher mean scores in epidemiology than ADN male students (p= 0.025).
Error bar of mean scores by different groups of respondents (Figure 1).

Click here for Figure 1: Mean scores by different groups of respondents

Mean scores at 95 percent confidence intervals show that the highest score was achieved by BSN students and the lowest by males in the ADN program (Figure 1).

DISCUSSION
Using teachers' mean scores as a standard, students' knowledge in different areas of microbiology was assessed. Thus, it was possible to identify areas of the microbiology course that required modification in order to improve the students' knowledge of the subject. As previously reported (Al-Kandari et al., 2009), the number of teachers available to participate in the study was much fewer than the number of students. Similarly, more females than males participated in the study (Al- Kandari & Vidal, 2007) possibly because nursing is not a preferred profession among males. Besides, it is the policy of the nursing college in Kuwait to admit only females to the BSN program (Al-Kandari et al., 2009). Although, students' scores generally increased with level of enrollment, ADN level 2 female students consistently had lower scores than those in level 1, irrespective of the subject area. This may be due to the fact that level 2 female students were a weaker batch.

Microbiology is a compulsory course for pre-registration nursing education (Goetz et al. 1992; Choe & Shin, 1999; Jordan et al., 1999; Wong & Wong, 1999; Henderson, 2000). Most students in the BSN program are registered nurses who had obtained Associate Degree in Nursing (ADN). The higher scores by the BSN students in the present study may be due to the fact that they had previously studied microbiology in their pre-registration training. Moreover, they had practiced nursing and therefore realized the importance of microbiology in their professional practice. This underscores the fact that students perform better in biosciences when they appreciate the importance of the subject in clinical practice (Davis et al., 2010).

Male students had lower mean scores than females because nursing is not popular with men and therefore they show less interest in the nursing courses, including microbiology. Oliveira et al. (2002) also observed that female dental students had higher scores than males. Previous studies reported that male nursing students suffered from heavy mental pressure and showed low identity to the nursing specialty (Lian-di & Ning, 2006; Ding et al., 2008). All groups of respondents had the highest mean scores in immunity and infection control which are the subject areas most relevant to nursing practice. On the other hand, all groups had lowest mean scores in pathogenicity, possibly because this subject area is sometimes viewed as less relevant to nursing practice. Davis (2010) reported that doctors and service users expect nurses to be able to discuss pathogenesis of diseases. Therefore, there is a need to improve on the course content and teaching of pathogenicity in nursing programs so that nurses may be able to explain disease processes to patients in the course of their professional practice. Lower knowledge in epidemiology among recipients may be attributed to the fact that epidemiology is taught in lectures but it is not reinforced by nursing practice.

Previous studies on teaching of bioscience in nursing programs have dealt with performance in the subject as a predictor of success in licensing examinations (Carpio et al., 1999; Wong & Wong, 1999; Reynolds, 2006) or the importance of microbiology in clinical practice (Atulomah & Oladepo, 2002; Denny-Smith, 2006), whereas reports on microbiology course content in nursing education (Reynolds, 2006; Goetz et al., 1999; Choe & Shin, 1999) discussed relevance of the different subject areas, the present study focuses on students' knowledge of each area of microbiology and the results have been used to identify aspects of the course content that need improvement. This approach may be applicable in the improvement of the contents of other basic science courses.

CONCLUSION
Students were weak in areas of pathogenicity and epidemiology. Therefore, the course content in these areas of microbiology needs to be improved.

The nursing program in Kuwait has good microbiology course content, covering the subject areas most relevant to nursing practice being, infection control and immunity in which nursing students had the highest knowledge. Students had least knowledge of pathogenicity concerning pathogens and the disease process that are more academic aspects of microbiology, not directly relevant to nursing practice. Enhancement of nurses' knowledge in pathogenicity could improve their discussion with doctors and service users. Improvement in epidemiology could reflect on nurses' awareness of numbers in record keeping for statistical purposes.

Acknowledgements
The cooperation of the nursing faculty in data collection was most appreciated. The research study was supported by Research Grant No.CN-09-01 of the Public Authority for Applied Education and Training (PAAET), Kuwait. The statistical analysis was by Dr. P. N. Sharma, Health Sciences Center, Kuwait.

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