Undergraduate nursing students' education and training in aseptic technique: A mixed methods systematic review

This is an open access article under the terms of the Creat ive Commo ns Attri bution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2021 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 1School of Healthcare Sciences, Cardiff University, Cardiff, UK 2City University of London, London, UK 3School of Healthcare Sciences, Cardiff University, Cardiff, UK 4School of Healthcare Sciences, Cardiff University, Cardiff, UK


| BACKG ROU N D
Over the years, approaches to teaching and assessing aseptic technique have changed in the UK to align with broader changes in nurse education. Until the mid-1990s, all nursing students were required to demonstrate competence in a single test before they were allowed to register. Throughout the mid-1990s pre-registration nursing courses moved from hospital-based schools of nursing to universities, with universities responsible for their own arrangements to assess competence. This lack of standardisation is one of the numerous problems affecting both the university-based teaching of aseptic technique and students' experiences during clinical placements. A recent survey, designed to explore teaching and assessment of aseptic technique in UK undergraduate nursing education, established a lack of consistency and inaccuracies relating to the principles of asepsis (Hawker et al., 2020). Additionally, more than one guideline was identified as underpinning teaching by 88% of the universities surveyed. These findings corroborate studies exploring other key infection prevention issues, notably hand hygiene (Sundal et al., 2017;Zimmerman et al., 2020) and probably contribute to the differences in practice described by Preston (2005) and Unsworth and Collins (2011). In the research by Hawker et al. (2020), there were marked variations in the number of hours devoted to teaching and assessing aseptic techniques. Aseptic technique was predominantly taught by university lecturers, with teaching approaches including classroom-based sessions, simulation in clinical skills laboratories and self-directed learning. Variations in the practice of aseptic technique have been identified by nursing students during clinical placements, with good clinical role models often unavailable (Gould & Drey, 2013;Ward, 2011). Opportunities for qualified nurses to update their knowledge and skills related to aseptic technique are limited, and their understanding of the underlying principles of asepsis has been reported to be suboptimal (Gould et al., 2018(Gould et al., , 2021. As a result, nurse educators and mentors in clinical placements may be poorly equipped to teach and assess students.
No systematic reviews investigating undergraduate nursing students' education and training in aseptic technique appear to have been undertaken. A systematic review was undertaken to explore undergraduate nursing students' education and training in aseptic technique internationally and identify scope for improvement as stipulated in international policy (World Health Organization 2016a, 2016b, 2016c, Department of Health, 2019.

| Aim
To appraise and synthesize evidence from empirical studies exploring undergraduate nursing students' education and training in aseptic technique internationally.

| Objectives
The objectives of the systematic review were as follows: 1. To establish the effectiveness of different teaching/learning methods for aseptic technique upon nursing students' knowledge and competence.
2. To examine reported levels/findings of nursing students' knowledge, competency and confidence in undertaking an aseptic technique as outcomes of learning.
3. To explore students', educators' and qualified nurses' perceptions of education and training in aseptic technique in undergraduate nursing programmes.

| Design
A mixed methods review was chosen to address the different objectives about effectiveness (quantitative) and experience (qualitative) to increase understanding of nursing students' education and training in aseptic technique (Bressan et al., 2016). This review was informed by the Joanna Briggs Institute (JBI) methodology for mixed methods systematic reviews and adopted a convergent segregated approach to synthesis and integration (Hong et al., 2017;Lizarondo et al., 2020). This approach is characterised by an independent synthesis of qualitative and quantitative data followed by integration of quantitative and qualitative evidence (Lizarondo et al., 2020).
No reporting guidelines for mixed methods studies reviews exist (Fleming et al., 2008). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (Moher et al., 2009) (Tong et al., 2012) were followed.

| Search methods
The following databases were searched from January 1996 to  Davey (1997). MeSH terminology and keywords were used for aseptic technique, infection prevention, healthcare-associated infection, nursing students, nurse education, training and assessment (see File S1 for search strategy).
Additional search strategies included: searching the internet with a general browser (Google Scholar); screening reference lists of papers already retrieved and hand-searching high-yield key journals (American Journal of Infection Control, Journal of Advanced Nursing, Journal of Infection Control, Nurse Education Today).
The inclusion criteria were as follows: (1) empirical studies (qualitative, quantitative or mixed methods); (2) focusing upon undergraduate nursing students' learning, teaching and assessment of aseptic technique in university or clinical placements; (3) exploring aseptic technique as a whole concept applied in any invasive procedure; (4) measuring nursing students' knowledge, competency, confidence in undertaking an aseptic technique (5) students', educators' or qualified nurses' perceptions of teaching, learning and assessment of aseptic technique in the university or clinical practice setting in undergraduate nursing programmes.
Exclusion criteria were as follows: (1) non-empirical papers-literature reviews, opinion papers or editorials; (2) other healthcare students' learning, teaching and assessment of aseptic technique (3) individual components of an aseptic technique only, i.e., hand hygiene and (4) no outcome measures reported for aseptic technique.

| Search outcomes
The database searches located 1147 papers. The selection process is summarised in the PRISMA flow diagram (Moher et al., 2009) (see Figure 1). After the removal of duplicates, there were 538 papers for screening.
All studies were assessed for relevance by screening the titles and then abstracts and if a judgment could not be reached the full paper was retrieved for assessment. A screening tool was developed based on the inclusion criteria to ensure consistency throughout the screening process. All 56 potentially eligible papers were screened by two reviewers (CH, DJG) against the inclusion criteria using the screening tool. Arbitration from a third independent reviewer was available but not required. Of 538 potentially eligible papers, 27 met the inclusion criteria.

| Quality appraisal
The quality of studies included in the review was evaluated using different critical appraisal tools depending upon study design (see File S2). The Critical Appraisal Skills Programme (CASP) (2020) checklists for randomized trials and qualitative studies were used for assessing the methodological quality of intervention studies (n = 6) and qualitative studies (n = 8), respectively. The methodological quality of eight cross-sectional studies (n = 8) and quantitative, descriptive studies (n = 5) were assessed using the Specialist Unit for Review Evidence (SURE) (2018) critical appraisal checklist for cross-sectional studies. Two reviewers independently assessed the quality of each study and were in agreement. No studies were excluded following the quality appraisal. The quality assessment was used to identify the strengths and limitations of the evidence and inform assessment in the confidence of the review findings.

| Data extraction
Data were extracted from the included papers using a standardized data extraction table as described by guidance from the Centre for Reviews and Dissemination (2009). The extracted data included the following: (1) authors, year and country; (2) aim; (3) study design; (4) sample; (5) intervention where applicable; (6) data collection methods and (6) key findings -for nursing students' competency, knowledge and confidence levels and students' educators' or qualified nurses' perceptions of teaching, learning and assessment of aseptic technique (see Tables 1-3). Two reviewers involved in the screening and quality appraisal, independently extracted data and another reviewer cross-checked the data extraction table for accuracy (Lizarondo et al., 2020). Any disagreements in data extraction were resolved by discussion with a third reviewer (Lizarondo et al., 2020). Data extraction for thematic synthesis is described in the next section.

| Synthesis
A convergent segregated approach was used whereby independent synthesis of qualitative and quantitative data was followed by integration of quantitative and qualitative evidence (Hong et al., 2017;Lizarondo et al., 2020). A meta-analysis was not feasible to meet objective 1 because of the heterogeneity of the intervention studies. Therefore, a narrative synthesis was undertaken using the following tools and techniques identified under two elements of Popay et al.'s (2006) framework for narrative synthesis; tabulation, developing textual descriptions, grouping and clustering of studies to characterize the key outcomes and findings (competence and knowledge) across studies in developing a preliminary synthesis and concept mapping for exploring relationships in the data.
Quantitative evidence and qualitative evidence from observational studies were synthesized separately and then a narrative summary produced, which is presented under objective 2, linking and organizing the findings across the outcomes of interest which were as follows: (1) competency, (2) knowledge and (3) confidence to provide a configured analysis (Lizarondo et al., 2020). Narrative summaries allow for the juxtaposition of different types of evidence (Dixon-Woods et al., 2005). Quantitative evidence and qualitative evidence were integrated using configurative analysis. This involved constant comparison of the quantitative evidence and qualitative evidence, in order to organize/ link the evidence into a line of argument (Lizarondo et al., 2020;Tong et al.,2012).
Thematic synthesis was undertaken in which findings from the observational studies (quantitative and qualitative evidence) were synthesized together (Harden et al., 2018) to address objective 3.
Although more commonly associated with the synthesis of qualitative research, thematic synthesis was used as a pragmatic approach to the synthesis of qualitative and quantitative studies with a similar focus (Fleurke et al., 2020). Two stages of Thomas and Harden's (2008) three-staged approach to thematic synthesis were followed, which involved independent inductive coding and the development of descriptive codes and a coding framework followed by the generation of themes by the first reviewer. Only quantitative data relevant to perceptions or experiences of learning, teaching and assessment were extracted primarily from survey findings and assigned a textual description for coding to allow integration with qualitative data (Lizarondo et al., 2020). The second and the third reviewer checked the coding and thematic synthesis process. The findings are presented under the following key themes: (1) observing good and poor role models, (2) congruence between university teaching and clinical practice and (3) variations in opportunity for learning and assessment.
F I G U R E 1 Study selection process based on the PRISMA diagram (Moher et al., 2009)

| Description of studies
The review included 27 studies, a summary of each included study can be found in Tables 1-3, (for further information see File S3).
Five of the six studies were undertaken in the university setting (Jeffries et al., 2002;Melby et al., 1997;O'Neill, 2001;Walsh et al., 2011;Wright et al., 2008). One study (Zhang, 2015), took place in clinical practice. knowledge and competence (see Table 4 for a summary).
Two studies, each testing intervention was designed to improve mental processes to enhance students' performance of aseptic technique during a wound dressing, produced conflicting findings

TA B L E 4 Different learning/teaching methods and effect on knowledge and competence
Three studies, comparing the effectiveness of different instructional methods for aseptic technique in different clinical procedures in the simulated environment, yielded mixed findings (Jeffries et al., 2002;Melby et al., 2007;Walsh et al., 2011). A pre-and post-test study by Jefferies et al. (2002), identified no significant differences in knowledge (no p-value reported) between students who received didactic teaching of aseptic technique as applied to wound dressings (n = 50) or interactive, self-directed learning (n = 70). This finding might be explained by students in both groups demonstrating similarly high levels of knowledge at baseline. An RCT investigating the value of a demonstration in students' (n = 16) learning of intramuscular injection technique found that students who received a demonstration maintained asepsis. Asepsis was not maintained in those who did not receive the demonstration (Melby et al., 2007).
However, this was based only on one students' videotaped performance. A pre-and post-test study by Walsh et al. (2011), comparing the effectiveness of peer, expert and computer-assisted learning of urinary catheterization in nursing (n = 25) and medical (n = 35) students, reported significant reductions in breaks in aseptic technique and increased checklist and global rating scores from pre-to post-test (p < .05) but no significant differences between groups (p > .05).
Zhang's (2015) non-randomized trial investigated the effectiveness of standardized teaching ward rounds compared with traditional ward rounds in clinical practice. Nursing students (n = 120) who received standardized teaching ward rounds had significantly higher knowledge (p = .006) and skills scores (p = .046) for aseptic technique than students (n = 120) who received traditional ward rounds.

| Objective 2:
Examine reported levels/ findings of nursing students' knowledge, competency and confidence in undertaking an aseptic technique as outcomes of learning.
Nine observational studies: six cross-sectional surveys, two qualitative studies and one descriptive study reported levels/ findings in relation to nursing students' knowledge (n = 5), competency (n = 4) and confidence to perform an aseptic technique (n = 2) (see Table 3).

| Competency
Six observational studies reported upon nursing students' competency (Cebeci et al., 2015;Gonzalez & Sole, 2014;Mackey et al., 2014;Rush et al., 2014;Uysal, 2016;Watts et al., 2009). Five studies identified errors or breaches in aseptic technique made by students, but errors were reported differently (Cebeci et al., 2015;Gonzalez & Sole, 2014;Mackey et al., 2014;Uysal, 2016;Watts et al., 2009 Two studies reported breaches in aseptic technique to be the most common error made by students during medication administration (Cebeci et al., 2015;Uysal, 2016). In Cebeci et al.'s (2015) cross-sectional survey of nursing student's (n = 324) medication errors, deviation from aseptic technique was the most common error reported by students in 23.8% of cases. Similarly, in Uysal's (2016) retrospective, analytical study of nursing students' practical skills examination papers (n = 605), failure to adhere to the principles of asepsis was the most common mistake (

| Confidence
Two observational studies reported students' confidence to undertake aseptic technique to be moderate to high (Carter et al., 2017;Gonzalez & Sole, 2014). In Gonzalez and Sole's (2014) descriptive study, nursing students' (n = 13) mean confidence was 3.6 on a 5point scale, suggesting moderate confidence in their ability to perform urinary catheterization in the simulated environment despite the majority of students breaching aseptic technique. Likewise, in Carter et al.'s (2017) online survey of nursing students (n = 3678) described previously, only 12% reported not feeling confident in using aseptic technique when inserting and maintaining invasive devices.

| Objective 3: Explore students', educators' and qualified nurses' perceptions of education and training in aseptic technique in undergraduate nursing programmes
Eleven observational studies, three cross-sectional surveys; one descriptive study, one analytical study and six qualitative studies, focused upon students', educators' and qualified nurses' perceptions of the effectiveness of teaching and assessment of aseptic technique (see Table 3). Ten studies explored nursing students' perceptions/experiences of learning aseptic technique in clinical placements (Carter et al., 2017;Geller et al., 2010;Gould & Drey, 2013;Ribu et al.,2003;Stayt & Merriman, 2013;Ward, 2010Ward, , 2011Ward, , 2012aWard, , 2012bWestphal et al., 2014). One qualitative study explored infection prevention nurses' perceptions of aseptic technique education and training (Cox et al., 2014). Three qualitative studies also explored mentors' perceptions (Ward, 2011(Ward, , 2012(Ward, , 2012a. Half of these studies (n = 6) originated from the UK. Three themes emerged and included observing good and poor role models, congruence between university teaching and clinical practice, and variations in opportunity for learning and assessment.

| Observing good and poor role models
The first theme was observing good and poor role models. Nursing students reported observing both good and poor aseptic technique practices in different clinical placements (Carter et al., 2017;Geller et al., 2010;Gould & Drey, 2013;Ribu et al., 2003;Ward, 2010Ward, , 2012aWard, , 2012bWestphal et al., 2014). Opinions about aseptic technique practices in community settings were conflicting with criticisms of both nursing and medical practice (Gould & Drey, 2013;Ward, 2010). In Ward's (2010) qualitative study, nursing students (n = 40) some nurses were seen to have poor practices: "I saw some-one…they re-used the stitch cutter on someone else" while community nurses were reported to have good practices: "district nurses were particularly good…do it in a proper aseptic non-touch manner".
In comparison, nursing students (n = 488) in Gould and Drey's (2013) survey were highly critical of aseptic technique practices in community and long-stay settings.
In three studies, nursing students reported observing qualified nurses breaching aseptic technique by contaminating susceptible sites, equipment and the sterile field during different invasive procedures (Geller et al., 2010;Ribu et al., 2003;Westphal et al., 2014).
In Ribu et al.'s (2003) descriptive study, nursing students (n = 30) reported only 60% of nurses washed their hands before and after wound dressing ulcers, and three incidences of breaches in aseptic technique. Similarly, in Westphal et al.'s (2014) qualitative study, analyzing student's (n = 96) assignments, students identified three incidences of breaches in aseptic technique during the insertion of invasive devices by qualified nurses, one incidence is captured in the following quote: "the nurse crossed her arm over the sterile field and used her non-sterile hand to adjust the gloves… and allowed the urinary catheter to fall against the patient's leg and continued to insert it". Students (n = 500) in Geller et al.'s (2010) retrospective, analytical study reported 17.2% breaks in aseptic technique observed in clinical practice over a three-year period, but were trained as part of their programme to report infection control hazards or near misses.

| Congruence between university teaching and clinical practice
The second theme described congruence between university teaching and clinical practice. Three studies provided conflicting findings of congruence between what is taught about aseptic technique in university and what is observed in clinical practice (Carter et al., 2017;Cox et al., 2014;Ward 2011). In two qualitative studies, students (n = 31) and mentors (n = 32) (Ward 2011) and infection prevention nurses (n = 8) (Cox et al.'s 2014) reported conflicting practices and a theory-practice gap in aseptic technique as illustrated by the following quotes from infection prevention nurses: "universities seem teach something different to what's happening on the ground" and "those basic aseptic techniques are just missing" and a student: "setting up an intravenous line aseptically am I doing it right? Am I doing it wrong". By contrast, in Carter et al.'s (2017) survey, 89% of students (n = 3768) reported agreement between what was taught in university and observed in clinical practice.

| Variations in opportunity for learning and assessment
The final theme was about variations in opportunity for learning and assessment. Two studies provided insight concerning students' perceptions of how aseptic technique was taught in university (Carter et al., 2017;Ward 2011). In Ward's (2011) qualitative study, mentors (n = 32) and students (n = 31) perceived small group teaching to be more effective for learning than large lectures. The findings of Carter et al.'s (2017) survey suggested wide variation in the type and duration of aseptic technique education that students received.
These authors speculated that the nature of the educational experience might influence the ability and confidence to practice.
Two studies reported that students might have variable or limited opportunities to practice and be assessed in their ability to undertake aseptic technique in university and clinical placements (Stayt and Merriman 2013;Ward 2011). In Ward's (2011) qualitative study, mentors (n = 32) and students (n = 31) identified the need for assessment of aseptic technique as shown by the following student quote "someone actually coming out on the wards to assess us, test us…". In Stayt and Merriman's (2013) survey of nursing students' (n = 421) perceptions of skills development in placements, 44% and 63.1% of students reported sometimes or never having the opportunity to practice and for assessment, respectively.  (Carter et al., 2017;Davey, 1997;Gonzalez and Sole, 2014). The remaining studies largely focused upon teaching/learning and assessment of different clinical procedures, requiring an aseptic technique. More important issues such as the lack of agreement over the aim, definitions and principles of aseptic technique and the impact of this in undergraduate nursing programmes have been overlooked.

| DISCUSS ION
It is recommended that policy-makers should as a matter of priority reach a consensus about an internationally agreed definition of aseptic technique and produce international guidelines for aseptic technique including the aim and underlying principles.
Recommendations for education and practice are to ensure that practitioners and educators are regularly updated in aseptic technique and reinforce the underlying principles of asepsis when teaching students. Students should be also provided with greater opportunities for learning, practice and assessment of aseptic technique.
The findings of this review confirm that the evidence required Further qualitative studies are needed to explore nursing students' understanding of aseptic technique. Only one much earlier study undertook an in-depth examination of nursing student's understanding of aseptic technique and deemed it to be poor (Davey 1997). Other studies either measured students' knowledge of when to apply an aseptic technique or accepted that students understood the meaning of aseptic technique without assessment (Carter et al., 2017;Ferreira Baptista et al., 2013;Mitchell et al., 2014;Simonetti et al., 2019). Nursing students need to know not only when to apply an aseptic technique, but also comprehend the principles of aseptic technique to ensure safe practice (NMC 2018).

| CON CLUS ION
The findings of this systematic review suggest that education and training in aseptic technique could be improved, but should be viewed cautiously given the poor methodological quality of the studies. Although aseptic technique is a core skill with nursing students globally required to learn it, it has attracted very little research attention compared to other infection prevention practices such as hand hygiene. Suboptimal undergraduate nurse education and training in aseptic technique may impede the development of nursing students' knowledge, understanding and competency. Further research is required to explore how teaching and assessment of aseptic technique in undergraduate programmes might be enhanced.

ACK N OWLED G EM ENTS
This research was funded by Cardiff University as part of a PhD studentship.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the author(s).

PEER R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.14974.