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ISSUES IN CLINICAL NURSING

doi: 10.1111/j.1365-2702.2006.01404.x

Student nurses experiences of caring for infectious patients in source


isolation. A hermeneutic phenomenological study
Irene Cassidy

RGN, RM, RNT, BNS, MSc

Lecturer, Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland

Submitted for publication: 10 November 2003


Accepted for publication: 22 July 2005

Correspondence:
Irene Cassidy
University of Limerick
Limerick
Ireland
Telephone: 35361234215
E-mail: irene.cassidy@ul.ie

C A S S I D Y I ( 2 0 0 6 ) Journal of Clinical Nursing 15, 12471256


Student nurses experiences of caring for infectious patients in source isolation. A
hermeneutic phenomenological study
Aim. To illuminate issues central to general student nurses experiences of caring for
isolated patients within the hospital environment, which may assist facilitators of
learning to prepare students for caring roles.
Background. Because of the development of hospital-resistant micro-organisms,
caring for patients in source isolation is a frequent occurrence for supernumerary
students on the general nursing programme. Despite this, students perceptions of
caring for this client group remain under researched.
Design and methods. Through methods grounded in hermeneutic phenomenology,
eight students in the second year of the three-year undergraduate programme in
general nursing were interviewed using an un-structured, open-ended and face-toface interview approach. Data analysis was approached through thematic analysis.
Results. Four themes emerged: The organization: caring in context, Barriers and
breaking the barriers, Theory and practice, Only a student. The imposed physical,
psychological, social and emotional barriers of isolation dramatically alter the
caring experience. Balancing the care of isolated patients to meet their individual
needs while preventing the spread of infection has significance for students.
Applying infection control theory to the care of patients in source isolation is vital
for students personal and professional development. Perceptions of supernumerary
status influence students experiences of caring for these patients.
Relevance to clinical practice. Designating equipment for the sole use of isolated
patients assists students in maintaining infection control standards. Balancing the
art and science of caring for patients in source isolation is important to reduce
barriers to the studentpatient relationship and to promote delivery of holistic care.
Staff nurses should consider using available opportunities to impart recommended
isolation practices to students thereby linking the theory of infection control to
patient care. Providing structured, continuing education for all grades of staff would
acknowledge the interdependence of all healthcare workers in controlling hospitalacquired infection.

Key words: caring, infectious, nursing, phenomenology, source isolation, student


nurse

Introduction
Hospitals are vulnerable to new infections, which result
from changes in both the general population and hospital
 2006 Blackwell Publishing Ltd

environment (Parker 1999). Approximately, one in every 11


hospital patients at any one time will develop a hospitalacquired infection (National Audit Office 2000). Infection
control is integral to patient care and assists in reducing
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I Cassidy

morbidity and mortality (Curran 2001). Source isolation or


barrier nursing is described as one way nurses can contribute
to controlling the spread of transmissible infection within
general hospitals (Glover 2000, Wilson 2001).
Use of single-room isolation along with transmission-based
precautions (commonly known as source isolation) is taken
for patients known or suspected to be infected or colonized
with pathogens spread by air, droplet or contact routes
(Garner 1996). These precautions have provided an alternative to placing some patients in infectious disease hospitals.
However, caring for isolated patients may vary depending on
the structure of the organization, available resources and the
changing epidemiology of the hospital-acquired infection
(Mac Kenzie 1997, Gould 2000, Storr 2000).
Patients perspectives of source isolation suggest that the
imposed environment and isolation procedures, associated
with the science of nursing, provide barriers to physical,
sensory and psychosocial needs (Knowles 1993, Davies &
Rees 2000, Rees et al. 2000). Isolated patients often feel
shunned, neglected, lonely, abandoned, inferior, bored,
frustrated and stigmatized (Oldman 1998, Mayho 1999,
Maunder et al. 2003). Moreover, isolation precautions limit
visual, auditory and sensory cues and may create communication barriers between patient and nurse (Mac Kenzie
1997).
Nurses have a critical role in ensuring that, for patients in
source isolation, psychological demands, stresses and uncertainties are not exacerbated by nursing interventions but are
reduced to promote effective coping (Knowles 1993, Davies
& Rees 2000, Rees et al. 2000). Tailoring care to individuals
needs, helps reduce stresses associated with extended periods
of separation, contributing to positive experiences of isolation (Ward 2000, Myatt & Langley 2003). Finn (1997)
suggested that some nurses lack knowledge and skills
necessary to plan and evaluate appropriate infection control
care. Consequently, nurses may misinterpret source isolation
guidelines (Wagenvoort et al. 1997). This could result in
either ineffective precautions or over isolation and placement
of persons in single rooms when standard precautions could
suffice (Knowles 1993, Prieto & Clark 1999, Riley 2000,
Ward 2000).
Donning protective equipment such as masks, gloves and
aprons reduces the speed of response to patients and limits
verbal and non-verbal communication (Knowles 1993, Oldman 1998, Mayho 1999, Adams 2000). Nurses also report
lack of confidence in dealing with the psychological needs of
isolated patients (Knowles 1993). Perceptions of personal
danger are often exacerbated by uncertainty about the impact
of infections (Maunder et al. 2003). Isolation nursing is an
area filled with prejudice and fears that limits nurses from
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really seeing the person (Sadala 1999). Nurses are fearful of


contracting infections and being seen as negligent (Gammon
1998). Hence, staff may carry out irrational infection control
precautions believing that they will better protect themselves
and others (Mac Kenzie 1997).
Sadala (1999) conducted a phenomenological study in
South America with 18 nursing students to understand
meanings given to caring for patients within a designated
isolation unit. The study described how anxieties students
initially experienced started to diminish as they began to
establish therapeutic relationships with patients (Sadala
1999). Apart from the latter study, there is a dearth of
nursing research explicating the unique challenges and
experiences faced by the students as they care for infectious
isolated patients. To contribute to the preparation of general
student nurses for caring roles, it is important to illuminate
issues central to their experiences of providing this care.

Purpose
The purpose of this study was to explore and describe the
meanings of second year student nurses attached to caring for
infectious patients in source isolation within the general
hospital setting.

Methodology
The Gadamerian hermeneutic phenomenological approach
guided this study. Key philosophical concepts within this
approach are prejudgements, dialogue, hermeneutic circle
and fusion of horizons (Koch 1996). Gadamerian hermeneutics acknowledges the prejudgements of the researcher
and conceptualizes the researcher as an active participant in
the interpretation process (Van Post & Eriksson 1999).
Gadamers approach emphasizes the importance of dialogue
so that the existential world is opened and understood (Koch
1999). The notion of change or development of understanding between researcher and participants throughout the
research process is referred to by Gadamer as the hermeneutic
circle (Gadamer 1975, Fleming et al. 2003). The role of
understanding is to show how a fusion of horizons has
occurred (Koch 1996). As the only researcher, the use of a
hermeneutic phenomenological approach made it possible to
engage with participants to create a collective description of
the experience of caring for infectious isolated patients.

Methods
The site selected was a group of general hospitals within a
particular health board region in the Republic of Ireland.

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Issues in clinical nursing

Student nurses experiences of caring for infectious patients in source isolation

None of these hospitals had a designated isolation ward.


Within the site, there were 55 second year students on the
general diploma programme. During the data collection
period, some of these were on placement in general hospitals
and some were on outside placements such as: obstetrics
and intellectual disability. Caring for patients in source
isolation would not have been expected during the outside
placements and students may not have found the idea of
being interviewed about isolation relevant at that time.
Through purposive sampling 13 introductory letters were
sent to second year students on clinical placements within the
general hospitals inviting them to participate in the study if
they had cared for a patient in source isolation and were
willing to be interviewed about their experiences. Eight
students who fulfilled these inclusion criteria consented to
participate and were subsequently interviewed. All eight were
female. Prior to the interviews, participants would have
received approximately 22 hours microbiology and 37 hours
infection control theory. Infection control theory explored
areas like hospital-acquired infection, standard precautions
and isolation precautions with application to specific infections like methicillin-resistant Staphylococcus aureus
(MRSA) and Clostidium difficile.

Ethical considerations
Ethical approval was obtained from the local hospital ethics
committee. Permission to undertake the study was also granted
from the director of nursing and principal tutor. Participants
were informed in writing of the study and their right to decline
to participate or withdraw at any time. Potential power
imbalance between researcher and participants was acknowledged. It was left to each individual to make follow-up contact
with the researcher if they wished to take part. This aimed to
protect students so the decision to become involved was truly
theirs. Written informed consent was obtained. Anonymity of
participants was ensured by the use of a coding system. Other
measures such as storing data in a locked press and reporting
the findings so that participants could not be identified by their
individual responses upheld confidentiality.

Data collection and data analysis


Inherent within phenomenology is the use of methods such as
interviewing, which can access participants subjective experiences (Cormack 2000). Hermeneutics conceptualizes the
researcher as an active contributor in the interpretation
process. Meanings emerge as participants and researcher
engage in dialogue (Van Post & Eriksson 1999). Dialogue
was achieved through unstructured open-ended and face-

to-face interviews. Permission to record interviews on tape was


secured. Each interview commenced with one open-ended
question Tell me, about your experiences of caring for
infectious patients in source isolation. On average, interviews
lasted 55 minutes. A reflective diary and field notes were also
used.
Data analysis was thematic. The framework used was
eclectic and adapted from Burnard (1991) and Gijbels and
Burnard (1995). Analysis incorporated philosophical concepts from Gadamer (1975) such as prejudgements, dialogue,
hermeneutic circle, fusion of horizons and perspectives from;
Benner (1994) such as thematic analysis, and DeSantis and
Ugarriza (2000) on the concept of theme as used in qualitative research.
Audiotapes were transcribed verbatim. Transcriptions
were reviewed against audiotapes to assure consistent and
accurate recording of interviews. Immersion in data occurred
through listening to tapes, re-reading transcripts and studying
field and reflective comments. Notes were made in transcripts, which identified meaningful perspectives, patterns,
stances, concepts and concerns. In the next stage of analysis,
the latter were surveyed and similar ideas merged into higher
order headings or aspects. Aspects were then captured as
themes that portrayed and unified students experiences
(DeSantis & Ugarriza 2000).

Trustworthiness
To ensure credibility within a Gadamerian approach, researcher self-awareness is essential (Koch 1999). Throughout the
study, researcher prejudgements were acknowledged using
intuition and a reflective diary. In keeping with beliefs of
hermeneutic phenomenology, validation occurred by asking
the eight participants to check if interview transcripts, data
analysis and interpretation processes accurately reflected their
experiences. An audit trail was retained to ensure that the
research process was open, transparent and justifiable. Anonymous word-for-word excerpts from participants narratives
are included in the report so that other students may recognize
the experiences described. Information on the research setting
and sample are included to assist readers to judge transferability of findings to other contexts.

Findings
Four main themes emerged:
The organization: caring in context;
Barriers and breaking the barriers;
Theory and practice;
Only a student.

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The organization: caring in context

when you hear that some people are in isolation, the first thing that

Students were exposed to the realities of trying to implement


isolation precautions within the context of a busy general
hospital. Sometimes not having enough single rooms, which
could be used for isolation, influenced implementation of
precautions and posed stresses on students and ward staff
alike. One participant described how there were:
two patients in the isolation rooms with Clostridium difficile.
There was also another three on the main ward with it and there was
just no where to put them (S-7).

Design, size and structure of some rooms used for isolation


within the general wards influenced students implementation
of precautions. Consequently, they often had to choose
between closing the door and adhering to isolation precautions or leaving it open for patient comfort.
Difficulties in securing designated equipment in some
wards left students feeling uneasy and confused. Using
communal ward equipment such as sphygmomanometers,
which are difficult to clean between patients, evoked feelings
of discomfort that students could be contributing to the
spread of infection in the clinical area. Some students were
reluctant to verbalize concerns regarding the use of communal equipment on isolated patients; in case, this was misinterpreted as laziness or avoidance of work.
Several students felt that the busy nature of the ward often
resulted in the infection control aspects of isolation being
given less priority because they did not fit into established
routines or they were not cultivated within these routines.
Planning nursing care so that as many interventions as
possible were carried out at the same time was recognized as
important in controlling the infection and workload/time
associated with putting on protective equipment. This had
implications for the frequency of contact patients received
from students. For example:
theyre always left till the end to be washed (S-3).

Because isolated patients may not have nurses calling into


them as often, some students felt that they may be left there.
It was noted that they did not mean, left there as in neglect
of physical needs:
you wouldnt leave them just sitting there and not being washed or
whatever. But mentally, theyre kind of just, there (S-2).

Barriers and breaking the barriers


There were perceived threats regarding the potential for
acquiring certain infections from isolated patients:

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comes into your head is what have they can I catch it? Is it
contagious ah? (S-1)

Frequency of contact was associated with greater potential


for acquiring infection, such as:
if Im in contact with this person all day every day then I might catch
what they have (S-4).

Established beliefs and values may exacerbate concerns about


the potential infectiousness of certain client groups. Isolation
was valued as a safety net that protected staff from acquiring
infection:
he was query [suspected of having] HIV but he was on the main
ward and nobody would go near him cause he wasnt in isolation
(S-7).

Fears of contracting infections may result in panic and


students taking unnecessary measures:
some people would have weird ideasthey think if I wash my
hands that isnt good enough, I nearly have to bleach them off (S-6).

Wearing protective equipment at all times or not going into


isolation rooms as much were measures taken to deal with
concerns regarding contagiousness:
people do tend to stay away or avoid them and not go in and talk
to them as much orpeople would gown up before they would talk
to them or just ask them a question (S-4).

Conflict between balancing the care of isolated patients to


meet individual needs while preventing spread of infection
permeated several interviews:
you need a balance there as wellyoure caught up in yourself
trying to protect yourself but then the nursing care of the patient is
not as holistic compared with a patient on a ward that has no
infection (S-8).

However, for some students, as their knowledge and experience of nursing deepened, they realized that:
if you take the right precautions and wash your hands properly and
do whatever you have to do, you know that youll be OK (S-1).

Students demonstrated understanding of the physical, social


and psychological effects of source isolation. One participant
suggested that isolated patients must feel socially rejected,
others commented that they may even feel like aliens. There
was a perception that the ability to cope with the experience
and confines of isolation varied depending on individual
patients and their life experiences:

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Issues in clinical nursing

Student nurses experiences of caring for infectious patients in source isolation

they would be out farming all day and we turn aroundand oh


sorry now youve to stay in this room . By God and theyre all
there thinking of the cattle and sheep and the dogs and the whole lot
(S-6).

One reported experience with an isolated patient who might


growl at you if you entered the room illustrated the
importance of nursepatient communication as a means of
breaking barriers:
Just asking him a question was breaking the barrier I suppose (S-4).

Students felt that nurses need to incorporate the importance


of infection control procedures into their caring role if they
are to fulfil that role competently.
Patient education was considered particularly important
because patients cannot see infections like MRSA. Students
found that education made a positive difference to patients
experiences of isolation. Patients did not seem to be as
anxious about being isolated or about the special precautions
that were being taken. Through experiential learning students, found that patient education helped foster student
patient relationships. However, there were undertones that
patient education may not be prioritized within the care
situation because of time limitations and emphasis on
routines and physical care.
Visitor education was also perceived as unstructured. Lack
of factual information or misinformation could increase
visitor anxiety, which in turn may heighten patient stress
thereby reinforcing alienation. One participant provided her
experience of a visitors unrealistic fears of calling on a
relative with MRSA:
she wanted to bring the bottle of hibiscrub with her and disinfect
the whole family and then burn the clothes they had on, get into the
new clothes and go home. She had completely picked it up as a lifethreatening illness. Andshe thoughtshe couldnt breast feed
cause shed kill the [her] child (S-6).

Theory and practice


Participants felt uncomfortable when inconsistent implementation of isolation took place. Inconsistencies related to either
a relaxed approach to isolation practices or relapsed knowledge of infection control.
Students and other healthcare staff might become relaxed
towards particular infections when they are exposed to them
on a daily basis:

Practices such as clinical waste bags being left outside


isolation rooms instead of inside; mentors seeming unaware
of certain infection control policy recommendations and staff
wearing protective equipment outside isolation rooms were
considered ineffective.
However, undertaking isolation precautions the right way
led to a sense of satisfaction and feeling good about self.
Participants valued the importance of linking microbiology
and infection control theory to their nursing care, as in:
now I understand why (S-1).

Students had been exposed to two infection control modules,


one in first year before the first clinical placement and another
module at the beginning of second year. One participant felt
that there was:
a good balance with the theoryits always fresh in your mind
(S-1).

However, they were not introduced to microbiology until


second year:
in doing maintaining a safe environment and learning about MRSA
in first yearit wasnt until I did microbiology in second year that
oh, yes thats really what it isprobably if they both were both
carried out together it would make more sense (S-5).

It was suggested that, irrespective of the education, students


have been taught, if ward nurses are relaxed about implementing isolation precautions then:
youre going to get relaxed about it also (S-8).

Positive role models were valued for teaching the students


correct isolation procedures, for acting as co-learners and
involving students in clinical learning situations. One student
commented that some staff nurses were brilliant. That staff
nurses acknowledge the importance of integrating psychological care into the caring role was also valued. Students
appreciated mutual sharing of information on isolation
precautions, that staff nurses could even ask students:
does this match up with what youre after doing in class? (S-7)

Awareness that organizational, staffing constraints and


knowledge deficit may impact on staff nurses ability to be
effective role models was evident. One participant commented that some staff nurses might not have knowledge of
isolation precautions fresh in their mind so they may need
to:

when we first heard it in first year we were all saying oh yea MRSA,

take another course on infection control themselves so that they

MRSA but now I think weve become relaxed about it up there, were

can pass on the information to students (S-5).

not using the special precautions were supposed to use (S-8).

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It was suggested that re-education regarding infection control


precautions should start with all grades of staff if isolation
precautions are to be implemented effectively.

Only a student
Students often felt hard-done-by and their standards of care
belittled when other members of the multidisciplinary team
did not adhere to recommended infection control practice.
One student anticipated the reaction she would receive if
she were to remind a doctor to wash his/her hands before
leaving an isolation room:
if you do say it to a junior doctor or even an older doctor oh theyd
kinda be looking at you going what are you doing telling me what to
do? (S-2).

Feelings of powerlessness and lack of confidence to make


suggestions regarding patient care stemmed from students
perceptions of their position within the organization:
you do get that kind of reaction, who do you think you are
asking youre only a student, you know youre only a student still is
there (S-5).

Fitting in and beginning to think as a staff nurse, were


important to the experience of caring for isolated patients.
The feeling that you want to:
go into third year in September and you want to ease into the
nurses jargonand no-one wants to be like the pestthats forever
nit picking at things (S-3).

Being the perfect nurse also makes students stand out and
standing out even if it is because you are doing the right
thing may be uncomfortable. Hence, the importance of
balancing fitting in with being accountable for practice.

Discussion
Implementation of isolation precautions varies depending on
available resources (Gould 2000). Accessibility and design of
rooms, provision of equipment and approaches to care
delivery frequently placed students in the situation of
adjusting their care of isolated patients to the context of the
hospital environment.
The small space within some single rooms often meant that
students faced the choice of closing the door and adhering to
recommended isolation precautions or leaving it open for
patient comfort. Prieto and Clark (1999) reported similar
findings. Moreover, lack of individual or non-functioning
equipment frequently resulted in students using the same
sphygmomanometers on isolated and non-isolated patients.
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Compromising isolation practices left them feeling somewhat


uneasy. Prieto and Clark (1999) also identified concerns by
healthcare workers that communal use of equipment could
act as sources of infection. Designating equipment such as
sphygmomanometers and stethoscopes for isolated patients
(particularly with infection spread through direct contact) is
an important infection control measure (Sheff 1998, Borton
2001). This initiative would reduce discomfort experienced
by students, and assist effective implementation of source
isolation.
A number of students seemed determined not to allow
ward routines hinder integration of isolation precautions into
their practice. Nevertheless, physical care or the need to
undertake procedures was seen as a reason to call into rooms.
Courtenay (1998) found that infection control practices were
often not planned to meet patients individual needs but were
task oriented to maintain ward routine. Indeed, observations
and dressing changes were highlighted as reasons to enter
isolation rooms (Knowles 1993). Nurses are and feel more
easily accountable for the physical care they give than the
psychological care they could provide (Johnson 1996).
Integrating physical care into nursing routines was valued
as important to promote patient comfort and well-being.
Routines may function to bring about a sense of predictability, time control and familiarity, which are important for time
management and reducing stress and anxiety (Chapman
1983, Martin 1998, Waterworth 2003). Ward routines may
also serve to reduce stress and anxiety associated with caring
for patients who may be quite ill and suffering from
loneliness and psychological isolation.
Isolated patients have reported feeling stigmatized, powerless, anxious and depressed (Gammon 1998, Oldman 1998,
Mayho 1999). Knowles (1993) found that although nurses
often understood individuals responses to isolation, they did
not take account of these and alter their caring practices.
However, in this study, students frequently used a number of
compensatory tactics to make the experience more tolerable. Interventions such as getting the newspaper and finding
opportunities to communicate with patients were undertaken
to compensate for lack of diversional activities in isolation
rooms. Facilities, which keep patients in touch with the
outside world, are vital to improve the isolation experience
(Rees et al. 2000, Ward 2000). Maunder et al. (2003)
emphasized the usefulness of providing telephone access,
books and television for individuals isolated with severe acute
respiratory syndrome (SARS). Balancing infection control
practice with meeting individual needs was perceived as
important in this study. That general nursing students are in
a unique position to provide psychological care for isolated
patients is significant. Facilitators of learning should

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Student nurses experiences of caring for infectious patients in source isolation

acknowledge and build on the important role that supernumerary students provide in ameliorating negative consequences of source isolation.
Providing patients with information about their illness and
associated infection control measures is vital (Myatt &
Langley 2003). Education decreases anxiety, depression and
increases self-esteem and sense of control (Gammon 1998,
Rees et al. 2000, Ward 2000). However, competing demands
and emphasis on physical care reduced the priority given to
education. Consequently, students generally handled it
through personal, unstructured and covert approaches.
Visitor education presented greater challenges as students
experienced it as largely unstructured, unplanned and anxiety
provoking. White (2003) highlights the importance of having
guidelines for visitors to infectious patients. Nurses should
consider using the nursing process and care plans when
dealing with information giving (Greenwood 1998). Integrating written and verbal education into care plans would meet
patients needs and help students gain knowledge and
confidence in patient and visitor education. Local guidelines
or standards for isolation practice could provide guidance for
staff and student nurses.
Students look to model behaviours and demeanour of
nurses they encounter in clinical practice (Jackson & Mannix
2001). Courtenay (1998) highlights the powerful influence of
effective rolemodelling on clinical learning about infection
control issues. Students were beginning to discern effective
and ineffective models of practice. Ineffective role models
demonstrated complacency towards isolation or were considered to have insufficient up-to-date knowledge of isolation.
Du Toit (1995) calls this the selection of antimodels.
Effective supervisory support from Registered Nurses has a
major influence on student learning in clinical practice
(Ohrling & Hallberg 2000, Jackson & Mannix 2001,
Lofmark & Wikblad 2001, Spouse 2001, Lee et al. 2002).
Effective role models were nurses who taught students the
right way of going about caring for isolated patients. While
organizational and staffing constraints may impact on staff
nurses ability to be effective role models, using every
available opportunity to link infection control theory to
patient care helps make learning meaningful contributing to a
sense of student satisfaction.
Fitting in and beginning to think as staff nurses were
important to students experience of caring for isolated
patients. Fitting in and learning to get on with work without
questioning have been discussed elsewhere (Bassett 1993,
Nolan 1998). On one hand, students were trying to be true to
their own beliefs and values of good isolation care. On the
other hand, they were trying to blend in with the staff nurse
role, adjust to the business of wards and nursing routines.

Students may learn to conform to cope with the reality of


becoming a nurse to create a smooth path towards their final
goal (Gray & Smith 1999). However, there were apprehensions that if infection control theory was not applied to caring
for isolated patients then students may become relaxed and
complacent about their own practices. There was a sense that
if one starts conforming to poor practice where do you draw
the line as an accountable practitioner. This has been
supported elsewhere (Day et al. 1995).
As students gained confidence, they felt less at risk of
modelling ineffective practice because they had sufficient
knowledge upon which to base their care. Courtenay
(1998) suggested that students believed that infection
control practices taught on the ward were more important
than those taught in the classroom. However, this study
indicated that students believed that it was important to
link theory of infection control and microbiology to
practice. Knowledge of isolation was fresher in their
minds and they were motivated to uphold high standards
of practice. Sequencing microbiology and infection control
theory throughout the preregistration programme in general
nursing was considered important to support students in
caring for isolated patients. Corlett (2000) identified that
careful sequencing of theory and practice is important to
bridge the theory practice divide supports this point.
A spiral curriculum where students are progressively
re-introduced to the theory of infection control and
microbiology may facilitate this initiative.
Students were familiar with and understood the reason
behind maintaining isolation practices and source isolation
and the importance of controlling the spread of infection.
They had already received a significant amount of theory
two infection control modules and a microbiology module,
which possibly impacted significantly on their reported
experiences. With deepening knowledge and experience,
students were beginning to place fears of caring for
infectious patients into perspective. However, concerns
regarding personal risks of acquiring infection sometimes
created obstacles particularly within studentpatient relationships. Not going into isolation rooms as often and
wearing personal protective equipment during all nurse
patient interactions provided a sense of security. Sadala
(1999) described how symbols and objects of isolation such
as aprons, gloves and masks acquire meanings that
represent keeping a distance thereby reducing anxiety.
Wearing protective equipment may assist students to perform the caring role expected of them as professionals
(Sadala 1999).
According to Wilson (2001), the use of personal protective
equipment should be related to the mode of spread of

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I Cassidy

micro-organisms. There were differing perceptions regarding


the appropriate use of gloves and aprons when entering
isolation rooms. Wilson (2001), suggests that the use of
protective equipment such as gloves and aprons should be
related to the mode of spread of micro-organisms. Hence, for
infection spread by direct contact, gloves and aprons need
only be worn for interventions which require direct contact
with the patient or his/her secretions, lesions or excretions.
Alternatively, Garner (1996) suggests that gloves should be
worn entering an isolation room irrespective of the activity
being undertaken. The latter approach was adopted in the
facilitation of infection control modules. As the student group
was relatively large (fifty-five), this standardization or rules
and regulations provided an easy framework for educator
and students to work with and aimed to reduce the margin of
error in dealing with infectious patients.
However, this approach may encourage students to
develop alternative frameworks as described by Courtenay
(1998), regarding the motility, spread and survival of microorganisms. Furthermore, not specifically relating modes of
spread of micro-organisms to infection transmission may
discourage a critical thinking approach necessary to care for
isolated patients in a practical and realistic manner (Courtenay 1998, Prieto & Clark 1999). Including small group
workshops within infection control modules connecting the
use of protective equipment to motility, spread and survival
of micro-organisms would challenge personal beliefs relating
to risks of acquiring infection thereby encouraging critical
thinking and realistic approaches to care.
Students perceived that knowledge deficit and complacency
among healthcare workers frequently contribute to inadequate isolation practices. Indeed, hospital-acquired infections
are often related to poor knowledge, motivation and low
awareness of need for infection control (Mokabel et al.
1998). Nurses and other healthcare workers have attributed
confusion regarding the correct implementation of isolation
precautions to feelings of uncertainty (Prieto & Clark 1999).
Inconsistencies in the application of isolation precautions
have been documented elsewhere (Mokabel et al. 1998,
Prieto & Clark 1999). A recent study demonstrated that
healthcare compliance with MRSA precautions is poor (Afif
et al. 2002).
It is vital that staff possess educational skills to provide
students with good practice-based education (Lofmark &
Wikblad 2001). In turn, this could assist students to apply
knowledge, skills and attitudes necessary for safe and
effective nursing of patients in source isolation. Support,
education and feedback so that employees can follow the
right infection control processes are vital for patient health
and well-being (White 2003). Providing structured contin1254

uous education for healthcare workers could acknowledge


the vital roles of all healthcare staff in preventing and
controlling hospital-acquired infection.
However, students within this study seemed unsure of how
to assert themselves within the multidisciplinary team relative
to making suggestions or partaking in decision making on
infection control issues. There are similarities with the
portrayal of nurses in a subservient position, the function of
which is to hide the degree of skills, knowledge and
information they possess (Porter 1991). This highlights the
need to create a common vision or awareness among
healthcare workers about the interdependence of all staff in
preventing and controlling infection.

Limitations
Hermeneutic phenomenology recognizes multiple realities of
an experience (Morse & Field 1996). This study was
undertaken at one research site in the Republic of Ireland.
Findings must be considered as a contribution to widening
the understanding of caring for patients in source isolation.
Gaining experiences of students; at different stages of
education, on undergraduate degree programmes in general
nursing and those in different cultural settings could add to
the depth and breadth of knowledge on students perceptions
of caring for this client group.

Conclusion
Nursing patients in source isolation is influenced by the
context within which such care is provided. Caring
experiences and student nursepatient relationships are
dramatically altered by the uniqueness of imposed physical,
psychological, social and emotional barriers. Balancing care
to meet individual needs while preventing spread of
infection had significant meaning for students and explicates the challenges of integrating the art and science of
nursing. Application of theory to practice is vital for
personal and professional development of student nurses
and needs to be recognized and nurtured within clinical
practice.

Acknowledgements
This paper is based on my dissertation as part fulfilment of an
MSc in Nursing though the Royal College of Nursing and the
University of Manchester. Therefore, I would like to thank
my supervisor Conal Hamill for his guidance and support. I
would also like to thank An Bord Altranais for their
monetary support.

 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 12471256

Issues in clinical nursing

Student nurses experiences of caring for infectious patients in source isolation

Contributions
The study design, data collection, data analysis and manuscript preparation were undertaken by IC.

References
Adams L (2000) Lonely planet. Nursing Times 96, 53.
Afif W, Huor P, Brassard P & Loo V (2002) Compliance with
methicillin-resistant Staphylococcus aureus. American Journal of
Infection Control 30, 430433.
Bassett C (1993) Socialisation of student nurses into the qualified
nurse role. British Journal of Nursing 2, 179182.
Benner P (ed.) (1994) The tradition and skill of interpretive phenomenology in studying health, illness and caring practices.
Interpretive Phenomenology: Embodiment, Caring and Ethics in
Health and Illness Sage, California, pp. 105118.
Borton D (2001) Isolation precautions, part 2: matching conditions
to precautions. Nursing 31, 18.
Burnard P (1991) A method of analysing interview transcripts in
qualitative research. Nurse Education Today 11, 461466.
Chapman G (1983) Ritual and rational action in hospitals. Journal of
Advanced Nursing 8, 320.
Corlett J (2000) The perceptions of nurse teachers, student nurses
and preceptors of the theory-practice gap in nurse education.
Nurse Education Today 20, 499505.
Cormack D (ed.) (2000) The Research Process in Nursing, 4th edn.
Blackwell Science, Oxford.
Courtenay M (1998) The teaching, learning and use of infection
control knowledge in nursing. NT Research 3, 118130.
Curran E (2001) Reducing the risk of healthcare-acquired infection.
Nursing Standard 16, 4552.
Davies H & Rees J (2000) Psychological effects of isolation nursing
(1): mood disturbance. Nursing Standard 14, 3538.
Day R, Field P, Campbell I & Reutter L (1995) Students evolving beliefs about nursing: from entry to graduation in a fouryear baccalaureate programme. Nurse Education Today 15,
357364.
DeSantis L & Ugarriza D (2000) The concept of theme as used in
qualitative nursing research. Western Journal of Nursing Research
22, 351372.
Du Toit D (1995) A sociological analysis of the extent and influence
of professional socialisation on the development of a nursing
identity among nursing students at two universities in Brisbane,
Australia. Journal of Advanced Nursing 21, 164171.
Finn L (1997) Nurses documentation of infection control precautions: 1. British Journal of Nursing 6, 607611.
Fleming V, Gaidys U & Robb Y (2003) Hermeneutic research in
nursing: developing a Gadamerian-based research method. Nursing Inquiry 10, 113120.
Gadamer H (1975) Truth and Method, 2nd edn. Sheed and Ward,
London.
Gammon J (1998) Analysis of the stressful effects of hospitalisation
and source isolation on coping and psychological constructs.
International Journal of Nursing Practice 4, 8496.
Garner J (1996) Guideline for isolation precautions in hospitals, part
1. Evolution of isolation practices. American Journal Infection
Control 24, 2452.

Gijbels H & Burnard P (1995) Exploring the Skills of Mental Health


Nurses. Developments in Nursing and Health Care 5. Avebury,
Hants, England.
Glover T (2000) How drug-resistant microorganisms affect nursing.
Orthopaedic Nursing 19, 1925.
Gould D (2000) Infection control: principles for safe practice in the
care of older adults. Elderly Care 12, 1823.
Gray M & Smith L (1999) The professional socialization of diploma
of higher education in nursing students (Project 2000): a longitudinal qualitative study. Journal of Advanced Nursing 29, 639
647.
Greenwood J (1998) Meeting the needs of patients relatives. Professional Nurse 14, 156158.
Jackson D & Mannix J (2001) Clinical nurses as teachers: insights
from students of nursing in their first semester of study. Journal of
Clinical Nursing 10, 270277.
Johnson M (1996) Student nurses: novices or practitioners of brilliant
care? Nursing Times 92, 3437.
Knowles H (1993) The experience of infectious patients in isolation.
Nursing Times 89, 5356.
Koch T (1996) Implementation of a hermeneutic enquiry in nursing:
philosophy, rigour and representation. Journal of Advanced
Nursing 24, 174184.
Koch T (1999) An interpretive research process: revisiting phenomenological and hermeneutical approaches. Nurse Researcher 6,
2034.
Lee W, Cholowski K & Williams KA (2002) Nursing students and
clinical educators perceptions of characteristics of effective clinical
educators in an Australian university school of nursing. Journal of
Advanced Nursing 39, 412420.
Lofmark A & Wikblad K (2001) Facilitating and obstructing factors
for development of learning in clinical practice: a student perspective. Journal of Advanced Nursing 34, 4350.
Mac Kenzie D (1997) MRSA; The psychological effects. Nursing
Standard 12, 4953.
Martin GW (1998) Ritual action and its effect on the role of the nurse
as advocate. Journal of Advanced Nursing 27, 189194.
Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M,
Sadavoy J, Verhaeghe L, Steinberg R & Mazzulli T (2003) The
immediate psychological and occupational impact of the 2003
SARS outbreak in a teaching hospital. Canadian Medical Association Journal 168, 12451251.
Mayho P (1999) Barrier grief. Nursing Times 95, 2425.
Mokabel F, Hamer S & Collings L (1998) Infection control activities
in six hospitals: a comparison. Nursing Standard 12, 3438.
Morse J & Field P (1996) Nursing Research, The Application of
Qualitative Approaches, 2nd edn. Stanley Thornes Publishers,
Cheltenham.
Myatt R & Langley S (2003) Changes in infection control practice to
reduce MRSA infection. British Journal of Nursing 12, 675681.
National Audit Office (2000) The Management and Control of
Hospital Acquired Infection in Acute NHS Trusts in England.
(HC230). National Audit Office, London.
Nolan C (1998) Learning on clinical placement: the experiences of six
Australian student nurses. Nurse Education Today 18, 622629.
Ohrling K & Hallberg I (2000) Student nurses lived experience of
preceptorship. Part 2 the preceptorpreceptee relationship.
International Journal of Nursing Studies 37, 2536.

 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 12471256

1255

I Cassidy
Oldman T (1998) Isolated cases. Nursing Times 94, 6770.
Parker L (1999) Managing and maintaining a safe environment in the
hospital setting. British Journal of Nursing 8, 10531066.
Porter S (1991) A participant observation study of power relations
between nurses and doctors in a general hospital. Journal of
Advanced Nursing 16, 728735.
Prieto J & Clark J (1999) Dazed and confused. Nursing Times 93,
5153.
Rees J, Davies H & Birchall C (2000) Psychological effects of source
isolation (2): patient satisfaction. Nursing Standard 14, 3236.
Riley B (2000) An isolated problem. Nursing Times 96, 3031.
Sadala M (1999) Taking care as a relationship: a phenomenological
view. Journal of Advanced Nursing 30, 808817.
Sheff B (1998) VRE and MRSA: putting bad bugs out of business.
(vancomycin-resistant enterococcus, methicillin-resistant Staphylococcus aureus). Nursing March, 17.
Spouse J (2001) Bridging theory and practice in the supervisory
relationship: a sociocultural perspective. Journal of Advanced
Nursing 33, 512522.

1256

Storr J (2000) MRSA 2000. NT Plus 96, 34.


Van Post I & Eriksson K (1999) A hermeneutic textual analysis of
suffering and caring in the peri-operative context. Journal of
Advanced Nursing 30, 983989.
Wagenvoort J, Gelissen L & Timpert H (1997) Ethical aspects in
infection control. Infection Control and Hospital Epidemiology
18, 304305.
Ward D (2000) Infection control: reducing the psychological effects
of isolation. British Journal of Nursing 9, 162170.
Waterworth S (2003) Time management strategies in nursing practice. Journal of Advanced Nursing 43, 432440.
White J (2003) Infection control in todays world. Kansas Nurse 78,
13.
Wilson J (2001) Infection Control in Clinical Practice, 2nd edn.
Bailliere Tindall, Edinburgh.

 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 12471256