Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: https://www.tandfonline.com/loi/imte20

The sociocultural contribution to learning: Why

did my students fail to learn Aseptic Non-Touch
Technique? Multidimensional factors involved in
medical students’ failure to learn this skill

Dawn Jackson, David Wall & Julie Bedward

To cite this article: Dawn Jackson, David Wall & Julie Bedward (2012) The sociocultural
contribution to learning: Why did my students fail to learn Aseptic Non-Touch Technique?
Multidimensional factors involved in medical students’ failure to learn this skill, Medical Teacher,
34:12, e800-e812, DOI: 10.3109/0142159X.2012.714874

To link to this article: https://doi.org/10.3109/0142159X.2012.714874

Published online: 30 Aug 2012.

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 2012; 34: e800–e812

WEB PAPER

The sociocultural contribution to learning:

Why did my students fail to learn Aseptic
Non-Touch Technique? Multidimensional
factors involved in medical students’ failure
to learn this skill
DAWN JACKSON, DAVID WALL & JULIE BEDWARD
University of Birmingham, UK

Abstract
Background: Infection control in the hospital environment is a topical issue in the UK. Aseptic Non-Touch Technique (ANTT) has
been recommended as an example of best practice for clinical skills requiring aseptic technique. ANTT is taught to clinical staff and
to medical students at a West Midlands teaching hospital.
Aims: To determine the effectiveness of ANTT training within an undergraduate population and to explore the factors involved in
medical students’ failure to learn this skill
Method: 132 Students underwent training and assessment in ANTT. A sample of 42 students underwent re-testing in ANTT 7–10
weeks later. Student questionnaires and semi-structured interviews with students and trainers were undertaken to determine
students’ daily practice of ANTT, and practice observed in staff.
Results: Student performance deteriorated significantly 10 weeks after initial ANTT training ( p 5 0.001). Qualitative data
demonstrates an emphasis on assessment, poor observed practice in staff, and a lack of resources in the clinical setting. Further
themes include acceptance of hierarchy, and a lack of belief in ANTT amongst students.
Conclusion: In order to bring about effective training in ANTT, we must look to the sociocultural contribution of the hospital
environment alongside formal ANTT training.

Introduction
Practice points
Infection control in the hospital environment is a topical issue
. Students’ ANTT performance deteriorated significantly
in the UK. A reduction in rates of healthcare associated
after 10 weeks.
infection (HCAI) is high on the National Health Service
. Problems with formal training include lack of work-
agenda, and this is highlighted both in the media and in
place-based teaching.
government policy. Darzi (2008) has emphasized the need to
. Assessment may drive learning, resulting in surface
improve clinical behavior, and address practices such as basic
learning.
hygiene and aseptic technique.
. Students modify practice due to lack of resources, and
Despite these aims, little research is available on effective,
are influenced by observation of staff.
evidence-based aseptic techniques. Much of hospital aseptic
. For learning of ANTT to occur, we must consider the
practice is anecdotal or ritualistic (Rowley 2001). In response
formal, informal and hidden curricula.
to this, Aseptic Non-Touch Technique (ANTT) was developed
as a guideline for practice in the aseptic technique and was
recommended as an example of best practice in the aseptic
technique (Pratt et al. 2007). hospital environment means that medical students are
Formal ANTT training has been implemented at many NHS exposed to multiple healthcare professionals and influences
trusts in the UK (Rowley & Clare 2009). In addition to staff, as they implement new skills. Hafferty (1998) outlines
ANTT training is often delivered to undergraduate medical this concept in his description of the curriculum triad,
students. Despite this training, I felt that my students were not where formal, informal and the hidden curricula are
learning ANTT. considered. This study therefore aims to consider the
The literature suggests that formal training is not the multiple factors involved in medical students’ learning of
only way in which students learn. The complexity of a ANTT.

Correspondence: Dawn Jackson, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, USA. Tel: 0121 333 9999; fax: 0121 333
9998; email: dvjackson@doctors.org.uk

e800 ISSN 0142–159X print/ISSN 1466–187X online/12/O120800–13 ß 2012 Informa UK Ltd.

DOI: 10.3109/0142159X.2012.714874
 The sociocultural contribution to learning

Touch non-key
parts with
confidence

Always wash Take appropriate

ANTT infective
hands effectively
precautions

Never
contaminate key
parts

Figure 1. The key principles of ANTT.

Background . For clinical staff, a background of clinical practice or

experience exists. In contrast, Year 3 students are unfamiliar
There are four cornerstones of ANTT, and these are outlined in
with much of the equipment used in the training, and
Figure 1.
potentially with some of the terminology of the ANTT
It has been estimated that 150–250 NHS hospitals use ANTT
lecture and assessment.
as standard practice (Rowley & Clare 2009). In Rowley and
Clare’s (2009) audit of ANTT training within seven trusts, five
In addition to the formal training format, the literature also
trusts demonstrated a positive improvement in rates of
suggests that the sociocultural environment contributes to
hospital-acquired infection. In this respect, evaluation of
medical student learning. As outlined by Hafferty (1998), a
ANTT suggested it to be a tool capable of reaching the highest
multidimensional learning environment exists. He describes it
levels in the Kirkpatrick Hierarchy – changes to behavior and
as comprising of three spheres: the Formal (taught)
improvement in patient care (Kirkpatrick 1998).
Curriculum, the Informal Curriculum (learning that is largely
In a large teaching hospital in Birmingham (the hospital in
ad hoc and interpersonal), and the Hidden Curriculum
which this research project was undertaken), all staff and
(influences that function at the level of organizational structure
medical students at induction are trained and assessed on their
and culture). In light of these observations and reflections, the
understanding of ANTT. The training format involves a short
following research questions were raised:
lecture on the principles of ANTT, followed by a demonstra-
tion (on a model arm) of cannulation using ANTT. Trainees are (1) Is the current ANTT training format effective for an
then assessed on their ability to perform a cannulation using undergraduate population?
ANTT. If the trainee passes the assessment, it is expected that (2) What is the sociocultural contribution to student
they are competent to perform ANTT in the clinical setting. learning and practice of ANTT?
However, this assumption may or may not be correct.
This project outlines an evaluation approach to answering
these research questions.
Rationale for study
There are clearly differences in the student and staff popula-
Methods
tions who receive ANTT training: The study was conducted in two phases (Figure 2):
Phase 1:
. Many students ( particularly Year 3 students) will not
attempt practical procedures for weeks or months after . Two cohorts of 56 students were trained in ANTT. 22 and
their ANTT training, whereas staff members usually under- 24 students were re-tested 7–10 weeks later. All 46 re-tested
take clinical procedures regularly. students were interviewed.
e801
D. Jackson et al.
Phase One
September 2009 – March 2010
Test and Re-test of Year 3 students
September
BATCH ONE –Year 3
Week 1 Week 10
n=56 Re-Test: n=22
Training and Interview: n=22
test
Phase Two
April/May 2010: questionnaire to Year 3 and Year 5 medical students (n=72)
June 2010: Focus group with Year 5 medical students (n=4)
June 2010: Semi-structured interviews with Nurse Educators (n=2) and Nurse Manager
(n=1)
Figure 2. Summary of methods.
Phase 2:
. 72 students in Years 3 and 5 answered a 63-item question-
naire about attitudes and opinions relating to ANTT.
. Interviews were conducted with two nurse educators and
one nurse manager.
. Interviews were conducted with four Year 5 students.
Phase 1
. A cohort (n ¼ 56) of Year 3 medical students were trained
and assessed in ANTT on arrival to their placement at a
single teaching hospital site. Students can ‘‘pass’’ or ‘‘fail’’
(and subsequently re-sit) their initial assessment.
. A sample of this cohort underwent re-testing in ANTT
(n ¼ 22, Batch One). After the re-test, each student was
interviewed and asked to comment on their daily
practice of ANTT, and the practice they had observed
in staff.
. A second cohort (n ¼ 56) of new students arrived for
placement and underwent the same ANTT training and
assessment. Seven to 10 weeks later, a sample was invited
for re-test according to the same conditions as those used
for Batch One (n ¼ 24, Batch Two).
All available students were invited to participate. Students
were not informed of the nature of the study until the time of
re-test to avoid confounding of results in students who may
revise the skill. Students on re-test were assessed in the same
conditions, with the same assessment criteria as those used in
the initial assessment (Figure 3).
e802
January
BATCH TWO – Year 3
Week 1 Week 10
n=56 Re-Test: n=24
Training and Interview: n=24
Test
Analysis of test and re-test data
‘‘Pass’’ and ‘‘Fail’’ rates were entered into SPSS. Pass rates on
re-test were compared with secondary data gained from ANTT
pass rates yielded at initial training. The McNemar test was
used to compare the means for pass rates on initial and re-
testing (Cohen et al. 2007).
Analysis of Phase 1 interview data
A pilot group of 10 students initially underwent re-testing and
subsequent interview. These were conducted by a single
researcher (DJ, Education Fellow). Responses were handwrit-
ten and key statements transcribed verbatim during interview.
Data gained from the first 10 interviews were reviewed and
emergent themes were listed. These then formed a template
for the analysis of subsequent interviews, responses from
which were recorded on a pro forma (Cohen et al. 2007). The
data were analyzed using content and coding methods (Coffey
& Atkinson 1996).
Phase 2
Questionnaires. A 63-item voluntary, anonymous question-
naire was distributed to medical students in Years 3 and 5
during the time of their end-of-year examinations. Responses
were largely ‘‘tick box,’’ with opportunity to make free-text
comments at the end of the survey (Cohen et al. 2007). The
questions explored demographic details, with questions on
attitudes and opinions on the teaching and practice of ANTT. It
was piloted with another member of the research team and

ANTT EVALUATION
STUDENT ID:
YES NO
Appropriate dress
Wash Hands
Cleaned trolley
Correct use of sterile field
Correct tourniquet technique
Cleaning of injection site
Re-touch of site?
Touched key parts?
Correct application of
dressing
Correct use of sharps bin
Understanding of recording in
notes
Figure 3. Record of student performance on re-test.
appropriate adjustments were made prior to distribution. The
final questionnaire is included in the Appendix.
Semi-structured interviews. One-to-one interviews were
undertaken with three members of staff at the teaching
hospital used in Phase 1 of the study: two experienced nurse
educators and a nurse manager (responsible for leading the
ANTT training project at the hospital).
Interviews were undertaken by a single member of the
research team (DJ, Education Fellow), and were recorded
using a boundary microphone and dictaphone. Interviews
were transcribed verbatim by the interviewer.
Group interview. All Year 5 students (senior students) at the
teaching hospital were invited for group interview (n ¼ 15).
These students rotate through a number of hospitals during
their training, and could therefore offer insight into training
and practice elsewhere. Four students attended the interview.
Ethical considerations. Ethical approval was gained from the
University Of Birmingham School of Education (the University
responsible for the training of the main researcher in this
project). Approval was also sought from the University at
which the students were studying. This was to ensure that
University staff were in agreement for their students to be
invited to participate in the project.
If practices were detected in the project that potentially
could compromise patient safety, correction and re-training
was given to the student at the point of detection.
Results
Retention of ANTT skills
Batch One results: 21 of the 22 students passed their initial
ANTT training assessment. Only two of the 22 students passed
on re-testing at 10 weeks. This indicates a significant deteri-
oration in scores ( p 5 0.001 using the McNemar test).
The sociocultural contribution to learning
Notes
Batch Two results: 23 out of 24 students passed their initial
assessment. Eight of the 24 students (33%) passed on re-
testing. This again suggested significant deterioration in
performance over time, with a p-value 5 0.001(using the
McNemar test; Figure 4).
Phase 1ne – Interview data
All Year 3 participants agreed to interview (n ¼ 46):
Use of ANTT in daily practice
46% of students felt they do not use all elements of ANTT in
their daily practice (n ¼ 21). Table 1 outlines those elements of
ANTT or safe practice that students themselves deemed to
neglect in their daily practice.
Phase 2 – Questionnaire data
Seventy-two questionnaires were returned (response rate of
70.6%). Students had undergone ANTT training at a variety of
training hospitals (10 in total).
Reliability
The reliability of questionnaire responses was assessed
using Cronbach’s alpha. This yielded a figure of 0.766 when all
variables were considered.
Training in ANTT
Only seven students (9.7%) had not received formal
training in ANTT at their training hospital. Most training
formats involved lecture (n ¼ 43) or demonstration (n ¼ 50),
with little patient-centered learning in the format of ‘‘patient
practice’’ (n ¼ 8) (Figure 5).
(Student opinion of formal ANTT training
This was rated on a 5-point Likert scale. Responses on the
whole were positive, with all aspects of formal training scoring
a median of 3 or more.
Staff role modeling of ANTT
FY1 doctors were observed in every case by respondents
(100%). Consultants were observed least, by only 22.5% of
students.
e803
D. Jackson et al.

ANTT "Pass" Rates at Initial Test and Re-Test

25

20

Frequency "Pass" Grade 15

Batch One
Batch Two
10

0
Initial Test Re-test (7-10weeks)
Time of ANTT Assessment

Figure 4. ANTT ‘‘pass’’ rates at initial test and re-test.

really stressed out about their catheterisation.

Table 1. Elements of ANTT neglected by students.
Neglected aspect of ANTT/safe practice
Use of unclean surfaces
Re-touch of cleaned injection site
Infrequent hand-washing
Not wearing gloves
Not wearing apron
Student perception of staff practice of ANTT
Students were asked to rate each role of staff on their use of
ANTT on a Likert scale (1 ¼ poor, 5 ¼ excellent). Every staff
role was rated favorably, with phlebotomists rated most highly
(median ¼ 5), and consultants least (median ¼ 4). Elements felt
most neglected by staff are outlined in Table 2.
Phase 2 – Thematic analysis
Interview data were used to illuminate and establish themes
relating to ANTT training and practice. Key themes are
outlined within this section.
Lack of belief in ANTT
This centered on doubts about its benefits and validity in
clinical practice:
People say there are studies, but I’ve never seen any
(Year 5 undergraduate – Participant One)
I’m not sure if it’s like a practical way. Well, the way
we were shown, I’m not sure it’s applicable to clinical
practice.
(Year 5 undergraduate – Participant One)
Assessment driving learning
The experienced teacher described a focus on assessment,
with students requesting revision sessions to improve their
ANTT in procedures:
Although, I have to say this year, certainly I’ve
noticed this time, they’ve [medical students] been
e804
Because a lot of people have been failing on
ANTT. Cos I’ve been doing some revision sessions
Frequency for a few of them. And it’s around ANTT and
catheterisation. It was less about the actual proce-
14
5 dure and more about, again, ‘‘what can we touch,
2 what can’t we touch?
2
(Interview – Experienced teacher)
1
Surface learning
Students feel they need to learn a series of steps:
I always found it difficult because, it’s probably just
me, but I just feel there’s so many different bits to it. It
was always hard to remember.
(Year 5 Undergraduate – Participant One)
Students were not always afforded the opportunity of
immediate application of ANTT training:
And if they’re not going out into practice and doing it,
which most of them can’t, that’s when they’re going
to lose.
(Experienced Teacher)
Poor role-modeling of ANTT
It’s probably not as good in practice as when you first
get taught. I think as well because a lot of junior
doctors that you’re doing it with often say like, ‘‘Oh,
you don’t need to do that. Don’t bother doing that’’.
Like wearing gloves. A lot of doctors don’t do that.
They say, ‘‘Oh you don’t need that’’.
(Year 5 undergraduate – Participant Two)
Lack of resources
Lack of trolleys, disposable tourniquets and sharps bins
were cited most frequently:
They don’t have very many around actually on the
ward [sharps bins], and they don’t have very many
small ones, so nearly every time you don’t have a
sharps bin.
(Year 5 undergraduate –Participant Two)

Patient
Lecture Demonstration Practice
43 50
Figure 5.
Table 2. Survey responses: elements of ANTT neglected by
staff.
Mean frequency
(Likert scale
1 ¼ infrequently,
Component of ANTT 5 ¼ frequently)
Cleaning trolley/tray before equipment 2.39
Re-touch site 2.70
Not disposing of sharps in cubicle 2.80
Acceptance of hierarchy
Students are influenced by a hospital hierarchy, and change
practice based on instructions of more senior staff.
And then why would we argue with somebody who
is above our station as to why we’re drying it for
longer?
(Year 5 undergraduate – Participant Three)
Discussion
The results clearly demonstrate a significant deterioration in
undergraduate performance in ANTT over time, with the
majority of students failing the assessment just 10 weeks after
their initial training. The task of the researcher was therefore to
aim to determine why this might be the case. Potential factors
that may be responsible can be considered by looking to the
curriculum triad: the formal, informal and hidden ANTT
curriculum (Hafferty 1998).
Formal curriculum
Students were largely positive about formal ANTT training, but
were often not able to put their ANTT skills into practice
after training. Whilst lectures and demonstrations may appeal
to some, different types of learner do exist (Gardner 1983;
Honey & Mumford 1987).
References to ‘‘steps’’ and ‘‘difficulty remembering’’
may suggest that the learners achieved only ‘‘surface
learning’’ of ANTT following formal training (Marton
& Saljo 1984 in Butt 2007).
The assessment used in formal training appeared to be
adequate in assessing surface learning of ANTT. However, it
did not assess deep learning, or whether students could use
ANTT in the clinical environment.
The sociocultural contribution to learning
Model
Practice Web Written
8 25 6 13
Summary of training formats.
If this is indeed the case, then both the teaching format and
the assessments may be driving the learning.
From these comments, there may therefore be a case to
consider a change to the timing of ANTT training, to allow
students to immediately begin using their skills on the wards.
In addition, changing the teaching to a ward-based, clinical
setting may help with student engagement and make the skill
feel more relevant to practice.
A change to the assessment could help trainees to focus on
principles of ANTT, rather than ‘‘steps’’ and ‘‘surface learning’’.
However, a change to assessment should be viewed with
caution. Miller (1990) states that no single assessment
of clinical practice is adequate. By simply replacing the
current assessment, we may simply cause the learner
to focus on a different aspect of ANTT, whilst neglecting
another.
Informal curriculum
Undergraduate students frequently observe members of hos-
pital staff performing ANTT, particularly FY1 Doctors. The
impact of this observation on their practice of ANTT constitutes
an aspect of the informal curriculum, and raises a number of
questions. The first is whether the undergraduates are observ-
ing good practice, or bad practice. Based on questionnaire
data, the undergraduate opinion seems to suggest that staff
practice of ANTT is largely good. However, interview data
suggests that students are also exposed to the observation of
bad practice. Furthermore, they are, at times, directly
instructed by staff to undertake poor practice. Variations in
staff practice demonstrated in this study are in keeping with
the variation demonstrated in Rowley and Clare’s (2009)
evaluation of the implementation of ANTT across a number of
trusts in the UK.
Although examples of poor practice and instruction have
been given, the second question is to consider the impact of
this on undergraduate performance. Certainly social construc-
tivists such as Vygotsky (1978) would suggest that observation
of others within a community of practice would have a
significant impact on the subsequent behavior of learners
(Bonk & Cunningham 1998).
On interview, students cite examples of times when they
have modified their practice based on the advice of staff, even
if they know it to be wrong. A second noteworthy element is
the fact that students and staff most frequently neglect the
same element of ANTT: the use of clean surfaces to transport
equipment. This may be related to a generic lack of resources,
or coincidence. However, it may also relate to the fact that
undergraduates are hugely influenced by what they observe in
e805
D. Jackson et al.
staff, and therefore modify their clinical practice to emulate the
behavior they observe.
Hidden curriculum
Hafferty (1998, p. 104) describes the Hidden Curriculum as:
A set of influences that function at the level of
organisational structure and culture.
Results from this study indicate that students are exposed to
elements of the Hidden Curriculum with regards to their
learning of ANTT. The first of these is the apparent lack of
resources, and the subsequent adaptation of ANTT of staff and
students. These findings were also demonstrated in Rowley
and Clare’s (2009) study of ANTT, and indicate a universal
problem of a lack of tools to adequately undertake the
procedure.
Lempp and Seale (2004) found that medical undergradu-
ates, as a result of the Hidden Curriculum, demonstrated a loss
of idealism and acceptance of hierarchy. Interestingly, these
themes were also strong in these data. Students and staff alike
clearly demonstrate evidence of a lack of belief in ANTT, and
in interviews, question its efficacy. However, during formal
training, students were deemed to be enthusiastic and atten-
tive. This change in attitude from enthusiasm to one of
skepticism may be related to their exposure to the sociocul-
tural setting within the hospital, and could represent the effect
of the Hidden Curriculum. Students also appear to have an
awareness of hierarchy within the hospital culture and, at
times, accept this hierarchy.
Training students using the same resources as those
available in the clinical context appears an obvious suggestion
for change. However, this change in itself is unlikely to be
sufficient. Within educational change, beliefs and understand-
ing are seen to be foundations for achieving lasting reform
(McLaughlin & Mitra 2001). Addressing the lack of belief in
ANTT amongst students and staff appears to be fundamental to
bringing about effective learning in ANTT.
Limitations of this study
. The test and re-test method did not evaluate student’s ability
at all levels, such as the ability to synthesize their knowl-
edge and skill in ANTT across a variety of clinical skills
(Bloom 1956).
. Methods in this study utilize the subjective reporting of
students. This may introduce bias and questions relating to
reliability. Multiple mixed methods were implemented to
minimize this.
. The group interview in this study was small – with just four
students, all final year. It is recommended that the more
group interviews, across year groups, should be
undertaken.
. Medical students from a single university provided opinion
and observation of staff. These may not be generalizable
elsewhere.
. The key researcher in this study (DJ) was also responsible
for the education of the students involved. Participants were
informed of the voluntary and anonymous nature of the
e806
study at all occasions, but this may have led to bias or
inconsistency in student responses.
Conclusion
ANTT training and its use in clinical practice appears to confer
significant benefit to patients with reported reduction in the
rates of MRSA in UK hospitals (Rowley & Clare 2009). It
therefore appears to show benefit at the highest level of
Kirkpatrick’s Hierarchy, ‘‘Impact on Society’’ (Kirkpatrick
1998).
However, educational interventions such as ANTT training
can be costly, requiring considerable financial, staff and time
resources. Alongside patient outcomes, training ideally should
demonstrate further benefits, such as educational impact,
trainee satisfaction and a change to practice (Kirkpatrick 1998).
This study has shown that undergraduate performance in
ANTT deteriorates significantly 10 weeks after training. In
addition, many undergraduates admit to modifying ANTT, or
failing to use ANTT, in their daily clinical practice.
This would suggest that training in ANTT amongst
undergraduates is not entirely optimal, and may suggest that
change is needed.
The literature states that educational change should be
viewed objectively, and seen as multidimensional (Fullan
2007). With this viewpoint, it is possible to regard change
objectively by ‘‘identifying and describing its main separate
dimensions’’ (Fullan 2007, p. 29).
Within this study, problems with ANTT training have been
demonstrated at formal, informal and hidden curricula levels.
This suggests multifactorial reasons for the deterioration in
student performance in ANTT.
It follows that changes to ANTT training should not be
solely targeted at the ‘‘formal curriculum’’. Teaching a skill
without first considering the context in which it is to be
practiced can lead to ineffective learning. By taking a
multidimensional approach to changing this
educational intervention, we can aim for true and deep
educational reform.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of this article.
Notes on contributors
DAWN JACKSON, MBChB, MEd, is an Academic General Practice Trainee
in the West Midlands.
DAVID WALL, MBChB, MMed, PhD, FRCP, FRCGP, was Deputy
Postgraduate Dean in the West Midlands Deanery and Professor of
Medical Education.
JULIE BEDWARD, BSoc Sc, PGCE, PhD, at the time of this study was
Programme Lead for the Masters in Educations for Health Professionals.
The key researcher in this study (DJ) was also responsible for the education
of the undergraduate participants in the study.

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Appendix: Questionnaire

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