American Journal of Infection Control 42 (2014) 980-4

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

Factors influencing the self-perceived practice levels of professional

standard competency among infection control nurses in Korea
Jeong Sil Choi RN, MPH, PhD, ICAPN a, Kyung Mi Kim RN, PhD, ICAPN b, *
a
Gachon University College of Nursing, Incheon, South Korea
b
Semyung University Department of Nursing, Jecheon, Chungbuk, South Korea

Key Words: Background: This study investigated the self-perceived infection control (IC) knowledge and practice
Competence levels of professional standards competency (PSC) among Korean infection control nurses (ICNs) to
Infection preventionist identify factors that may influence PSC.
Methods: Using a self-reporting questionnaire method, we collected data from a total of 104 ICNs.
Results: The average self-perceived IC knowledge level was 3.1
0.8, with hand hygiene scoring the
highest at 3.7
0.8. The total proportion of responders who did not meet the expected standard in 4
future-oriented domains was 51.7%. Of the 4 domains, technology had the highest number of re-
spondents meeting the desired standard (57%). There were significant differences in self-perceived levels
of PSC in relation to ICN specialist certification and continuing education (eg, extra coursework, con-
ference attendance) in the field. Self-perceived practice levels of PSC also were significantly correlated
with age, years of total clinical experience, years of ICN experience, hospital bed count, and IC knowledge.
Predictors of self-perceived practice levels of PSC were knowledge and years of ICN experience.
Conclusion: Educational programs are needed to promote knowledge and competency, the lack of which
was recognized by the ICNs. Also, various efforts are needed to prevent turnover of ICNs with a high level
of competency.
Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Today’s health care system requires nurse specialists to translate
their knowledge and skills into practice to provide quality care.1 In
particular, infection control (IC) knowledge levels are closely
related to patient safety and the quality of the health care services
offered. Identifying and reinforcing consistent levels of professional
standards competency (PSC) for infection control nurses (ICNs) can
ensure the delivery of quality health care to patients.
The concept of competency encompasses a combination of skills,
performance, and daily behavior.2 Competencies provide a frame-
work of practice standards designed to assist new practitioners in a
specialty in developing necessary skills.3 According to Murphy et al,4
knowledge and skill are essential components of professional com-
petency, along with additional components, including communica-
tion, values, reasoning, and teamwork. Since the mid-1990s, studies
on competencies and practice standards in the IC profession have
been conducted by the Association for Professionals in Infection
Control and Epidemiology (APIC), the Canadian Community and
* Address correspondence to Kyung Mi Kim, RN, PhD, ICAPN, 65 Semyung-ro,
Jecheon, Chungbuk, South Korea.
E-mail addresses: icpkim@semyung.ac.kr, icpkim@catholic.ac.kr (K.M. Kim).
Conflict of interest: None to report.
Hospital Infection Control Association (CHICA-Canada), and the
Australian Infection Control Association.4 In addition, APIC and
CHICA-Canada used their studies to develop a set of professional and
practice standards for use in evaluating ICN competencies.5
Murphy et al.4 identified 4 future-oriented domainsd
leadership, infection prevention and control, technology, and per-
formance improvement and implementation sciencedwhich are
linked to the Certification Board of Infection Control (CBIC) core
competencies. The authors explained that these 4 future-oriented
domains will enable ICNs to build these core competencies,
thereby advancing in their careers from novice to expert. Bobay
et al6 suggested that experience as an RN was highly correlated
with age and clinical nursing experience, whereas certification and
initial educational preparation were not significantly correlated
with competencies. Other studies also have identified IC experience
and the number of hospital beds as factors influencing ICN com-
petency.7,8 Nonetheless, despite a heightened interest in the com-
petency of individual ICNs as an attempt to promote the concept of
health care as it relates to successful infection control, few studies
have evaluated standards of ICN competency.
Many Korean ICNs have taken a 1-month IC course for nurses
(offered by a national university hospital based in Seoul), various

0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2014.05.023
 J.S. Choi, K.M. Kim / American Journal of Infection Control 42 (2014) 980-4
short-term IC training courses (based at other Korean-based uni-
versity hospitals), or an IC training series of basic and advanced
courses. The latter has been offered annually by the Korean Society
for Nosocomial Infection Control (KOSNIC) since 1996. In addition,
some nurses have received ICN specialist certification from the
Korean Ministry of Health and Welfare by taking the certification
examination after completing a master’s course in accordance with
the Medical Treatment Law.9 Because Korean ICNs have such
diverse clinical and educational backgrounds, their reported diffi-
culties in performance of their duties vary. In addition, it is believed
that this diverse training leads to different levels of nursing com-
petency within the profession.
The specific goals of this study were to investigate the general
characteristics, self-perceived knowledge level of IC, and self-
perceived practice levels of IC PSC among Korean ICNs, and to iden-
tify the factors related to the self-perceived practice levels of PSC.
METHODS
Design and sampling
This study was conducted between December 2012 and January
2013. Data collection was completed via an e-mailed query and
questionnaire sent to 285 ICNs whose e-mail addresses were
publicized in the 2012 Korean Association for Infection Control
Nurses (KAICN) address book. This book included the contact in-
formation of nurses in both temporary and permanent positions;
however, the questionnaire confirmed that respondents held per-
manent nursing positions. Both ICNs and nurses with an interest in
IC can become members of the KAICN; ICNs holding temporary
positions were excluded because their duties tend to be simple
tasks, like data input.
Of the 191 ICNs who viewed the e-mail, 105 replied (55%
response rate). All responses were through the voluntary partici-
pation of the subjects. One questionnaire was excluded because it
was incomplete, leaving data from a total of 104 ICNs for analysis.
This study was approved by the Institutional Review Board of
the Semyung University Oriental Medicine Hospital, and each
participant provided written consent.
Study tool
The self-reporting questionnaire was composed based on a re-
view of the literature.4,5,10 The questionnaire consists of 3 parts:
general characteristics of ICNs, self-perceived IC knowledge, and
self-perceived practice levels of PSC. In this study, PSC is defined as
an individual’s competence in his or her professional role as an ICN.
A total of 22 items on self-perceived IC knowledge level were
developed using the CBIC’s core competencies as a baseline.4,10
These items were measured on a 5-point Likert scale: 1, “I have
fully sufficient knowledge”; 2, “I have sufficient knowledge”; 3, “I
have a medium level of knowledge”; 4, “I have insufficient
knowledge”; and 5, “I have very insufficient knowledge.” A higher
score indicates greater knowledge of IC (Cronbach’s a ¼ 0.92).
The questionnaire on PSC was developed from the professional
and practice standards of APIC-CHICA5 and the 4 future-oriented
domains of Murphy et al.4 This questionnaire consisted of 44
questions, including 8 questions on leadership, 20 questions on
infection prevention and control, 11 questions on technology, and 5
questions on performance improvement and implementation sci-
ence. Practice levels of PSC were measured on a 5-point Likert scale
as well, from 1 (“I do not perform at all”) to 5 (“I perform very
well”). A higher score indicates greater PSC (Cronbach’s a ¼ 0.96).
A category with a score of 4 points was considered to indicate
sufficient knowledge and practice level of that competency to
981
perform IC tasks independently as a professional in the field of
infection prevention and control. Therefore, only those respondents
with a score of 3 points were included in the analysis. Two
nursing professors and 2 ICN specialists reviewed the surveys for
content and clarity.
Data analysis
Data analysis was performed using SPSS 20.0 (IBM, Armonk,
NY). The self-perceived knowledge level of IC and practice levels of
PSC showed a normal distribution (Kolmogorov-Smirnov test).
Frequency, percentage, mean, and standard deviation (SD) were
used for identification of respondents’ general characteristics.
Mean and SD were used to measure self-perceived knowledge
levels of IC and practice levels of PSC. The independent t test was
used to examine the relationships between demographics and the
practice levels of PSC. Pearson correlation was used to test corre-
lations among the main variables. Hierarchical multiple linear
regression analysis was used to determine the predictive factors of
practice levels of PSC.
RESULTS
Differences in self-perceived practice levels of PSC by general
characteristics
The average reported clinical experience was 15 years, and the
average IC specialty experience was 5 years. Slightly more than
one-half (52%) of the subjects had less than 5 years of experience in
IC at the time of the survey. Almost 40% of the responding ICNs
were working in Seoul. The average hospital bed count was 821
beds. Forty-seven percent of the respondents were certified as ICN
specialists through the Korean Ministry of Health and Welfare,
35.6% completed an IC course before accepting an appointment as a
dedicated ICN, and 97.1% reported attending academic conferences
or training courses provided annually by the KAICN and KOSNIC.
Significant differences in the self-perceived practice levels of PSC
were observed in relation to IC certification (P < .001) and atten-
dance at an academic conference or training course (P ¼ .041).
Self-perceived knowledge of IC and practice levels of PSC
Self-perceived IC knowledge level
The mean (
SD) self-perceived IC knowledge level was
3.1
0.8. The total proportion of responders who did not meet the
desired standard (a score 4 on the Likert scale) was 62.3%. The
knowledge level of hand hygiene scored the highest, at 3.7 (
0.7).
Of the self-perceived knowledge levels of IC reviewed, the lowest
scores were recorded in research (2.5
1.0) and construction and
renovation (2.5
0.9). At 85.6%, the domain of construction and
renovation in patient care facilities had the highest percentage of
respondents not meeting the desired standard. The percentage of
responders who did not meet the desired standard was lowest for
hand hygiene, at 35.6% (Table 1).
Self-perceived practice levels of PSC according to 4 future-oriented
domains
The total percentage of subjects who did not meet the desired
standard for this section (a score 4 on the Likert scale) was 51.7%.
The technology domain scored the highest of the future-oriented
domains (3.5
0.7) and had the highest percentage of re-
spondents meeting the desired standard (57%). The lowest scoring
domain was performance improvement and implementation sci-
ence (3.0
1.1), which also had the lowest percentage of re-
spondents meeting the desired standard, at 36.2% (Table 2).
982 J.S. Choi, K.M. Kim / American Journal of Infection Control 42 (2014) 980-4

Table 1 Table 2
Self-perceived knowledge level of infection control PSC in the 4 future-oriented domains

Category Mean
SD %* Competency Mean
SD %*

Hand hygiene 3.7
0.7 35.6 Domain 1: Leadership and program management 3.3
0.9 51.8
Initiation and discontinuation of isolation/barrier 3.6
0.8 41.3 Recommends changes in practice based on clinical 2.8
1.1 75.0
precautions as indicated outcomes and financial implications
Patient placement, transfer, and discharge 3.4
0.8 50.0 Collaborates with others as a leader, facilitator, and 3.9
0.9 34.6
Employee/occupational health 3.4
0.8 51.9 team member
Recall of potentially contaminated equipment and 3.3
0.9 52.9 Supports others as an infection control professional 3.7
1.0 34.6
supplies when the infection control team is organized
Management of patient care products and medical 3.3
0.8 58.7 Domain 2: Infection prevention and control 3.3
0.9 52.6
equipment Understands advantages and disadvantages of complex 2.7
1.0 83.7
Education 3.2
0.9 59.6 diagnostic tests (eg, polymerase chain reaction) and
Surveillance and epidemiologic investigation 3.1
1.0 59.6 interprets results
Quality improvement and patient safety 3.2
0.8 60.6 Is involved in the establishment of patient care 4.1
0.8 21.2
Specific direct and indirect care setting IC 3.2
0.9 60.6 environment to reduce infection risks during
Cleaning, disinfection, sterilization 3.1
0.9 61.5 construction and renovation
Environmental hazards 3.2
0.8 65.4 Domain 3: Technology 3.5
0.7 43.0
Immunization programs for patients 3.1
0.9 66.3 Uses automated algorithmic detection of possible HAIs 2.6
1.2 78.8
Influx of patients with communicable diseases 3.1
0.9 67.3 Accesses the clinical database (eg, EMR, OCS) 4.3
0.8 17.3
Management and leadership 2.9
1.0 69.2 Domain 4: Performance improvement and 3.0
1.1 63.8
Infection risk from therapeutic and diagnostic procedures 3.1
0.9 70.2 implementation science
and devices Has sufficient skills and experience to use performance 2.8
1.2 70.2
Effective communication and feedback 2.9
0.9 71.2 improvement tools (eg, Plan, Do, Study, Act; Six
Identification of infectious disease 2.9
0.9 74.0 Sigma; Lean)
Research 2.5
1.0 84.6 Is aware of the need for performance improvement 3.5
1.0 49.0
Construction and renovation of patient care facilities 2.5
0.9 85.6 Average 3.05
1.14 51.7
Average 3.1
0.8 62.3
OCS, order communication system.
*Proportion of responders who did not meet the desired standard. *Proportion of the responders who did not meet the desired standard. The table only
shows the highest and lowest values.

Correlation among variables and self-perceived practice level of PSC

Self-perceived practice level of PSC was significantly correlated
with age (r ¼ 0.39; P < .01), years of total clinical experience
(r ¼ 0.32; P < .01), years of ICN experience (r ¼ 0.83; P < .01),
number of hospital beds (r ¼ 0.23; P < .01), and self-perceived
knowledge of IC (r ¼ 0.77; P < .01) (Table 3).
Predictors of self-perceived practice levels of PSC
Hierarchical regression was used to examine the effects of
general characteristics of the respondents and their self-perceived
knowledge levels of IC. General characteristics, including age, years
of total clinical experience, years of ICN experience, ICN specialist
certification, and academic conference or training course atten-
dance, were controlled for in the first block, based on previous
studies2,6-8 suggesting that demographic variables might be asso-
ciated with self-perceived practice levels of PSC. Self-perceived
knowledge level of IC was added in the second block.
In the first model, age, years of total clinical experience, years of
ICN experience, number of hospital beds, ICN specialist certification,
and academic conference or training course attendance increased
the explained variance by 69.2% (F ¼ 47.275; P < .001). The coeffi-
cient of years of ICN experience was significant (b ¼ 0.792;
t ¼ 10.606; P < .001). This indicates that self-perceived practice levels
of PSC increased with increasing time working as an ICN.
When self-perceived knowledge level of IC was entered into the
second model, the explained variance was increased by 8.80%
(F ¼ 62.035; P < .001). The full model accounted for 78.0% of the
variance in self-perceived practice levels of PSC (Table 4).
DISCUSSION
This study has attempted to contribute to the promotion of
health care quality by measuring the self-perceived knowledge
level of IC and practice levels of PSC of Korean ICNs. This study is the
first work to investigate the competency of Korean ICNs. Our goal
was to clarify areas of competency that need strengthening, as well
as to create opportunities for comparison between Korean infection
preventionists and those from other countries to contribute to the
international growth of ICN competency.
The Nursing Expertise Self-Report Scale was developed using the
Benner model of clinical competence.2 Garland,11 in a study using
this model to identify ICU nurses’ self perception of clinical compe-
tence, found that a self-perception scale can be useful in identifying
clinical competency. In that study, significant differences in practice
levels of PSC were related to ICN specialist certification and atten-
dance at academic conferences or training courses. Goldrick reported
that certification validated knowledge and clinical competency in a
specialty.12 In Korea, ICN specialist certification is acquired through a
national qualifying examination after graduating from a specialist
nursing program based at a university graduate school.9 Our data
demonstrate that this ICN specialist program enhanced the ICNs’
practice levels of PSC. Annual participation in academic conferences
and training courses was also shown to be beneficial to ICN com-
petency; however, 62.3% of the respondents still rated their knowl-
edge as insufficient. It seems that this outcome may be related to the
wide range of IC experience, from 2 months to 19 years in the field,
among responding ICNs.
Most respondents reported having insufficient knowledge in the
areas of research and construction and renovation in patient care
facilities. These domains included tasks that the respondents per-
formed less often during their daily duties. According to Her et al,13
Korean ICNs report the desire to participate in programs, such as
statistics, as related to IC practice. APIC and CHICA-Canada suggest
that infection preventionists participate in IC prevention and related
research on their own or work collaboratively on research to develop
practice standards in these fields.5 This suggests that ICN programs
should be research-based or be developed to require an advanced
degree with a strong research orientation. In addition, ICNs need to
be encouraged to do their own research on IC practices.
Of the PSC in the 4 future-oriented domains, the technology area
had the ICNs’ highest self-perceived levels of competency. This
result could be related to ICNs’ need to access patient information,
including the electronic medical record (EMR), for monitoring.4
Some studies have reported that using the EMR enables precise
 J.S. Choi, K.M. Kim / American Journal of Infection Control 42 (2014) 980-4 983

Table 3
Mean
SD and Pearson correlation among the main research variables (n ¼ 104)

Variable 1 2 3 4 5 6
1. Practice of PSC 1.00 - - - - -
2. Age 0.39** 1.00 - - - -
3. Years of clinical experience 0.32** 0.95** 1.00 - - -
4. Years of ICN experience 0.83** 0.52** 0.45** 1.00 - -
5. Number of hospital beds 0.23** 0.26** 0.24* 0.20 1.00 -
6. Knowledge of IC 0.77** 0.32** 0.24* 0.65** 0.16 1.00
Mean
SD 3.05
1.14 37.5
6.00 14.93
5.94 5.40
3.95 821.38
514.88 3.11
0.76
Observed range 1-5 23-53 2-30 0.2-19 99-2780 1-5

*P < .05, **P < .01, independent Pearson correlation test.

Table 4
Predictors of practice levels of PSC (n ¼ 104)

Step Predictor b t P R2 change Adjusted R2 F (P)

1 Age 0.073 0.413 .680 0.692 0.692 47.275 (<.001)
Years of clinical experience 0.123 0.716 .476
Years of experience as infection control nurse 0.792 10.606 <.001
Number of hospital beds 0.066 1.170 .245
ICN specialist certification* 0.770 1.173 .243
Attendance of academic conference or training course* 0.079 1.404 .163
2 Knowledge of IC 0.395 6.365 <.001 0.088 0.780 62.035 (<.01)

NOTE. Computed by independent hierarchical multiple linear regression analysis.

*Dummy variable (certification: yes, 1; no, 0; attendance, 1; nonattendance, 0).

monitoring and helps save time and labor.14,15 Most ICNs in the
present study were working at hospitals where they were able to
easily use the hospital information systems, including the EMR,
order communication system, and picture archiving communica-
tion system. Thus, they reported high levels of competency when
using information technology. However, the scores were low on the
item “uses automated algorithmic detection of possible hospital
associated infections (HAIs).” An automated algorithm with high
sensitivity and specificity is more useful than manual surveillance
for detection of HAIs and helps save time and labor.16
Among the 4 future-oriented domains, the percentage of re-
spondents achieving the desired standard score was lowest for the
performance improvement and implementation science domain.
Although IC is considered an important part of improving patient
safety,17 programs related to the promotion of quality are rarely part
of the educational courses offered to ICNs. Education on the use of
quality promotion tools used to support the adequacy of IC programs
should be provided.
Infection preventionists must understand the economic envi-
ronment in which they work to manage and improve infection
prevention and control programs effectively and efficiently.4
However, in the leadership domain, more than 70% of the
responding ICNs felt insufficiently capable of working in IC from a
cost-benefit assessment or financial implication standpoint.
Encouraging the ICNs to take business coursework as part of their
continuing education could help decrease this percentage.
The self-perceived practice level of PSC was significantly
correlated with age, years of total clinical experience, years as an
ICN, hospital bed count, and self-perceived knowledge level of IC.
This finding is consistent with the results of Sekimoto et al,18 who
found that ICNs working for large hospitals demonstrated high
competency levels, believed to be related to the fact that most large
hospitals are educational institutions with a well-established
infrastructure for IC. One-half of the responding ICNs had less
than 5 years of experience in IC, suggesting that ICN turnover is
relatively frequent. Her et al.13 reported that Korean ICNs feel high
levels of work-related stress owing to heavy workloads and role
conflicts as professional nurses, and suggested that such stress
could be a factor in the high turnover rate in the field.
Improvements in working conditions are needed to prevent ICNs
with high competency levels from choosing to leave the profession.
As predictors of self-perceived practice levels of PSC, knowledge,
and IC experience have a high impact on the explanation. This
result suggests that ICNs should be encouraged to continue within
the IC field, and that more research is needed to develop programs
to support that retention.
Our e-mail survey had some limitations. The response rate for the
questionnaire was only 55%. In addition, the questionnaire was a self-
reporting survey, which could have a bias for measuring ICNs’ knowl-
edge and competency. Regardless, however, this study is meaningful in
measuring the level of knowledge and competency of a specific group
of ICNs and identifying predictors of level of PSC. Comparative analyses
of competency in ICNs working in other countries should be consid-
ered. It is believed that continuous improvement in ICNs’ knowledge
and competency will be helpful for HAIs prevention.
CONCLUSION
In this study, we were able to identify the self-perceived knowl-
edge level of IC and PSC among Korean ICNs. The majority of ICN
respondents rated their knowledge level of IC as insufficient, with
the lowest knowledge level in the area of the construction and reno-
vation of patient care facilities. Of the 4 future-oriented domains
studied, the technology domain showed the highest level of self-
perceived practice levels of competency. Predictors of self-perceived
practice levels of PSC were self-perceived IC knowledge and IC expe-
rience. Educational programs are needed to promote knowledge and
competency, the lack of which was recognized by the ICNs. In addition,
efforts are needed to prevent turnover of highly competent ICNs.
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