Practical nurse students’ misconceptions about infection prevention and control

Abstract

When teaching infection prevention and control (IPC), nursing education tends to focus on skills and fostering good practice rather than challenging students’ thinking. Therefore, students’ misconceptions about IPC receive less attention than they deserve. The purpose of the study was to make an inventory of student nurses’ misconceptions about IPC before instruction and to make these misconceptions visible to teachers. The study was conducted in one vocational institute in Finland and is based on the answers of 29 practical nurse students before IPC training. The students took an online test requiring them to justify their answers to two multiple-true–false questions: 1) What is the main route of transmission between patients in healthcare facilities, and 2) What is the most effective and easiest manner to prevent the spreading of pathogens, e.g., multi-resistant bacteria in long-term care facilities? Analysis of the students’ written justifications resulted in three mental models: 1) the Household Hygiene Model manifesting lay knowledge learned in domestic situations, 2) the Mixed Model consisting of lay knowledge, enriched with some professional knowledge of IPC, and 3) the Transmission Model manifesting a professional understanding of IPC. The first two mental models were considered to be misconceptions. Only one of the participants showed a professional understanding (i.e., the Transmission Model). To conclude, student nurses manifested systematic patterns of misconceptions before instruction. Unless the students are confronted with their misconceptions of IPC during instruction, it is likely that these misconceptions will impede their learning or make learning outcomes transient.

Full text

Vol.:(0123456789)
Vocations and Learning (2024) 17:143–164
https://doi.org/10.1007/s12186-023-09337-8
1 3
RESEARCH
Practical nurse students’ misconceptions aboutinfection
prevention andcontrol
RiikkaEronen1 · LauraHelle1 · TuirePalonen1 · HennyP.A.Boshuizen1,2
Received: 25 November 2022 / Accepted: 18 September 2023 / Published online: 12 October 2023
© The Author(s) 2023
Abstract
When teaching infection prevention and control (IPC), nursing education tends to
focus on skills and fostering good practice rather than challenging students’ think-
ing. Therefore, students’ misconceptions about IPC receive less attention than they
deserve. The purpose of the study was to make an inventory of student nurses’ mis-
conceptions about IPC before instruction and to make these misconceptions visible
to teachers. The study was conducted in one vocational institute in Finland and is
based on the answers of 29 practical nurse students before IPC training. The stu-
dents took an online test requiring them to justify their answers to two multiple-
true–false questions: 1) What is the main route of transmission between patients in
healthcare facilities, and 2) What is the most effective and easiest manner to prevent
the spreading of pathogens, e.g., multi-resistant bacteria in long-term care facilities?
Analysis of the students’ written justifications resulted in three mental models: 1)
the Household Hygiene Model manifesting lay knowledge learned in domestic situ-
ations, 2) the Mixed Model consisting of lay knowledge, enriched with some profes-
sional knowledge of IPC, and 3) the Transmission Model manifesting a professional
understanding of IPC. The first two mental models were considered to be miscon-
ceptions. Only one of the participants showed a professional understanding (i.e., the
Transmission Model). To conclude, student nurses manifested systematic patterns
of misconceptions before instruction. Unless the students are confronted with their
misconceptions of IPC during instruction, it is likely that these misconceptions will
impede their learning or make learning outcomes transient.
Keywords Nurse· Student· Infection prevention and control· Misconception·
Mental model· Conceptual change
Extended author information available on the last page of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

144
R.Eronen et al.
1 3
Introduction
Background andaim
Although the healthcare system is meant to prevent and treat diseases, and to care for
patients, it repeatedly fails to achieve this goal. Treatments can have side-effects that
need to be treated in turn, and procedures can be performed carelessly. An exam-
ple of the latter is healthcare associated infections (HAI) (Cieslak etal., 2009). The
World Health Organization (WHO, 2016) defines HAI as an infection that occurs
in a patient during the process of care, which was either not present or incubat-
ing at the time of admission. HAI is a serious threat to public health. For instance,
about 8.9 million episodes of HAI are estimated to occur in EU countries yearly;
1% of the cases are lethal (Suetens etal., 2018). Of these infections 50% could have
been prevented by consistent and careful application of professional hand hygiene
(WHO, 2016). Nevertheless, it was found that a majority of the healthcare work-
ers (HCWs) do not adhere to these procedures. Improvements of the HAI situation
must come from healthcare practice and education, but these are difficult to accom-
plish. The recent experiences during the Covid-19 pandemic made the benefits of
hygiene practices very clear. The public campaigns that emphasised wearing surgi-
cal masks and washing and disinfecting hands led to a reduction in incidence of res-
piratory and gastrointestinal virus infections. However, despite the increased use of
hand disinfectants HAIs did not decrease (Dapper etal., 2022). Dapper etal. (2022)
hypothesised that increased use of hand disinfectants helped protect the staff but did
not influence the protection of the patients. Infection prevention and control (IPC)
and hand hygiene are mainly taught as skills in nurse training programmes (Kısacık
etal., 2021; Korhonen etal., 2019). Such training programmes mostly focus on good
practice, whilst challenging the pre-existing beliefs of students receives less atten-
tion; however, these beliefs warrant more consideration. In this article, we focus
on these beliefs in order to discover how far they correspond with professional IPC
knowledge.
Conceptual change andinfection prevention andcontrol
When student nurses start their studies, they have a basic knowledge of how to
take care of their own personal and domestic hygiene as this is a general learning
requirement in life (Boshuizen & Marambe, 2020; Moll etal., 1992; Vosniadou
etal., 2001). A wealth of knowledge is already accumulated during early child-
hood by observing parents at home, e.g., from the revulsion parents show when
confronted with unpleasant smelling food or bodily secretions (Curtis & Biran,
2001), and by learning from caretakers in nurseries or from teachers in schools
(Boshuizen & Marambe, 2020). This familiarity with domestic hygiene situations
results in a form of lay knowledge such as having a “gut feeling” for things, sub-
stances and odours which are “disgusting” (Curtis & Biran, 2001), and that wash-
ing one’s hands prevents the spreading of “bugs” and sicknesses. Some of this
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

145
1 3
Practical nurse students’ misconceptions aboutinfection…
knowledge causes physical reactions such as feeling the urge to withdraw when
touching slimy materials or knowing where to cough and how to clean one’s
hands.
In the course of vocational education, student nurses need to construct profes-
sional knowledge based on official guidelines of IPC. IPC is a scientific approach
and a set of practical procedures which prevent patients from being harmed by avoid-
able HAIs (WHO, 2016). HAIs are caused by lapses in IPC (Cieslak etal., 2009).
Vocational education does seem to influence student nurses’ knowledge of IPC,
but during clinical training discrepancies between theory and practice may appear
(Boshuizen etal., 2020; Cox etal., 2014; Korhonen etal., 2019). There is evidence
that student nurses’ knowledge and the ability to apply IPC are not sufficient (AL-
Rawajfah & Tubaishat, 2015; Kelcíkova etal., 2012). The nursing curricula should
prepare students to understand and apply IPC knowledge in a professional way in a
range of clinical situations (Cox etal., 2014). It is possible that existing preconcep-
tions may interfere with the construction of professional knowledge.
There is a strong line of earlier research on the misconceptions, preconceptions,
alternative conceptions, naïve theories or mental models of learners which educators
see as barriers to knowledge restructuring (Guzzetti etal., 1993). This lay knowl-
edge has proven to be difficult to modify (Vosniadou & Brewer, 1992). In the con-
text of IPC, nurses may have a preconception emphasising the importance of self-
protection (Dapper etal., 2022; Jansson etal., 2016; Jeong & Kim, 2016). Unknown
patients may be considered “dirty” (Curtis & Biran, 2001), and nurses need to pro-
tect themselves from the patients’ “bugs” with, e.g., gloves. In other domains, stud-
ies about the persistence of faulty mental models, e.g., of the cardiovascular sys-
tem have demonstrated that not all medical students reach the necessary scientific
level of understanding about the circulatory system even after instruction (Ahopelto
etal., 2011; Mikkilä-Erdmann etal., 2012; Södervik etal., 2019). According to Chi
(2013), a mental model is an organised collection of an individual’s beliefs. It can
be an internal representation of a concept, or an interrelated system of concepts.
Individuals use mental models to solve problems or answer questions (Vosniadou &
Brewer, 1992).
It has been argued that students’ prior misconceptions are often hard to trans-
form into scientific knowledge because students attempt to reconstruct professional
knowledge based on their misconceptions (Boshuizen & Marambe, 2020; Meren-
luoto & Lehtinen, 2004). This process can result in the enrichment of existing mis-
conceptions—instead of a transformation—because some but not all false beliefs are
altered based on the instruction (Vosniadou etal., 2001). This enrichment occurs
at an easier level of learning (Merenluoto & Lehtinen, 2004), whereas Conceptual
Change requires a more profound revision of students’ mental models (Vosniadou
etal., 2001). Before this occurs, students might have mixed, or fragmented concep-
tions about the topic.
When students are taught to be mindful of their existing misconceptions instead
of being merely taught scientific knowledge, the result may lead to belief revi-
sion (Chi, 2013; Vosniadou et al., 2001). This revision of existing misconception
may result in the abandonment of previous misconceptions and the acquisition of
enriched knowledge, which according to Södervik etal. (2019) occurs gradually.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

146
R.Eronen et al.
1 3
An alternative line of inquiry stresses that students do not need to abandon their
lay conceptualisations (Linn, 2008; Lundholm, 2018; Solomon, 1983). Instead,
naïve models based on everyday knowledge and scientific models learned in educa-
tional settings can coexist in the minds of learners. The scientific models are learnt
in a meaning-making process involving a perpetual process concerning the interpre-
tation of isolated pieces of knowledge and reflections regarding a coherent whole
(Halldén, 1993; Halldén etal., 2009). Importantly, in this view on the conceptual
change process, the role of education is to offer more powerful ideas and discussion
of context (private context of one’s own home versus professional context) so that
students can build their meta-knowledge by learning to identify differences between
these two ways of thinking (Lundholm, 2022) (See Fig.1).
In education, students are expected to see the difference between conceptions
generated by everyday experiences and perceptions, and the concepts and evidence
created by scientific communities. While concepts refer to classifications and the set
of knowledge the person associates with the concept’s name, conceptions are sys-
tems of explanation (White, 1994) (see Fig.1). Lay thinking and scientific thinking
differ in many important ways. First, lay thinking is based on personal values, which
are likely to be influenced by cultural norms and stem from personal preferences
and cultural influences. For example, cultural norms about hygiene and cleanliness
dictate what is edible and what is not, when one washes oneself, or what can be
touched with bare hands. Instead, professional thinking needs to be built on profes-
sional values which include that absolute priority is given to the patient’s safety;
IPC procedures are viewed as a means of ensuring patient safety. Second, in lay
thinking, causality tends to be understood as a simple linear relation (e.g., use of
gloves blocks pathogen spreading) without taking into consideration an emerging
process with multiple feedback loops as in the scientific model. Third, lay thinking
Fig. 1 Common sense context versus professional/scientific context based on Lundholm (2018, 2022)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

147
1 3
Practical nurse students’ misconceptions aboutinfection…
relies on personal experience, whereas scientific thinking relies on a review of the
accumulated empirical evidence (see Fig.1). Students also need to learn the context
of applicability i.e., an awareness regarding which system of explanation and related
IPC procedures to use under different circumstances (Halldén, 1999; Lundholm,
2018); students need to know that in household cleaning activities a pair of gloves
can be put on without applying a hand rub in advance, while in healthcare facilities
this is mandatory. Students’ values and identities are part of this process. Little by
little they must learn to think like a nurse.
Finally, learning to think like a professional is likely to be moderated by motiva-
tional factors such as control beliefs and the influence of significant others (see Pin-
trich etal., 1993). It is important to know what kind of lay conceptions the students
bring into vocational education so that teachers are able to identify lay conceptions
and assist the students in making comparisons between the two ways of thinking.
There are essentially two types of values: the values of the discipline and the values
and emotions that the students hold (see Fig.1).
Therefore, the purpose of the present study is to make an inventory of practi-
cal nurse students’ misconceptions about IPC. The following research questions are
addressed: 1) What kind of misconceptions of IPC are held by students? 2) How
prevalent are these misconceptions?
To make the misconceptions “visible”, the students were asked to answer some
multiple-true–false questions and to justify their answers. Based on these written
justifications, the research team created mental models to describe the typical ways
students thought about IPC.
Methods
Context ofthestudy
The study was conducted in the context of practical nurse education in Finland.
Practical nurse education leads to a vocational, upper secondary degree requiring
120 ECTS. The studies take approximately three years to complete (Finnish National
Agency for Education, 2018). Practical nurses are the largest group of healthcare
workers in Finland (Virtanen, 2020). They typically work in basic public healthcare
or private social care, including long-term care and day-care facilities. They also
work in specialised public medical care, e.g., inpatient wards, hospitals, ambulances,
or homecare depending on their specialisation (Finnish National Agency for Educa-
tion, 2018).
During their studies practical nurse students acquire a wide range of basic com-
petences related to nursing and care including observing the vital functions and
symptoms of patients. The students also obtain a medication administration licence
allowing them to dispense and administer medications via natural routes, and by
subcutaneous and intramuscular injections when instructed to do so. Regarding IPC,
the curriculum states that “students follow the principles of aseptic working meth-
ods” (Finnish National Agency for Education, 2018).
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

148
R.Eronen et al.
1 3
Participants
Participants were recruited from a vocational school in Finland immediately prior
to the outbreak of the COVID-19 pandemic. The first-year adult students had just
begun their studies in practical nursing, and the first author was the teacher of the
30-h compulsory course on IPC. The study was conducted during the course but
providing the material for the study was voluntary.
Of a total of 90 students, 67 students (74%) (54 females, 81%, 13 males, 19%)
provided their written consent to participate in the study. However, only 29 partic-
ipants (24 females, 83%, 5 males, 17%) supplied complete answers (i.e., answers
including written justifications) to the questions this study focused on, resulting in
a sample size of 29. The participants’ age varied from 18 to 55. Eight participants
were under 25years of age, thirteen were 26–40, and eight were over 40.
Materials andprocedures
As a part of their studies, the students took a test on IPC before the start of the
course. This test, containing multiple-true–false questions together with prompts to
justify one’s responses, was administered during the first lesson using an on-line tool
(Webropol). It was possible to complete the survey at home for those students who
were absent. The link to the test was sent via the school’s learning management sys-
tem with the possibility to complete it via a computer or a mobile device. The time
to complete the test ranged from 12 to 61min.
The present study is based on an examination of two questions from a more
extensive questionnaire developed explicitly for the purpose of this study. The valid-
ity and reliability of the entire questionnaire will be reported elsewhere.
Students were asked to indicate whether each of the four answers provided for
both questions were true or false (see Appendix1). A point was given for every
correct answer (a point for each true positive or true negative) with a maximum of
eight points. The first question ‘What is the main route of transmission between
patients in healthcare facilities?’ was inspired by the study conducted by Jeong and
Kim (2016); the second question ‘What is the most effective and easiest manner to
prevent the spreading of pathogens (e.g., multiresistant bacteria) in long-term care
facilities?’ was derived from the study by Caniza etal. (2007). The questions were
translated into Finnish and partly modified based on current, national, and interna-
tional guidelines. The present study is based on an analysis of the written justifica-
tions given for the two multiple-true–false questions.
Ethical approval
The study was granted ethical approval, (code 27/2019) by the Ethical review
board of the Finnish university involved in the study. The principal of the voca-
tional school granted the research permit. The participants were informed about the
research project, and informed consent was obtained at the beginning of the first
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

149
1 3
Practical nurse students’ misconceptions aboutinfection…
lesson. Permission via email was sought from those participants who did not attend
the first lesson. Participation in the study was voluntary. Participants or non-partici-
pants were not advantaged or disadvantaged in any way.
Data coding andanalysis
The data analysis was based on a method initiated by Patel and Groen (1986) who
investigated clinical reasoning in medicine. This method has been described very
succinctly by Van de Wiel etal. (2000). To enable comparison at a conceptual level,
students’ answers were rewritten as concept maps (Tversky, 2011). These concept
maps consisted of nodes and links between nodes. The nodes represent the differ-
ent concepts applied in a justification, and the links between nodes represent the
relationship between the concepts. To enable comparison between maps some stand-
ard abbreviations or elements were used: P for patient, HCW for healthcare worker,
arrow for connecting (causal) link, X connected to arrow for breaking that link,
att for attributes such as “has features of…, or instr for instrument such as “with
their hands”. The reliability of the methodology and validity of the outcomes was
monitored through a combination of independent coding and a discussion of any
differences.
Analysis proceeded in chronological order as follows:
1. The research team read through the justifications of questions 1 and 2. A subset of
19 protocols (i.e., cases) was selected and visually represented as concept maps.
2. The fourth author created two extreme prototypical models and visualised them
as concept maps (see Appendix2). The Household Hygiene Model was created
bottom-up, i.e., based on the students’ justifications. The term was inspired by
Moll etal., (1992, p 133) who used the term ‘household funds of knowledge’ to
refer to the ‘historically accumulated and culturally developed bodies of knowl-
edge and skills essential for household […] functioning’. The Transmission Model
was created using a top-down approach based on scientific knowledge of IPC
(WHO, 2016).
3. Then the first author attempted to categorise the cases into these two extremes.
To solve discrepancies, the research team created a third model called the Mixed
Model, which contained features of both of the two previous models.
4. These three models were translated into categorisation criteria (see Table1).
5. Using these criteria, the first author categorised the 19 cases into one of the three
mental models. The responses to the multiple-true–false questions were ignored
at this phase.
6. Authors 1, 2 and 3 discussed the decisions made by the first author in phase 5.
This resulted in transferring some cases to another category.
7. The fourth author worked independently as a second coder. This resulted in disa-
greement regarding four cases.
8. The team concluded that referring to “hand hygiene” instead of “hand disinfec-
tion” was a sufficient inclusion criterium for the Mixed Model. This resulted in
agreement regarding all cases.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

150
R.Eronen et al.
1 3
9. To check for coder agreement the remaining ten cases were categorised by the
first and fourth author independently. This resulted in complete agreement without
the necessity for further discussions.
Results: theThree Mental Models
Based on the analyses of the students’ justifications to questions 1 and 2, three
mental models were formed. These were defined as 1) the Household Hygiene
Model, 2) the Mixed Model, and 3) the Transmission Model (see Table1). The
three models found showed that there were two large subclasses of misconcep-
tions: household conceptions and household conceptions enriched with scientific
professional knowledge.
The background knowledge of IPC and use of terminology in the present
study requires some clarification. The main route of transmission is the HCWs’
direct contact with patients by means of undisinfected hands (WHO, 2009).
Other routes of transmission include airborne transmission (via dust) and drop-
let (respiratory) transmission.
Hand hygiene is considered a general lay expression for cleaning one’s hands
because there is no definition of how it should be applied. Hand disinfection
means rubbing alcohol-based liquid to disinfect the healthcare workers’ hands
(Pittet & Boyce, 2003). Hand disinfection (“hand rub”) is considered a pro-
fessional expression when used in this context. Hand disinfection is the easi-
est, cheapest, and most favourable way to prevent the spreading of pathogens
from the HCWs’ hands within healthcare. Improving HCWs’ hand disinfection
according to official guidelines reduces the spreading of pathogens between vul-
nerable patients and therefore prevents HAIs (WHO, 2009).
In contrast, washing one’s hands (hand wash) is an action whereby the
hands are cleaned using soap and water when they are visibly soiled. Several
authors (AL-Rawajfah & Tubaishat, 2015; Caniza etal., 2007; Jeong & Kim,
2016; Ward, 2013) consider handwashing sufficient. In this study, hand wash-
ing was not considered to be a professional manner for healthcare workers to
clean their hands at work. Finnish student nurses are taught according to the
guidelines provided by the local authorities and the WHO, which state that the
healthcare worker’s hands should be disinfected using an alcohol-based hand
rub unless visibly soiled (Sairaalahygienia- ja infektiontorjuntayksikkö, 2023;
WHO, 2009).
Gloves are disposable, and non-sterile. They are used during nursing proce-
dures where there is a risk of contact with any kind of secretion (Pittet & Boyce,
2003). Appropriate use of gloves is poorly understood among HCW (e.g., when,
and how to put on and take off gloves correctly). Using gloves insituations when
they are not indicated can lead to cross-contamination between patients, and a
waste of resources (WHO, 2009).
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

151
1 3
Practical nurse students’ misconceptions aboutinfection…
Table 1 The Three Mental Models and their criteria
HOUSEHOLD HYGIENE MODEL (Lay knowledge) MIXED MODEL (Between lay and scientific knowl-
edge)
TRANSMISSION MODEL (Scientific knowledge)
Main route of transmission
- No mention of the nurse as the pathogen-spreading
link between the patients
- Emphasis on the use of disposable gloves in patient
contact
- Patients and visitors, surfaces, and secretions are
reported as the main route of transmission
Hand hygiene
- No mention of hand washing, hand disinfection, hand
hygiene OR
- refers to “hand hygiene” or “hand wash” BUT
-does not mention “hand disinfection”
Language
- Uses everyday language e.g., “bugs”
Main route of transmission
- The nurse is the pathogen-spreading link between
patients (scientific) AND
- Patients and visitors, surfaces, and secretions are
reported as the main route of transmission (lay)
Hand hygiene
- Disinfection or hand rub or at least hand hygiene is
mentioned
Language
- Uses everyday language e.g., “bugs” (lay) or some
professional phrases (scientific)
Main route of transmission
- The nurse is the main pathogen-spreading link between
patients
Hand hygiene
- Hand disinfection mentioned
Language
- Uses professional vocabulary e.g., pathogens and
Standard Precautions
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

152
R.Eronen et al.
1 3
Household hygiene model
Instances of the Household Hygiene Model represent the clearest misconceptions
students have about IPC. In this model, the knowledge is based on lay knowledge
about domestic hygiene learned from everyday situations. It is typical of this model
that the HCW is not mentioned as the pathogen-spreading link between patients.
Instead, the patients and their visitors, surfaces, and secretions are reported as the
main route of transmission. These students speak about hand hygiene or hand wash-
ing, but they do not mention hand disinfection. They use everyday language instead
of professional language, with many of them emphasising the use of gloves in
patient contacts.
The mental model of Student 12 (see Fig.2) is presented, because it is closest
to the prototypical model of the Household Hygiene Model (see Appendix2). The
original justifications for Question 1 and 2 are presented on the left side of the fig-
ure, and on the right side the justifications are visualised in the form of a concept
map. Student 12 scored six out of eight points on the multiple-true–false test by
answering most questions correctly but failing to indicate that the main transmission
route is the healthcare worker’s hands.
The student was of the opinion that surfaces are the main route of transmission.
When the student’s justifications were analysed, it seemed that the student had no
idea of IPC in healthcare and believed that “poor cleaning” and “poor air qual-
ity” are the main routes of transmission, instead of the HCW’s hands. Perhaps by
poor air quality, the student was referring to airborne transmission. By stating that
“all relatives and healthcare workers prevent the spreading of pathogens by wash-
ing their hands”, the student was referring to basic household knowledge. This is
clearly incorrect: both relatives and HCWs are instructed to prevent the spreading of
pathogens by disinfecting their hands by using hand rub in healthcare settings.
Student 64’s mental model was also classified as an instance of the House-
hold Hygiene Model. The student scored two out of eight points on the multiple-
true–false questions, answering only two items correctly, namely 1) antibiotics are
not the most effective manner to prevent infections, and 2) hand disinfection is the
Fig. 2 First example of the Household Hygiene Model. (ID 12 = student pseudonym, Q1-2 = justi-
fications, P = patient, X = preventing spreading of pathogens, HW = hand wash, HCW = healthcare
worker, → = affects, causes)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

153
1 3
Practical nurse students’ misconceptions aboutinfection…
most effective manner to prevent the spreading of infections. The student specified
that surfaces touched by patients who do not attend to hygiene sufficiently spread
bacteria (see Fig.3) which is correct, but it is not the main route of transmission; it
is the HCWs’ hands that are the main route of transmission. The student also stated
that “Infections can be prevented with vaccinations” which is also correct, but again
not the correct answer to the question regarding the main route of transmission
(WHO, 2009). It remains unclear what exactly the student meant by stating that “the
right kind of protection can prevent the spreading of diseases”. Perhaps the student
meant using personal protective equipment, meaning gloves, gowns, and masks. As
in the case of Student 12, it is assumed that Student 64 had not internalised how
critical the healthcare worker’s role is in IPC, because in the written accounts other
people were held responsible for the spreading of pathogens.
The final example of the Household Hygiene Model (Student 63) is interesting,
because the student (see Fig.4) appears to have some working experience with the
elderly. In the response, the student emphasises the use of gloves in IPC, instead of
hand disinfection, which is typical of the household hygiene model. This student
seems to focus on self-protection and resorts to intuitive-emotional decision-making
(Aarkrog & Wahlgren, 2022) rather than protecting the patients. Similar to Student
64, Student 63 had the same two answers correct, with antibiotics not being the most
effective manner to prevent infections and hand disinfection being the easiest way to
prevent infections from spreading.
Student 63 justifies how surfaces and patients are the main route of transmission:
“All patients may not necessarily control themselves and spreading their own secre-
tions, while moving they touch the mouth (saliva) and then the surfaces of the corri-
dor etc.” The student may be referring to droplet transmission. There is some idea of
what patients and healthcare workers do, as evidenced by the comment “staff mainly
wash their hands regularly and use gloves”. Claiming that “preventing vaccinations
with protective gloves” is a clear misunderstanding of the purpose of gloves (Pittet
& Boyce, 2003). Gloves should be used only when there is risk of contaminating the
Fig. 3 Second example of the Household Hygiene Model (Student 64). (ID 64 = student pseudonym,
Q1-2 = justifications, P = patient, X = preventing spreading of pathogens, PPE = personal protective
equipment, → = affects, causes)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

154
R.Eronen et al.
1 3
Fig. 4 Third example of the Household Hygiene Model (Student 63). (ID 63 = student pseudonym, Q1-2 = justifications, P = patient, HCW = healthcare
worker, → = affects, causes)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

155
1 3
Practical nurse students’ misconceptions aboutinfection…
HCW’s hands with secretions. It also seems that the student has no awareness of the
purpose of disinfecting a nurse’s hands.
Ten of the 29 (34%) mental models provided by the students were classified as
instances of the Household Hygiene Model. Seven of these students scored 5–6
points out of a possible 8 from the multiple-true–false questions, and three students
scored between 2 to 4 points.
The mixed model
In the Mixed Model, the students expressed some understanding of the critical role
of the nurse in IPC. They expressed that the nurse is the main pathogen spreading
link between the patients which is correct, but patients and visitors, surfaces and
secretions were also reported as the main route of transmission as in the Household
Hygiene Model. Hand disinfection or a hand rub, central in IPC, is also presented
in this mental model. Everyday language such as “bugs” instead of professional
phrases such as pathogens, bacteria or virus are typically used.
The mental model of Student 51 is the most characteristic instance of the Mixed
Model (see Fig.5). The student scored only two points out of eight on the multi-
ple-true–false questions, stating that all the alternatives represent the main route of
transmission, and all the alternatives are the most effective and easiest manners to
prevent spreading of pathogens.
The student indicated professional knowledge and awareness of the critical role of
the nurse in IPC stating that “Staff should clean their hands before and after touch-
ing the patient. Protective gloves should be changed (between procedures/ when the
patient changes).” It is not clear what Student 51 meant by stating “If the secretions
are not handled properly, the contact surfaces are contaminated”. In any case, this
statement is interpreted as household hygiene knowledge because it is not the main
route of transmission. Whilst the knowledge of vaccinations and antibiotics is cor-
rect in the sense that they can prevent infections, it is not the correct answer to the
question regarding the most effective way to prevent infections. Stating that “Hand
rub and the use of gloves always” emphasises the use of gloves, but there is no
indication of the situations in which they are needed. Gloves should be used only in
contact with secretions, not always (Pittet & Boyce, 2003). Student 51’s comments
thus show some professional knowledge and some lay knowledge, which is typical
for the Mixed Model.
Eighteen of the 29 (62%) students’ mental models were classified as instances of
the Mixed Model. Six of these students scored a maximum of 8 points from the mul-
tiple-true–false questions. The remaining students scored between 2 and 6 points.
The transmission model
The Transmission Model is based on scientific knowledge of IPC. In this model,
the nurse is understood as the main pathogen spreading link between the patients
(WHO, 2016), and it is acknowledged that the patients need to be protected against
the spreading of pathogens by the HCWs’ hands. Hand disinfection, the cornerstone
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

156
R.Eronen et al.
1 3
Fig. 5 Example of the Mixed Model (Student 51). (ID 51 = student pseudonym, Q1-2 = justifications, P = patient, X = preventing spreading of pathogens, HR = hand rub,
HH = hand hygiene, HCW = healthcare worker, → = affects, causes)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

157
1 3
Practical nurse students’ misconceptions aboutinfection…
of IPC, is expected to be mentioned (Pittet & Boyce, 2003). In addition, the use of
professional language is a characteristic of this model (see Table1).
Only one of the concept maps (Student 18) was categorised as an instance of the
Transmission Model. The student scored a maximum of 8 points on the multiple-
true–false questions.
The student manifested professional knowledge in a written explanation by stat-
ing that the nurse is the pathogen spreading link “with poor hand hygiene health-
care workers spread diseases to other patients”, and the best way to prevent spread-
ing of pathogens is hand disinfection “because hand disinfection is the most efficient
and cheapest way to prevent the spreading of pathogens”. The student also used
professional language (e.g., “pathogens”) (see Fig.6).
Discussion
The purpose of this study was to make an inventory of the misconceptions of practi-
cal nurse students about IPC at the beginning of their studies, and to discover (1)
what kind of IPC misconceptions are held by students, and (2) how prevalent they
are. The Three Mental Models that were created based on the students’ justifications
indicated that every third student maintained beliefs that were corresponding to a
Household Hygiene Model. Patients and visitors, surfaces and secretions were seen
as the main routes of transmission and hence should be cleaned. The use of gloves
was emphasised, whereas neither the HCW nor hand disinfection were mentioned.
This set of beliefs seems to serve a self-protection goal (Dapper etal., 2022; Jansson
etal., 2016; Jeong & Kim, 2016). The Mixed Model was observed by almost two
thirds of the students. It included the same kind of household beliefs, for instance
claiming that bacteria spread easily from surfaces, but was enriched with some sci-
entific knowledge of IPC, i.e., knowledge about the role of the HCWs in spreading
disease and the importance of using hand rub before and after dealing with a patient.
It is important that teachers are aware of how their students encounter hygiene in
everyday life and what transgression of their in-built standards might mean to them.
Fig. 6 Example of the Transmission Model (Student 18). (ID 18 = student pseudonym, Q1-2 = justi-
fications, P = patient, X = preventing spreading of pathogens, HH = hand hygiene, HCW = healthcare
worker, → = affects, causes)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

158
R.Eronen et al.
1 3
Teachers should not confuse almost perfect test results with understanding and prac-
ticing IPC, not even as an indicator that a student is on the right tract. Only one
student expressed beliefs that are covered by the Transmission Model, reflecting sci-
entific and discipline knowledge. The Transmission Model focuses on protecting the
patient and is based on the scientific finding that the healthcare worker is the main
route of transmission; hand disinfection plays a crucial role in disrupting this trans-
mission route. Nevertheless, it should be noted that the Transmission Model is only
a starting point for the HCW to learn very detailed IPC related routines for perform-
ing nursing procedures in compliance with the guidelines (Heininger etal., 2021;
Purssell & Gould, 2022).
It can be concluded that all the students except one demonstrated beliefs that
could be classified as household conception or mixed conceptions that have self-
protection as a common value. A majority of the students also understood the role of
healthcare workers in spreading disease and the importance of hand disinfection as a
means to prevent this. At the same time, they believed that wearing gloves can also
serve that role without necessarily being aware of the potential danger that gloves
can also be transmitters. The study design makes it impossible to draw conclusions
on how many students entertain specific lay beliefs. The extent of the students’ jus-
tifications for the answers to the multiple-true–false questions varied widely, which
is a limitation of the study. Some of the participants provided elaborated responses,
whereas others provided very short replies. However, this study provides evidence
that a very small minority of the students at this stage of education have developed
a scientific understanding of IPC in healthcare. These findings have implications for
nursing education.
Our findings are in line with findings in healthcare practice. Researchers of
compliance to hand hygiene standards in healthcare institutions have hypothesised
that a preference for prioritising self-protection can explain part of the disappoint-
ing effects of promotional campaigns. Evidence for this is found in the discrepancy
between hand rub ‘before patient contact’ (serving the patient) and ‘after patient
contact’ (serving self). During the COVID-19 pandemic both increased dramatically
but despite this the gap was not reduced (Israel etal., 2020).
The results of this study can be interpreted along the lines of transition from lay
to scientific understanding. In this view, transformations of earlier knowledge and
integration of scientific knowledge has to take place. In this process, knowledge
fragmentation and formation of synthetic conceptions may take place (Vosniadou &
Skopeliti, 2014), however, emotional or motivational factors may complicate these
transitions (Curtis & Biran, 2001; Pintrich etal., 1993). The results are also in the
line with earlier findings (Chi, 2013; Vosniadou & Skopeliti, 2014) that scientific
mental models hardly exist in a “pure” form but include various perspectives simul-
taneously (e.g., Solomon, 1983). In the present study, it could even be claimed that
the Household Hygiene Model represents a rather sophisticated set of knowledge
and skills that can in no way be called naïve. It is the context and goal that define its
applicability (WHO, 2009). We agree with the view of Lundholm (2018) and Hall-
dén (1999) that the lay model and the scientific model may coexist in the minds of
students and HCWs provided that students and HCWs are able to activate the scien-
tific/professional model in a professional context (see Fig.1). As Lundholm (2018)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

159
1 3
Practical nurse students’ misconceptions aboutinfection…
and Halldén (1999) emphasise: it is the learners who should become aware of their
own mental models and build meta-knowledge about the relation and differences
between the two, especially in regard to context demands and applicability.
Finally, the decision by an HCW to follow or not to follow IPC can also be con-
sidered a social dilemma. In a social dilemma, 1) the payoff for everyone to defect,
i.e., act in self-interest, is higher than the payoff for acting in the interest of the col-
lective regardless of what the others do, but 2) all individuals receive a lower payoff
if all defects. There is a temptation for HCWs to discard IPC and to relapse into lay
conceptions in the workplace simply because following IPC requires constant cogni-
tive effort without immediate payoff to the individual. The temptation is even higher
if the other HCWs are serving as poor role models (Cox etal., 2014; Oh, 2021). The
study by Harring and Lundholm (2018) indicated that students with knowledge of
social dilemmas showed more willingness to take personal responsibility in the con-
text of mitigating climate change. Research on the incorporation of social dilemmas
into teaching could be a direction for future research, as well as research on emo-
tional and motivational complicating factors.
The practical implication of the study is that developing an awareness of students’
mental models in different situations related to hygiene, and their appropriateness to
situation-specific demands, should be an explicit goal of nursing education. If the
mental model of nurses does not involve the nurse as the pathogen-spreading link
between patients, there is no reason for nurses to disinfect their hands or to learn
about standard procedures. This awareness is referred to as “meta-knowledge” in
Fig.1. The ability to be aware of one’s thinking and to monitor one’s thinking in
daily practice is important – even lifesaving, because in this context it is particularly
easy to relapse into deeply-rooted thinking habits. We believe that the three mental
models presented in this study can serve as reference points in class discussions on
students’ understandings of IPC.
Appendix1
The multiple-true–false questions = correct answer, = incorrect answer
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

160
R.Eronen et al.
1 3
Appendix2
The two prototypical concept maps; Household Hygiene Model on the left and
Transmission Model on the right side
(P = patient, X = preventing transmission of pathogens, HD = hand disinfection,
HH = hand hygiene, HW = hand wash, HCW = healthcare worker, → = affects,
causes)
Code availability Not applicable.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

161
1 3
Practical nurse students’ misconceptions aboutinfection…
Authors’ contributions The first author conceptualised, planned, collected the data, and wrote the original
draft. All authors participated in the conceptualisation of the study, analysis of the results, reviewing, and
editing the article. All authors read and approved the final manuscript.
Funding Open Access funding provided by University of Turku (including Turku University Central
Hospital). A total of EUR 3000 fromthe OPPI doctoral programme.
Availability of data and materials As explained to the participants, the data will not be disclosed available
to any third party.
Declarations
Ethics approval and consent to participate The study was granted ethical approval by the Ethical Review
Board of the Finnish university involved in the study. The principal of the vocational school granted the
research permit.
Consent for publication The students who volunteered to participate in this study were debriefed about
the study beforehand and signed an Informed Consent Form.Each authors has read and approved the final
version of the paper.
Competing interests The authors have no competing interests to declare that are relevant to the content
of this article.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative
Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permis-
sion directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/
licenses/by/4.0/.
References
Aarkrog, V., & Wahlgren, B. (2022). Goal orientation and decision-making in education. Vocations and
Learning, 15(1), 71–86. https:// doi. org/ 10. 1007/ s12186- 021- 09278-0
Ahopelto, I., Mikkilä-Erdmann, M., Olkinuora, E., & Kääpä, P. (2011). A follow-up study of medical
students’ biomedical understanding and clinical reasoning concerning the cardiovascular system.
Advances in Health Sciences Education, 16, 655–668. https:// doi. org/ 10. 1007/ s10459- 011- 9286-3
AL-Rawajfah, O. M., & Tubaishat, A. (2015). Nursing students’ knowledge and practices of standard
precautions: a Jordanian web-based survey. Nurse Education Today, 35(12), 1175–1180. https:// doi.
org/ 10. 1016/j. nedt. 2015. 05. 011
Boshuizen, H. P. A., & Marambe, K. N. (2020). Misconceptions in medicine, their origin and develop-
ment in education and working life. International Journal of Educational Research, 100, 101536.
https:// doi. org/ 10. 1016/j. ijer. 2020. 101536
Boshuizen, H. P. A., Vosniadou, S., & Lehtinen, E. (2020). Conceptual changes for and during work-
ing life. International Journal of Educational Research, 104, 101682. https:// doi. org/ 10. 1016/j. ijer.
2020. 101682
Caniza, M. A., Maron, G., Moore, E. J., Quintana, Y., & Liu, T. (2007). Effective hand hygiene education
with the use of flipcharts in a hospital in El Salvador. Journal of Hospital Infection, 65(1), 58–64.
https:// doi. org/ 10. 1016/j. jhin. 2006. 08. 011
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

162
R.Eronen et al.
1 3
Chi, M. T. H. (2013). Two kinds and four sub-types of misconceived knowledge, ways to change it, and
the learning outcomes. In S. Vosniadou (Ed.), International Handbook of Research on Conceptual
Change (pp. 49–70). Routledge. https:// doi. org/ 10. 4324/ 97802 03154 472. ch3
Cieslak, P. R., Lee, L. E., Papafragkou, E., & An, N. (2009). Recurring norovirus outbreaks in a long-
term residential treatment facility — Oregon, 2007. MMWR Morbidity and Mortality Weekly
Report, 58(25), 694–698. https:// www. cdc. gov/ mmwr/ previ ew/ mmwrh tml/ mm582 5a2. htm
Cox, J. L., Simpson, M. D., Letts, W., & Cavanagh, H. M. A. (2014). Putting it into practice: Infection
control professionals’ perspectives on early career nursing graduates’ microbiology and infection
control knowledge and practice. Contemporary Nurse, 49(1), 83–92. https:// doi. org/ 10. 1080/ 10376
178. 2014. 11081 957
Curtis, V., & Biran, A. (2001). Dirt, disgust, and disease: Is hygiene in our genes? Perspectives in Biology
and Medicine, 44(1), 17–31. https:// doi. org/ 10. 1353/ pbm. 2001. 0001
Dapper, L., Dick, A., Nonnenmacher-Winter, C., & Günther, F. (2022). Influence of public health and
infection control interventions during the severe acute respiratory syndrome coronavirus 2 pan-
demic on the in-hospital epidemiology of pathogens: In hospital versus community circulating
pathogens. Antimicrobial Resistance & Infection Control, 11(1), 140. https:// doi. org/ 10. 1186/
s13756- 022- 01182-z
Finnish National Agency for Education. (2018). Vocational Qualifications in Social and Health Care.
https:// eperu steet. opint opolku. fi/ eperu steet- servi ce/ api/ dokum entit/ 66711 97
Guzzetti, B. J., Snyder, T. E., Glass, G. V., & Gamas, W. S. (1993). Promoting conceptual change in
science: A comparative meta-analysis of instructional interventions from reading education and sci-
ence education. Reading Research Quarterly, 28(2), 117–159. https:// doi. org/ 10. 2307/ 747886
Halldén, O. (1993). Leaners’ conceptions of the subject matter being taught A case from learning history.
International Journal of Educational Research, 19(3), 317–325.
Halldén, O. (1999). Conceptual change and contextualisation. In W. Schnotz, S. Vosniadou, & M. Car-
retero (Eds.), New perspectives on conceptual change (pp. 53–65). Pergamon.
Halldén, O., Scheja, M., & Haglund, L. (2009). The contextuality of knowedge: An intentional approach
to meaning making and conceptual change. In S. Vosniadou (Ed.), International handbook of
research on conceptual change (pp. 537–560). Routledge.
Harring, N., & Lundholm, C. (2018). Does knowledge about social dilemmas generate cynical citizens?
[Paper presentation]. American Political Science Association Annual Meeting, August 30-September
2, Boston, USA.
Heininger, S. K., Baumgartner, M., Zehner, F., Burgkart, R., Söllner, N., Berberat, P. O., & Gartmeier, M.
(2021). Measuring hygiene competence: the picture-based situational judgement test HygiKo. BMC
Medical Education, 21(1), 410. https:// doi. org/ 10. 1186/ s12909- 021- 02829-y
Israel, S., Harpaz, K., Radvogin, E., Schwartz, C., Gross, I., Mazeh, H., Cohen, M. J., & Benenson, S.
(2020). Dramatically improved hand hygiene performance rates at time of coronavirus pandemic.
Clinical Microbiology and Infection, 26(11), 1566–1568. https:// doi. org/ 10. 1016/j. cmi. 2020. 06. 002
Jansson, M. M., Syrjälä, H. P., Ohtonen, P. P., Meriläinen, M. H., Kyngäs, H. A., & Ala-Kokko, T. I.
(2016). Simulation education as a single intervention does not improve hand hygiene practices: a
randomized controlled follow-up study. American Journal of Infection Control, 44(6), 625–630.
https:// doi. org/ 10. 1016/j. ajic. 2015. 12. 030
Jeong, S. Y., & Kim, K. M. (2016). Influencing factors on hand hygiene behavior of nursing students
based on theory of planned behavior: a descriptive survey study. Nurse Education Today, 36, 159–
164. https:// doi. org/ 10. 1016/j. nedt. 2015. 09. 014
Kelcíkova, S., Skodova, Z., & Straka, S. (2012). Effectiveness of hand hygiene education in a basic nurs-
ing school curricula. Public Health Nursing, 29(2), 152–159. https:// doi. org/ 10. 1111/j. 1525- 1446.
2011. 00985.x
Kısacık, Ö. G., Ciğerci, Y., & Güneş, Ü. (2021). Impact of the fluorescent concretization intervention on
effectiveness of hand hygiene in nursing students: a randomized controlled study. Nurse Education
Today, 97, 104719. https:// doi. org/ 10. 1016/j. nedt. 2020. 104719
Korhonen, A., Vuori, A., Lukkari, A., Laitinen, A., Perälä, M., Koskela, T., & Pölkki, T. (2019). Increas-
ing nursing students’ knowledge of evidence-based hand-hygiene: A quasi-experimental study.
Nurse Education in Practice, 35, 104–110. https:// doi. org/ 10. 1016/j. nepr. 2018. 12. 009
Linn, M. C. (2008). Teaching for conceptual change: Distinguish or extinguish ideas. In S. Vosniadou
(Ed.), International Handbook of Research on Conceptual Change (pp. 694–722). Routledge.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

163
1 3
Practical nurse students’ misconceptions aboutinfection…
Lundholm, C. (2018). Conceptual change and the complexity of learning. In T. G. Amin & O. Levrini
(Eds.), Converging Perspectives on Conceptual Change: Mapping an Emerging Paradigm in the
Learning Sciences (pp. 34–42). Routledge. https:// doi. org/ 10. 4324/ 97813 15467 139
Lundholm, C. (2022). Conceptual change and teaching - focusing on social science and climate edu-
cation. Keynote Speach Held at the 12th Conference on Conceptual Change, 8, 24–27. Zwolle,
The Netherlands.
Merenluoto, K., & Lehtinen, E. (2004). Number concept and conceptual change: Towards a systemic
model of the processes of change. Learning and Instruction, 14(5 SPEC.ISS), 519–534. https://
doi. org/ 10. 1016/j. learn instr uc. 2004. 06. 016
Mikkilä-Erdmann, M., Södervik, I., Vilppu, H., Kääpä, P., & Olkinuora, E. (2012). First-year medi-
cal students’ conceptual understanding of and resistance to conceptual change concerning the
central cardiovascular system. Instructional Science, 40(5), 745–754. https:// doi. org/ 10. 1007/
s11251- 012- 9212-y
Moll, L. C., Amanti, C., Neff, D., & Gonzalez, N. (1992). Funds of knowledge for teaching: Using a
qualitative approach to connect homes and classrooms. Theory into Practice, 31(2), 132–141.
https:// doi. org/ 10. 1080/ 00405 84920 95435 34
Oh, H. S. (2021). Knowledge, perception, and performance of hand hygiene and their correlation
among nursing students in Republic of Korea. Healthcare, 9(7), 913. https:// doi. org/ 10. 3390/
healt hcare 90709 13
Patel, V. L., & Groen, G. J. (1986). Knowledge based solution strategies in medical reasoning.
Cognitive Science, 10(1), 91–116. https:// doi. org/ 10. 1016/ S0364- 0213(86) 80010-6. 10.1016/
S0364-0213(86)80010-6.
Pintrich, P. R., Marx, R. W., & Boyle, R. A. (1993). Beyond cold conceptual change: the role of moti-
vational beliefs and classroom contextual factors in the process of conceptual change. Review of
Educational Research, 63(2), 167. https:// doi. org/ 10. 2307/ 11704 72
Pittet, D., & Boyce, J. M. (2003). Revolutionising hand hygiene in health-care settings: guidelines
revisited. The Lancet Infectious Diseases, 3(5), 269–270. https:// doi. org/ 10. 1016/ S1473-
3099(03) 00601-7
Purssell, E., & Gould, D. (2022). Teaching health care students hand hygiene theory and skills: a
systematic review. International Journal of Environmental Health Research, 32(9), 2065–2073.
https:// doi. org/ 10. 1080/ 09603 123. 2021. 19375 80
Sairaalahygienia- ja infektiontorjuntayksikkö. (2023). Hoitoon liittyvien infektioiden torjunnan perus-
teet Varsinais-Suomen hyvinvointialueella. Varsinais-Suomen hyvinvointialue /Tyks Sairaalahy-
gienia- ja infektiontorjuntayksikkö. https:// hoito- ohjeet. fi/ Ohjep ankki VSSHP/ Suosi tus hoitoon
liittyvien infektioiden torjunnasta.pdf
Södervik, I., Mikkilä-Erdmann, M., & Chi, M. T. H. (2019). Conceptual change challenges in
medicine during professional development. International Journal of Educational Research,
98(August 2018), 159–170. https:// doi. org/ 10. 1016/j. ijer. 2019. 07. 003
Solomon, J. (1983). Learning about energy: How pupils think in two domains. European Journal of
Science Education, 5(1), 49–59. https:// doi. org/ 10. 1080/ 01405 28830 050105
Suetens, C., Latour, K., Kärki, T., Ricchizzi, E., Kinross, P., Moro, M. L., Jans, B., Hopkins, S.,
Hansen, S., Lyytikäinen, O., Reilly, J., Deptula, A., Zingg, W., Plachouras, D., & Monnet, D. L.
(2018). Prevalence of healthcare-associated infections, estimated incidence and composite anti-
microbial resistance index in acute care hospitals and long-term care facilities: results from two
european point prevalence surveys, 2016 to 2017. Eurosurveillance, 23(46), 1–17. https:// doi.
org/ 10. 2807/ 1560- 7917. ES. 2018. 23. 46. 18005 16
Tversky, B. (2011). Visualizing Thought. Topics in Cognitive. Science, 3(3), 499–535. https:// doi. org/
10. 1111/j. 1756- 8765. 2010. 01113.x
Van de Wiel, M. W. J., Boshuizen, H. P. A., & Schmidt, H. G. (2000). Knowledge restructuring in
expertise development: evidence from pathophysiological representations of clinical cases by
students and physicians. European Journal of Cognitive Psychology, 12(3), 323–356. https:// doi.
org/ 10. 1080/ 09541 44005 01145 43
Virtanen, A. (2020). THL - Tilastoraportti 02/2020 Sosiaali- ja terveydenhuollon ammattioikeudet
2010 – 2018. https:// www. julka ri. fi/ bitst ream/ handle/ 10024/ 139099/ Tr02_ 20. pdf? seque nce= 5&
isAll owed=y
Vosniadou, S., & Brewer, W. F. (1992). Mental models of the earth: a study of conceptual change
in childhood. Cognitive Psychology, 24(4), 535–585. https:// doi. org/ 10. 1016/ 0010- 0285(92)
90018-W
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

164
R.Eronen et al.
1 3
Vosniadou, S., & Skopeliti, I. (2014). Conceptual change from the framework theory side of the fence.
Science and Education, 23(7), 1427–1445. https:// doi. org/ 10. 1007/ s11191- 013- 9640-3
Vosniadou, S., Ioannides, C., Dimitrakopoulou, A., & Papademetriou, E. (2001). Designing learning
environments to promote conceptual change in science. Learning and Instruction, 11(4–5), 381–
419. https:// doi. org/ 10. 1016/ S0959- 4752(00) 00038-4
Ward, D. J. (2013). The barriers and motivators to learning infection control in clinical placements: inter-
views with midwifery students. Nurse Education Today, 33(5), 486–491. https:// doi. org/ 10. 1016/j.
nedt. 2012. 05. 024
White, R. T. (1994). Conceptual and conceptional change. Learning and Instruction, 4, 117–121. https://
doi. org/ 10. 1016/ 0959- 4752(94) 90022-1
WHO. (2009). WHO Guidelines on hand hygiene in health care. In World Health Organization (Vol. 30,
Issue 1). World Health Organization Press. https:// apps. who. int/ iris/ bitst ream/ handle/ 10665/ 70126/
WHO_ IER_ PSP_ 2009. 07_ eng. pdf; seque nce=1
WHO. (2016). Health care without avoidable infections: The critical role of infection prevention and con-
trol. World Health Organization. https:// www. who. int/ publi catio ns/i/ item/ health- care- witho ut- avoid
able- infec tions- the- criti cal- role- of- infec tion- preve ntion- and- contr ol
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.
Authors and Aliations
RiikkaEronen1 · LauraHelle1 · TuirePalonen1 · HennyP.A.Boshuizen1,2
* Riikka Eronen
riikka.m.eronen@utu.fi
Laura Helle
laura.helle@utu.fi
Tuire Palonen
tuire.palonen@utu.fi
Henny P. A. Boshuizen
Els.Boshuizen@ou.nl
1 Department ofTeacher Education, University ofTurku, Turku, Finland
2 Open University oftheNetherlands, Faculty ofEducational Sciences, Heerlen, TheNetherlands
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center
GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers
and authorised users (“Users”), for small-scale personal, non-commercial use provided that all
copyright, trade and service marks and other proprietary notices are maintained. By accessing,
sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of
use (“Terms”). For these purposes, Springer Nature considers academic use (by researchers and
students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and
conditions, a relevant site licence or a personal subscription. These Terms will prevail over any
conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription (to
the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of
the Creative Commons license used will apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may
also use these personal data internally within ResearchGate and Springer Nature and as agreed share
it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not otherwise
disclose your personal data outside the ResearchGate or the Springer Nature group of companies
unless we have your permission as detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial
use, it is important to note that Users may not:
use such content for the purpose of providing other users with access on a regular or large scale
basis or as a means to circumvent access control;
use such content where to do so would be considered a criminal or statutory offence in any
jurisdiction, or gives rise to civil liability, or is otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association
unless explicitly agreed to by Springer Nature in writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a
systematic database of Springer Nature journal content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a
product or service that creates revenue, royalties, rent or income from our content or its inclusion as
part of a paid for service or for other commercial gain. Springer Nature journal content cannot be
used for inter-library loans and librarians may not upload Springer Nature journal content on a large
scale into their, or any other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not
obligated to publish any information or content on this website and may remove it or features or
functionality at our sole discretion, at any time with or without notice. Springer Nature may revoke
this licence to you at any time and remove access to any copies of the Springer Nature journal content
which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or
guarantees to Users, either express or implied with respect to the Springer nature journal content and
all parties disclaim and waive any implied warranties or warranties imposed by law, including
merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published
by Springer Nature that may be licensed from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a
regular basis or in any other manner not expressly permitted by these Terms, please contact Springer
Nature at
onlineservice@springernature.com