INTRODUCTION
Today, many people can expect to live longer than ever before. The World Health Organization projects that by 2030, one out of every six people globally will be aged 60 years or older [1]. South Korea in particular is witnessing a considerable increase in population aging. Currently, individuals aged 65 and older constitute 18.2% of the population in South Korea, with projections indicating that the country will transition into a super-aged society by 2025 [2]. This demographic shift has led to a surge in demand for nursing homes (NHs), with the number of NHs in South Korea reaching 4,346 in 2022, a 226% increase from 1,332 in 2008 [3].
Residents in NHs experience a variety of physical declines and frailties that require the assistance of healthcare professionals in their daily lives [4]. However, due to crowding and sharing of spaces, NHs have high transmission rates of infectious diseases, such as pneumonia [5]. Particularly after the recent COVID-19 pandemic, these infections have significantly threatened residents’ health and led to hospitalization and death [6].
Among NH residents, antibiotic treatment is frequently required for infectious diseases, particularly urinary tract infections (UTIs) and respiratory infections [7,8]. These infections can be life-threatening for older adults, with pneumonia and UTIs representing significant causes of mortality. In addition to these health challenges, infections contribute to increased costs for families and society [9]. Treatment and prevention efforts escalate healthcare expenses, whereas the deterioration of residents’ health imposes additional social and economic burdens.
Moreover, healthcare professionals in NHs, while crucial for implementing infection control measures for residents, can also act as vectors for disease transmission. Therefore, for infection prevention, it is essential to have well-trained experts who understand infection control principles and apply them in various situations [10]. Because improving the competence of professionals in infection control is positively related to their attitude toward caring for residents [11], educating and training NH staff in this area of care is essential.
However, NHs often face challenges in infection control due to a shortage of on-site staff providing direct care. This shortage makes it difficult to maintain proper hygiene practices and implement infection prevention measures. Additionally, the absence of standardized guidelines and the limited capacity for early infection response further complicate infection management [9,12].
A thorough understanding of the diverse environments of NHs is also necessary for infection control education and/or training of healthcare professionals. Worldwide, NHs have various models of care, with some having no trained healthcare professionals on staff and others having physicians on call 24/7 [13]. Consequently, a one-size-fits-all approach to infection control education or training is inadequate; a flexible, practical framework that can be adapted to different NH environments is needed [14].
For professional infection control education in the NH setting, a comprehensive understanding derived from both quantitative and qualitative data that can be applied in practice is deemed paramount. Therefore, a single research method is not sufficient; hence, mixed-methods research is needed to overcome the limitations of single-method approaches and to understand multifaceted factors [15]. The research question for this study is: “What is an infection control education framework adaptable to diverse NH environments through mixed-methods research?” Accordingly, this study aimed to develop a systematic educational framework utilizing a mixed-methods approach to enhance infection control education for NH personnel. The framework was designed to address the real-world demands of infection control through qualitative research and to assess its practicality and applicability using quantitative data. Ultimately, this study seeks to propose a practical and effective educational framework to improve the quality of infection control training and to support the capacity building of healthcare professionals in NHs.
METHODS
Ethic statement: This study was approved by the Institutional Review Board (IRB) of Korea University (IRB No. KUIRB-2020-0169-01). Participants received a thorough and detailed explanation of the study’s objectives and content. Informed consent was obtained from the participants.
1. Study Design
This study developed a framework through an exploratory sequential design using a mixed-methods approach (Figure 1). Mixed-methods research is a valuable approach as it combines the strengths of qualitative and quantitative methods while mitigating their respective limitations [16]. It enables researchers to uncover unexpected findings and obtain rich data by exploring diverse perspectives and methodologies. Multi-strategy research offers insights that might not have been anticipated [17], thereby enriching the research outcomes and providing a deeper understanding of the problem compared to single-method approaches [18].
By utilizing this approach, researchers can explain complex phenomena from multiple perspectives, offering a comprehensive understanding of the subject matter. NHs are inherently complex environments, involving various stakeholders—nurses, physical therapists, social workers, and caregivers—working collaboratively to address the multifaceted needs of residents. These needs include managing illnesses, handling emergencies, assisting with physical activities of daily living, and addressing psychological and emotional demands. To effectively understand and address this complexity, a mixed-methods approach was adopted for this study. The exploratory sequential design employed in this study was particularly advantageous, as it allowed for the development of a tool based on qualitative findings, which was then followed by a quantitative phase to derive results grounded in participants’ actual experiences [15,19]. Specifically, insights from the qualitative phase, including interviews, were directly incorporated into the questionnaire items for the quantitative phase of the Delphi survey.
1) Qualitative Study: Interviews
(1) Participants
The interviews aimed to explore the perspectives of experts on the provision of infection control training to practitioners. Therefore, the selection criterion for the participants was current employment as a nurse or physician specializing in infection control; four nurses and one physician specializing in infection control participated in this study. Their mean age was 45.20±14.34 years, and their career length in practice was 12.85±12.80 years. Regarding their education level, one participant had completed a bachelor’s degree, three had a master’s degree, and one had a doctoral degree .
(2) Data collection
The interviews were conducted over the phone or in person from July to August 2020 using a semi-structured questionnaire. The interviews ranged from 60 to 90 minutes in duration, and the first author took field notes. The initial interview questions were open-ended and included queries such as: “What do you think infection control training should be for practitioners?” and “What do you think should be included in up-to-date infection control training for practitioners?” If any questions arose during the interviews, the researchers sought additional clarification from the participants [20]. The targeted questions were formulated according to an adapted agent-based model (e.g., “What infection control training is required for practitioners given the health status, age, and other characteristics of older adults?”).
(3) Data analysis
The interview data were analyzed by conventional content analysis, an inductive approach to developing categories [20]. This method is suitable for analyzing the data in this study because the purpose of the inquiry was to describe the phenomenon without using pre-recognized categories. The researcher thoroughly reviewed the data multiple times to understand their overall meaning, focusing particularly on meaningful words, phrases, and sentences to generate codes. These initial codes were subsequently labeled, followed by the creation of groups composed of related codes by comparing their similarities and differences. These groups were further organized into categories and subcategories. The researchers then defined the generated codes, subcategories, and categories, while also assessing the relevance of the subcategories and categories [20].
(4) Trustworthiness
We ensured the trustworthiness of our study by following the four criteria outlined by Lincoln and Guba [21]: credibility, dependability, confirmability, and transferability. Credibility was established through member checking, where researchers collaborated to constantly review and verify interview results. To achieve dependability, we enlisted the assistance of a professor with extensive experience in qualitative research to conduct an audit trail. Confirmability was ensured by maintaining field notes and the researchers engaging in extensive discussions to achieve consensus. Lastly, we assured transferability by conducting interviews until theoretical saturation was reached. Additionally, we employed the Consolidated Criteria for Reporting Qualitative Research checklist [22] to verify the reliability of our data.
2) Quantitative Research: Delphi Survey
(1) Participants
Quantitative research involves the collection of numerical data (e.g., scores, ratios, frequencies), statistical analysis to derive objective and generalizable results, and the design of research processes using standardized procedures and structures. This approach ensures that repeated studies are likely to produce consistent or reproducible results. The Delphi survey exemplifies these characteristics of quantitative research. Using quantified data, such as mean scores, levels of agreement, and the content validity ratio (CVR), Delphi surveys evaluate expert opinions quantitatively and measure the level of consensus. Furthermore, as demonstrated in this study, qualitative data collected through initial interviews can inform the design of quantitative questionnaires for subsequent Delphi rounds [23].
Each round of the Delphi process involves iterative reviews by multiple experts to reach a consensus, thereby enhancing the validity and reliability of the research findings. Responses from each round are statistically summarized, and the consistency of expert opinions and trends over time can be quantitatively analyzed. This iterative process makes the Delphi survey particularly well-suited for quantitative research.
A Delphi survey was employed to obtain expert validity and reliability and to reach a consensus concerning the content required to provide infection control training to practitioners caring for older adults in NHs. Therefore, an expert should be present as a panelist [23]. We used the definition of “expert” proposed by Mauksch et al. [24]: “external cues based on years of experience.” The “years of experience” aspect is well documented, easy to verify, and less subjective than information on peer nomination, making it factual and clear [24]. The number of experts in a Delphi survey should be between 15 and 30 [25]; in this study, 20 professionals with at least 3 years of experience in NHs participated in the Delphi survey (Table 1).
(2) Data collection
The Delphi survey was conducted thrice, at an interval of 2 weeks between the rounds, from August to October 2020. In the first round, the respondents were instructed to rate the feasibility and importance of each item on a 5-point Likert scale (1, not at all important or disagree, to 5, very important or totally agree). In the second round, the participants were provided with the results of the mean, standard deviation (SD), interquartile range (IQR), and CVR for each item in the first survey and instructed to rate the items again. This step allowed them to compare their opinions on the previous round with those of the other panelists. In the third round, the participants were instructed to review the detailed items from the second round, modify them if necessary, and rate them while comparing their opinions with those of others from the previous round. Items with additional panelist comments were revised to reflect the minority opinion.
(3) Data analysis
We estimated the average (mean), SD, proportion of agreement, IQR, and CVR for each round of survey items using the following equation: [CVR=ne–(N/2)]/(N/2) (ne=number of panelists indicating an item score of ≥4, N=total number of panelists) [25]. The CVR of ≥0.42 obtained in this study indicated good content validity [26].
3) Interpretation: Framework
Step 3 aimed to develop an educational framework for infection control among NH practitioners. This step is organically connected to Steps 1 and 2. The results of Step 1 of the interview analysis were converted into Delphi survey items, and the results of the three rounds of the Delphi survey were presented as a framework.
RESULTS
1. Qualitative Study: Interviews
We extracted three main categories from the interviews: (1) recipient-centered, (2) interaction-centered, and (3) environment-centered categories.
1) Category 1: Recipient-Centered
The participants emphasized that infection control training must focus on understanding the target audience because any infection control action will involve them.
(1) Accepting health characteristics
According to the participants, practitioners caring for older adults should understand their health characteristics and base their infection control activities on this understanding: “A lot of older people have cognitive impairment or have difficulty communicating, so it’s hard to determine the symptoms of an infection through communication. I try to keep that in mind when I am managing them. I am like, ‘This person can’t express his symptoms very well, so I will focus on his nonverbal signs,’ and that is what I do.” (P2)
(2) Taking one more step toward better health conditions
The participants discussed the challenges of treating infections in older adults and suggested that practitioners should focus on patients feeling better today than they did the previous day: “The treatment of infections in older adults is a sluggish process. They will be hospitalized for a UTI, then they’ll get pneumonia, then they’ll be cured, then they will be discharged, then they’ll be hospitalized for another infection, then they’ll repeat the process, and then they’ll die. However, even if it is a small improvement from yesterday, it is good.” (P1)
(3) Responding sensitively to nonvisual and nonnumerical information
The participants noted the need for healthcare professionals to be sensitive to hidden infection symptoms in older adults: “Although fever is the most prominent infection symptom, older adults may have infections without fever. So, it is difficult to confirm an infection with only a thermometer. It is also important to look at the non-quantitative symptoms of infection, for example, looking at food intake and caring for mental changes.” (P2)
2) Category 2: Interaction-Centered
The participants reported that caregiving activities and communication between practitioners were important for infection control.
(1) Becoming each other’s observers and encouragers
The participants stated that it was vital for practitioners to communicate, in particular, to give and receive feedback on whether they were doing well in infection control: “I once gathered all the doctors and nurses in the nursing hospital and trained them. However, they said there were so many things they did not know when they were educated. ‘Will they be able to practice the contents of this infection control that I teach today in their field?’ I have a question about that. We need to give each other feedback on whether we are doing well.” (P4)
(2) Sticking to the infection control principles
The participants thought it was important to fundamentally understand and manage various infection routes: “We have so many droplet contact cases. Depending on the propagation path, that seems to be the most basic infection control target.” (P1)
(3) The search for solutions: As challenging as a game of hide and seek
The participants emphasized the necessity for specialized training that focused on identifying solutions while expressing concerns about the complexities involved in the infection control process for older adults: “Many dementia residents in NHs do not experience dramatic improvements in health outcomes when they develop pneumonia or UTIs. The problem is that the infection treatment process is complicated. Symptoms do not improve quickly, and finding suitable antibiotics is difficult.” (P1)
3) Category 3: Environment-Centered
The participants noted that managing the environment surrounding the residents was essential for infection control.
(1) Creating an environment safe from invisible germs
The participants emphasized the importance of preventing infection through a clean environment: “We need to work on prevention... many of them are very weak, so even if the germs are gone, it is hard for them to return to normal after treatment like younger people... The germs were gone during the hospitalization due to antibiotic treatment, but the process usually was not well managed.” (P3)
(2) Facilitating systemic support
The participants noted the need to provide adequate resources to practitioners for facilitating infection control activities: “I have researched how many alcohol wipes are used in NHs. I realized that there was a considerable disparity between NHs and looked at whether staff were supported to use as many alcohol wipes as needed. I found that, in some cases, the support for alcohol wipes was not enough for their proper use in NHs.” (P2)
(3) Facilitating human resources
The participants emphasized that human resources were also a critical component of infection control, stating that a lack of human resources increased caregivers’ workloads and resulted in them being distracted from infection control: “In the end, the most difficult thing for running NHs is that they do not have enough nursing staff, and even if they have practitioners, they can be a source of transmission if they are not properly trained in infection control.” (P5)
2. Quantitative Research: Delphi Survey
Twenty panelists participated in the Delphi survey. Of them, 19 completed the second and third rounds. One panelist dropped out of the study for personal reasons. In the first Delphi survey, the experts evaluated the suitability and importance of the items for NH infection control training. The CVR was >0.42 for each item. However, several panelists noted that “facilitation for systemic support and human resources” should not be an area for practitioner training but rather a domain requiring managerial expertise. Consequently, in the second round of the Delphi survey, we eliminated the topic “facilitation for systemic support and human resources” (items 9 and 10) owing to its low CVR. The third Delphi survey was an amended version of the second and was duly carried out. The results of the Delphi survey are shown in Figure 2 and Table 2. Based on the findings, items 1 through 8 were identified as suitable topics for infection control education for practitioners in NHs.
3. Interpretation: Framework
The framework was combined with successive outcomes in a step-by-step manner to create categories. Figure 3 displays the framework-creation process involving the interviews and the Delphi survey. The framework was composed of three distinct categories. The first category focused on recipients and included items such as characteristics of residents’ health, detection of subtle changes, and identification of nonverbal signs. The second category was centered on interactions, encompassing “effective communication among professionals, feedback and assessment among professionals, following infection control principles, and education based on problem-solving.” The third category was oriented toward the environment and featured “immunization and isolation to create a safe environment.”
DISCUSSION
Until recently, educating healthcare professionals about infection control in NH has been challenging due to the inherent complexity of health systems. These challenges stem from multiple interconnected factors that cannot be addressed using a single solution [27]. To fully address infection control in NHs, an integrated framework that considers residents’ health conditions, their communal living, and competencies of healthcare professionals is necessary [28]. This study introduces an infection control education framework integrating three key elements—recipient-, interaction-, and environment-centered—to enhance training effectiveness. Unlike previous studies, a holistic approach combining individual health characteristics, communication strategies, and environmental modifications ensures a more comprehensive and applicable infection control education across NH settings.
This study concluded that infection control training for NH practitioners should be recipient-centered, with the participants specifically identifying and understanding the health characteristics of NH residents and identifying the nonverbal symptoms of residents. It is important for practitioners to identify subtle changes in residents’ health [29]; however, there is a lack of awareness regarding the importance of these changes [30]. Infections in older adults may present with atypical symptoms, which can hinder early recognition of the infection [31]. Therefore, training should include education on atypical infection symptoms and clinical assessment skill development. This would enable NH practitioners to distinguish between normal aging processes and early indicators of infection, thereby improving timely intervention. To achieve this, case studies and simulation-based training could effectively enhance patient assessment skills and improve early detection capabilities [32].
Another essential component of infection control education is improving interaction-centered knowledge and skills to mitigate infection risks [33]. To enhance effective communication, training on standardized tools such as Situation-Background-Assessment-Recommendation (SBAR) and the organization of regular case conferences for staff can be beneficial [34]. In this process, the application of problem-based learning can be useful in enhancing critical thinking and improving practical response strategies among healthcare professionals [10].
The NH environment plays a crucial role in infection control, necessitating the inclusion of standard precautions, environmental hygiene, proper donning of personal protective equipment, hand hygiene, and infection prevention strategies in educational programs. Effective infection control measures require adequate infrastructure, including sufficient isolation areas, appropriately equipped hand hygiene facilities, and strategies to prevent overcrowding, all of which are essential for minimizing infection transmission [35]. However, NHs face challenges such as the lack of isolation rooms, waiting areas, and showers [35]. Houghton et al. [36] emphasized that essential practical measures in NHs included minimizing overcrowding, rapidly tracing infected residents, limiting visitors, and providing uncomplicated access to handwashing facilities. This implies that the educational curriculum should include aspects of facility management and architectural considerations. Given these infrastructural challenges, policy-level interventions should be considered to ensure infection control facility improvements in NHs. In addition, financial incentives or governmental support should be considered to encourage NHs to invest in infection-resistant architectural designs.
Moreover, the availability of qualified human resources is a critical factor in maintaining effective infection control. Although registered nurses and certified nursing assistants are integral to NH care, there is a growing global trend in the employment of unlicensed staff who provide direct resident care [37]. Given the increasing complexity of care needs in NHs, it is imperative that caregivers acquire the necessary competencies, including relevant clinical skills, theoretical knowledge, and practical expertise, to ensure optimal infection prevention and management. Previous studies underscore the critical role of staff retention in infection rates [38], as high turnover negatively impacts infection control efforts. To address this, educational programs should cover topics related to workplace stress management and professional resilience training, particularly considering the increased strain on NH staff during the COVID-19 pandemic [39].
Owing to the complexity of these systemic, human, and environmental factors, infection control in NHs necessitates further multidisciplinary studies involving fields such as medicine, architecture, and psychology. Furthermore, an interventional study, such as an randomized controlled trial or longitudinal research, should be conducted to validate the empirical effectiveness of infection control measures.
This study has some limitations. We cannot rule out the possibility of selection bias owing to the purposive sampling of the interviewees. However, to mitigate this issue, experts with appropriate experience in infection control were recruited for the interviews to ensure the collection of reliable qualitative data. Additionally, the number of facilities and practitioners who participated in the study was relatively small. Despite this, an appropriate number of participants were secured based on theoretical justifications, even under the intensified COVID-19 prevention measures. The sampling strategy for the Delphi survey was specifically designed to include diverse professional groups working in NHs, such as nurses, physical therapists, social workers, and caregivers, to capture the unique perspectives and experiences of each group. Furthermore, the Delphi survey was conducted anonymously and via mail, which helped overcome data collection constraints imposed by COVID-19 prevention measures and ensured data collection aligned with the study’s objectives. This was possible because the Delphi survey was anonymous and conducted by mail.
CONCLUSION
Effective infection control in NHs requires a seamless integration of research evidence and clinical practice to ensure that evidence-based strategies lead to measurable improvements in infection prevention. The framework developed in this study requires rigorous validation through intervention-based research to assess its real-world effectiveness and guide its implementation in diverse NH settings. A collaborative approach among researchers, healthcare professionals, and policymakers is crucial to refining infection control measures and facilitating their systematic implementation.
Continuous professional education should incorporate the latest research findings, integrating updated knowledge into infection control training programs and clinical protocols. Moreover, a multidisciplinary approach involving medicine, nursing, psychology, and architecture provides a comprehensive foundation for effective infection prevention strategies. Institutional policies must be structured to support the practical application of research-driven interventions, ensuring sufficient resource allocation and regular updates of infection control guidelines in response to emerging evidence. This includes establishing standardized infection control protocols, strengthening interdisciplinary training programs, and implementing policy-driven improvements in NH infrastructure and staffing.
To enhance real-world applicability, future research should focus on piloting and evaluating this framework in multiple NH environments, identifying best practices for optimizing its adoption. Strengthening the synergy between research and clinical practice will enable a more structured advancement of infection control measures, ultimately reducing infection rates and enhancing patient safety and care quality care in NHs.Table 2.
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