Knowledge, Attitudes, and Perceptions towards Hand Hygiene Practice Amongst Students at a Nursing College in Lesotho

Abstract

Background: Hands are critical vectors for microorganisms that cause healthcare-associated infections (HAIs). Hand hygiene, being done the right way, at the right time, and being given the right priority in a healthcare setting is an effective strategy to reduce HAIs and associated costs. Different strategies have been put in place to help improve hand hygiene compliance among healthcare workers; amongst them, continuous training is advised at all levels of care. Aim: This study, focusing on nursing students, aimed to describe their knowledge, attitudes, and perceptions towards hand hygiene, highlighting their crucial role in maintaining health and preventing infections. Methods: This study was a quantitative cross-sectional study. One hundred and fourteen questionnaires were distributed; 103 were filled out and returned by willing students at Maluti Adventist College, thus a 90% response rate. Results: 62% (64) demonstrated moderate knowledge, all had positive attitudes, and 61% (63) had a positive perception towards hand hygiene. There was a significant (p-value = 0.012) association between knowledge and training. Conclusions and recommendations: These provide valuable input for enhancing the World Health Organization’s (WHO) hand hygiene multimodal strategy, the SAFE LIFE Clean YOUR HAND campaign, and healthcare workers’ teaching curriculum. All stakeholders should implement strategies that prioritize knowledge dissemination to promote effective hand hygiene practices among healthcare workers worldwide.

1. Introduction

According to the World Health Organization (WHO) Sepsis Global Report [1], of 1000 hospitalized patients, 15 of them develop sepsis; the rate is 7 times higher in hospitalized neonates, with an estimated mortality rate of 20% to 30% globally. The WHO [2] report stipulates that in low- and middle-income countries, among the total number of surgeries done, about one-third of those become infected. Liu et al. [3] reported that in the United States, healthcare-associated infections (HAIs) are the sixth leading cause of death. Apalata et al. [4] reported 4.2% postsurgical infections in Mthatha among neurosurgical patients.

Hand hygiene is one of the infection prevention and control strategies that can reduce 50% of HAIs and reduce healthcare delivery cost by 16% [5,6]. During the COVID-19 pandemic, HAIs significantly reduced; this was associated with increased hand hygiene compliance among the healthcare workers [7]. Knepper et al. [8] study found that hospital-acquired infection rates by Clostridioides difficile decreased after hand hygiene performance was monitored and improved. Boyce et al. [9] found that the incidence of HAIs by other bacteria decreased by 56%, while C. difficile infections increased by 60%. Myatra [10] states that with increasing hand hygiene compliance, central line-associated bloodstream infection (CLABSI) rates decreased significantly from 12.5 to 8.6 per 1000 catheters. With 88% hand hygiene performance, the hospital-wide catheter-associated urinary tract infections, CLABSI, and C. difficile infection ratios decreased by 17.7%, 36.2%, and 16.5%, respectively [11]. At Groote Schuur Hospital, Cape Town, South Africa, the incidence of hospital-acquired infections was low at 0.03%, and the practice of preventative care bundles is thought to be a contributing factor [12].

To promote and influence compliance with hand hygiene and reduce these HAIs, the WHO [13] introduced five moments of hand hygiene. They provide guidance on the right times and the right way to practice hand hygiene through six steps and provide guidance on the best strategies to implement—the WHO multimodal hand hygiene improvement strategy.

Despite guidance being provided by WHO about hand hygiene through set standards and several studies proving its effectiveness, hand hygiene compliance has been a persistent challenge; healthcare workers (HCWs) clean their hands less than half of the time they should [14]. Nurses are taught hand hygiene techniques at college and practice in healthcare settings.

In the Republic of Korea, nursing students hand hygiene knowledge and perceptions were moderate [15]. Turkish students had positive perceptions [16]. In Zanjan teaching hospitals, knowledge was moderate (62%) and attitudes low (12%) [17]. In India, knowledge was moderate in nursing students, and attitudes were higher than attitudes of staff nurses [18]. Knowledge and attitudes were moderate in Cambodia [19]. In South Africa, Northern Cape, students had a pretest percentage score of 52%, and the objective structured clinical assessment (OSCA) score was 96% when they were assessed on knowledge about aseptic hand washing technique [20].

In Lesotho, no studies have explored hand hygiene knowledge, attitudes, and perceptions in nursing schools to identify gaps, inform the existing training curriculum, and promote good hand hygiene practices and work ethics when students are hired. Hence, this study aimed to describe the knowledge, attitudes, and perceptions towards hand hygiene among nursing students.

2. Methods

2.1. Study Design

The study was a descriptive cross-sectional design.

2.2. Study Period

Data were collected in November 2023.

2.3. Study Site

This study was conducted at Maluti Adventist College in Berea district, Lesotho. Maluti Adventist College is a Seventh-day Adventist-owned and operated higher education institution in Lesotho’s Berea District and Mapoteng area. It was founded in 1958 as a nursing school offering certificate and later diploma programs in general nursing. A diploma in midwifery was added in 1971, initially at the certificate level but later at the diploma level.

2.4. Population and Sampling

For this study, the study population was all student nurses in first, second, and third years and student midwives in Maluti Adventist College. The sampling approach employed was convenience sampling, a non-probability sampling. Population size for the first years was 39, second years 26, third years 28, and for the student midwives was 47.

2.5. Sample Size

The sample size (n) of the study population was calculated using Slovins’ formula [21] n = N/(1 + N${\mathrm{e}}^2)$, taking into account the following aspects:

Confidence level as 90%, e = 0.1.

The sample size was 114 students distributed as follows: 31 first years, 23 second years, 24 third years, and 36 student midwives. Response rate was at 90%.

2.6. Criteria

Inclusion criteria included students who were available during the period of data collection and students who signed the consent form to participate in the study.

Exclusion criteria included students not willing to participate in this research.

2.7. Parameters of Interest

Variables measured knowledge since training, why and how HAIs occurred, the role hand hygiene plays, and when and how to perform HH in various situations. Attitude variables included any positive or negative feelings associated with practicing hand hygiene at the appropriate times, as well as whether hand hygiene is considered optional or beneficial; perception variables included perceived benefits of HH and strategies to improve compliance, perceived severity if HH is missed, perceived barriers, and perceived susceptibility of patients.

2.8. Data Management and Analysis Plan

To collect data, questionnaires were adopted and merged [22,23]. The right of each individual to agree or refuse to take part in the study or refrain from participating at any time during the study was expressed. Written informed consent was obtained from participants prior to answering the questionnaire. The questionnaire was in English only as all participants are professionals and was self-administered. For confidentiality, the questionnaire was anonymous; only a unique identifier/code was used during data capture.

Data collected were stored in a secure place under lock and key during the process of collecting and analysis. Filled questionnaires were accessed by the researcher; only completeness checks of data were conducted at the point of questionnaire collection. The data were compiled, entered into Microsoft Excel, cleaned, coded, and summarized using Statistical Package for the Social Sciences (SPSS, Version 22) and Microsoft Excel, and then displayed using tables and bar charts. Normal distribution of data was checked with the Kolmogorov–Smirnov test and visualization of the histogram. Descriptive analyses were conducted, calculating frequencies and proportions for nominal variables (dichotomous and ordinal) and mean. Further analysis explored the association between demographic variables and knowledge, attitudes, and perceptions, considering a p-value ≤ 0.05 to be significant.

2.9. Data Interpretation

Interpretation of results was aligned with the three constructs we measured: knowledge, attitudes, and perceptions as shown in

Table 1. Interpretation of results per scale.

Scale	Interpretation
Hand hygiene knowledge scale	A scoring system was used, with one point given for each correct response to knowledge and 0 for an incorrect answer. A score of more than 75% was considered good, 50–75% moderate, and less than 50% poor [24].
Hand hygiene attitude scale	Attitudes toward hand hygiene was assessed using a seven-point semantic differential scale using seven different descriptors about participants feeling of practicing hand hygiene, the positive attitude was given 1 score, negative attitude 0 score. Attitude total score 50% and above was considered positive and a score below 50% was negative [25].
Hand hygiene perception scale	7-point Likert scale variables were collapsed into three categories, the answers 1, 2 and 3 were summed into one “negative” reply, left 4 as neutral, and collapsed 5, 6 and 7 into one “positive” reply [26]. Four questions were considered for the calculation as they mainly determine the perception of student nurses on hand hygiene. The total score ranged from 0 to 4, which was divided into negative, neutral and positive perceptions [27].

.

The association between demographic variables and knowledge, attitudes, and perceptions was calculated using the chi-squared test (≥5 expected frequencies) and Fisher’s exact tests (<5 expected frequencies). For association, knowledge score was collapsed into two (2) categories: good (good and moderate) and poor categories, attitudes categorized by median (was skewed) percent: <100% and 100%. A p-value less than 0.05 was considered statistically significant [20]. The perception score was collapsed into two (2) categories: negative (negative and neutral) and positive categories.

3. Results

3.1. The Demographics of the Study Participants

The majority of respondents were female, 88%. The age range of the respondents was 18–35 years, a mean age of 23 years, the standard deviation of 3, and 50% of them were between ages 20 and 25 years, with outliers of 33 and 35 years. The respondents were from first year (27%), second year (22%), and third year (19%) in general nursing classes, and 32% were from nursing and midwifery classes. Seventy-five percent (77) had hand hygiene training in the past three years.

3.2. Level of Knowledge about Hand Hygiene

Scores on knowledge ranged from 33% to 95%. About 62% of student nurses have moderate knowledge about hand hygiene, as shown in Figure 1.

Only 22% of student nurses knew the frequent source of germs that cause healthcare-associated infections are germs already present on or within the patient. Only 63% were aware that hands are critical vectors in transmitting healthcare-associated infections’ causal agents between patients.

To prevent patients from getting infected by microorganisms, 95% of students knew that hand hygiene should be done before touching patients, and 79% knew that it should be done immediately before aseptic/clean procedures, though a knowledge deficit was noted, as only 32% and 16% were aware that performing hand hygiene immediately after a risk of body fluid exposure and after touching patient surroundings does not benefit the patient but the healthcare worker, as shown in Figure 2.

Among hand hygiene actions targeted at protecting the healthcare worker, 91% of students were aware that they had to wash their hands after touching the patient, 71% after fluid exposure, 68% after patient surrounding exposure, and only 20% were aware that performing hand hygiene before an aseptic/clean procedure was to protect the patient, not the healthcare worker. This is shown in Figure 3.

Only 56% knew the minimum time needed for alcohol hand rub was 20 s to kill most germs on hands.

Figure 4 shows situations where hand rub and hand wash can be applicable. Knowledge was good (87–100%) to half of the situations; after removing examination gloves, the preferred method is hand rubbing/washing (100%); after visible exposure to blood, the healthcare worker has to perform hand wash (91%); and after emptying the bedpan (87%); for the other situations, knowledge was as low as 9–28%; after making a patient bed (9%), before giving an injection (21%), and before palpation of the abdomen (28%).

Only 32% (33) knew that hand cream does not promote colonization of germs on hands, but knowledge amongst those that promote colonization was good at 77–89%, as shown in Figure 5.

3.3. Attitudes of Student Nurses towards Hand Hygiene

All respondents had positive attitudes, as shown in Figure 6, with a median of 100% towards hand hygiene practice that ranged from 77–100% to every feeling point. All of the students felt practicing hand hygiene was beneficial; 98% felt it was reassuring, soothing (97%), not frustrating (96%), convenient (95%), necessary (92%), and practical (77%). Hand hygiene practicality was questioned by 23% of the respondents.

3.4. Perceptions towards Hand Hygiene among Student Nurses

Figure 7 shows that 61% of student nurses perceive hand hygiene positively.

Table 2. Student nurses’ perceptions (n = 103).

Question	Category	n (%)
In your opinion, what is the percentage of hospitalized patients who will develop a healthcare-associated infection (between 0 and 100%)	0–25%	17 (17)
	26–50%	18 (17)
	51–75%	25 (24)
	76–100%	7 (7)
	I don’t know	36 (35)
In general, what is the impact of a healthcare-associated infection on a patient’s clinical outcome?	Very low	9 (9)
	Low	20 (19)
	High	56 (54)
	Very high	18 (17)
What is the effectiveness of hand hygiene in preventing healthcare-associated infection?	Very low	1 (1)
	Low	12 (12)
	High	42 (41)
	Very high	48 (47)
Among all patient safety issues, how important is hand hygiene at your institution?	Low priority	2 (2)
	Moderate priority	21 (20)
	High priority	28 (27)
	Very high priority	52 (50)

shows the responses to questions on the perception of hand hygiene. Thirty-five percent (36) did not know how susceptible hospitalized patients are to healthcare-associated infections. Fifty-four percent perceived that healthcare-associated infections have a high impact on patient clinical outcomes. Hand hygiene is perceived as very highly effective by 47% of student nurses, and half of them view hand hygiene as very highly prioritized in their institution.

Student nurses (77%, 71%, 85%, 83%, 90%, 53%, and 88%) view leaders support, availability of alcohol-based hand rub, display of hand hygiene posters, trainings, visible clear instructions, feedback, and healthcare workers performing hand hygiene to have high influence in hand hygiene practice sustainability, respectively, and 51% view patients’ involvement to foster compliance to be low, as shown in

Table 3. Actions that can improve hand hygiene practice.

Action	Level	n (%)
Leaders and senior managers at your institution support and openly promote hand hygiene	Low	10 (10)
	Neutral	14 (14)
	High	79 (77)
The health facility makes alcohol-based hand rub always available at each point of care	Low	14 (14)
	Neutral	16 (16)
	High	73 (71)
Hand hygiene posters are displayed at point of care as reminders	Low	8 (8)
	Neutral	7 (7)
	High	88 (85)
Each healthcare worker receives education on hand hygiene	Low	5 (5)
	Neutral	13 (13)
	High	85 (83)
Clear and simple instructions for hand hygiene are made visible for every healthcare worker	Low	4 (4)
	Neutral	6 (6)
	High	93 (90)
Healthcare workers regularly receive feedback on hand hygiene performance	Low	34 (33)
	Neutral	14 (14)
	High	55 (53)
You always perform hand hygiene as recommended (Being a good example for your colleagues)	Low	4 (4)
	Neutral	8 (8)
	High	91 (88)
Patients are invited to remind healthcare workers to perform hand hygiene	Low	53 (51)
	Neutral	9 (8)
	High	41 (40)

.

Eighty-six percent of student nurses reported they perform hand hygiene at 76–100%, but amongst healthcare workers, only 43% perform hand hygiene at 76–100%.

Table 4. Level of importance attached to hand hygiene performance in healthcare settings.

Question	Level	n (%)
What importance does the head of your department attach to the fact that you perform optimal hand hygiene	Low	19 (18)
	Neutral	20 (19)
	High	64 (62)
What importance do your colleagues attach to the fact that you perform hand hygiene	Low	15 (15)
	Neutral	15 (15)
	High	73 (71)
What importance do patients attach to the fact that you perform optimal hand hygiene	Low	36 (35)
	Neutral	15 (15)
	High	52 (50)
How do you consider the effort required by you to perform good hand hygiene when caring for patients?	Low	9 (9)
	Neutral	7 (7)
	High	87 (84)

shows that hand hygiene performance of student nurses was of high importance to head of department (62%), colleagues (71%), and patients (50%). Eighty-four percent of student nurses agree that hand hygiene performance requires a large effort.

The association of variables is shown in

Table 5. Association of demographic variables and knowledge (n = 103).

Demographic Variables	N (%)	Poor Knowledge n (%)	Good (Good + Moderate) Knowledge n (%)	p-Values
Gender
Female	91 (88)	27 (30)	64 (70)	0.179
Male	12 (12)	1 (8)	11 (91)
Age (years)
Below 20	18 (17)	7 (39)	11 (61)	0.449
20–24	59 (56)	14 (24)	45 (76)
Above 24	26 (26)	7 (27)	19 (73)
Class level
1	28 (27)	12 (43)	16 (57)	0.061
2	23 (22)	7 (30)	16 (70)
3	19 (18)	5 (26)	14 (74)
4	33 (32)	4 (12)	29 (88)
Training
No	26 (25)	12 (46)	14 (54)	* 0.012
Yes	77 (75)	16 (21)	61 (79)

* Statistically significant (p-value = 0.05).

. A significant difference was established in a group trained in the last three years, at p-value 0.012. There was a difference in class-level knowledge, though not statistically proven; it was at 0.061. There was no difference in knowledge among different age groups and genders, at 0.449 and 0.179, respectively.

There was no statistical difference in attitudes; all students, despite their gender, age, class level, and recency of training, had the same feeling about hand hygiene at 1.225, 0.582, 0.911, and 0.937, respectively, as shown in

Table 6. Association of demographic variables and attitudes.

Demographic Variables		N (%)	Poor Attitude n (%)	Good Attitude n (%)	p-Value
Gender	F	91 (88)	31 (34)	60 (66)	1.225
	M	12 (12)	4 (33)	8 (67)
Age	Below 20	18 (17)	8 (44)	10 (56)	0.582
	20–24	59 (56)	19 (32)	40 (68)
	Above 24	26 (26)	8 (31)	18 (69)
Class level	1	28 (27)	11 (39)	17 (61)	0.911
	2	23 (22)	7 (30)	16 (70)
	3	19 (18)	6 (32)	13 (68)
	4	33 (32)	11 (33)	22 (67)
Training	No	26 (25)	9 (35)	17 (65)	0.937
	Yes	77 (75)	26 (34)	51 (66)

.

The difference between the respondents’ demographics and perceptions towards hand hygiene was not significant at p-values 0.677 for gender, 0.133 for age, 0.072 for class level, and 0.329 for training, as shown in

Table 7. Association of demographic variables and perceptions (n = 103).

Demographic Variables		N (%)	Negative (Negative + Neutral) Perception n (%)	Positive Perception n (%)	p-Value
Gender	F	91 (88)	36 (40)	55 (60)	0.677
	M	12 (12)	4 (33)	8 (67)
Age	Below 20	18 (17)	4 (22)	14 (78)	0.133
	20–24	59 (56)	22 (38)	36 (62)
	Above 24	26 (26)	14 (52)	13 (48)
Class level	1	28 (27)	6 (21)	22 (79)	0.072
	2	23 (22)	12 (52)	11 (48)
	3	29 (18)	6 (32)	13 (68)
	4	33 (32)	16 (48)	17 (52)
Training	No	26 (25)	8 (31)	18 (69)	0.329
	Yes	77 (75)	32 (42)	45 (58)

.

4. Discussion

All students had already started their practical in the clinical and communities, and the majority of them were trained in hand hygiene; this is the same as other studies [19,28], but about a quarter of them did not recall having trained in hand hygiene in the past three years; 88% of them were first-year students. This may mean that hand hygiene training was not yet prioritized as a preventative strategy before starting their practice, less of a recall bias as these students were recently enrolled in the nursing program.

4.1. Knowledge

More students (61%) had moderate knowledge about hand hygiene, which similar studies have also shown [15,17,28,29].

Only 63% of the students knew that hands play a critical role in transmitting microorganisms, which was found in Mutanekelwa et al. [28]. The proportion was even lower in the study by Mehta et al. [18] This gap in knowledge shows that the reasons behind hand hygiene reinforcement were not really understood, and this can affect the prioritization of hand hygiene as a strategy to reduce healthcare associated infections.

Only 22% of respondents knew the frequent source of germs that cause HAIs; this was as low as in other studies [18,28]. This can affect compliance with not only hand hygiene but even with other infection prevention and control strategies aimed at reducing patient-to-patient and healthcare worker transmission of germs.

This study found discrepancies in knowing who benefits when following hand hygiene moments; almost all (95%) students knew that hand hygiene should be done before touching patients, and 79% knew that HH should be done immediately before the aseptic/clean procedure to protect a patient from acquiring HAIs; similarly other studies [18,28], Huge knowledge deficit was noted, as only 32% and 16% were aware that performing hand hygiene immediately after a risk of body fluids exposure and after touching patient surrounding respectively, does not benefit the patient but the healthcare worker, this percentages were lower than in a study conducted in Zambia by Mutanekelwa et al. [28], they found knowledge at 81.9% and 54.6% respectively, while Mehta et al. [18] found knowledge at 75% and 30%. This knowledge deficit may affect targeted hand hygiene performance, though knowing too still can. Healthcare workers may perform hand hygiene only when it benefits them, after procedures [30,31].

Knowledge on choosing the right method (hand rubbing vs. hand washing) for the right opportunity was as low as 9% to 28% to half of the opportunities. The HH opportunity and method correctly matched were after removing examination gloves and hand rubbing/washing (100%), after visible exposure to blood and hand wash (91%); and after emptying the bedpan (87%). This high-level knowledge concurs with Mutanekelwa et al. [28], though the difference was observed in another study [18]. Knowing the right method and the right time for the right procedure is necessary to improve effectiveness in killing microorganisms and can help improve compliance.

Around half (42%) of students did not know that the minimum time for hand hygiene is 20 s; the proportion was even lower in Mehta et al. [18] When the duration is known and adhered to, it can improve effectiveness in killing microorganisms, save time, and improve compliance when less time is wasted, thereby improving quality of care [18,32].

Many students knew that there are practices that promote microorganisms’ colonization, like artificial fingernails, damaged skin, and jewelry. Though the poorly performed question was on regular use of hand cream at 32%, other studies concur with the findings [18,28]. This is good because knowing may influence avoidance of such practices, even in this era, where wearing jewelry and artificial nails/nail paint/gel and keeping nails long is currently fashionable.

4.2. Attitudes

Students felt that hand hygiene is beneficial, reassuring, soothing, not frustrating, convenient, necessary, and, lastly, practical above all feelings.

All students, despite their knowledge level, had a good attitude towards hand hygiene as a skill to be practiced in the healthcare setting, with most of them having all positive feelings (100%) towards it, though Tem et al. [19] found rather a moderate attitude that did not influence performance, while Javadpoor et al. [17] found an attitude score as low as 12%. Though the attitude was good, students worry about the practicality of hand hygiene. Performing hand hygiene in-between every patient service was not practical; this concurs with previous studies that found hand hygiene was missed during emergencies and during work overload [33]. A positive attitude influences performance and eagerness to learn more about hand hygiene.

4.3. Perceptions

Most students perceived patients are at 0–75% susceptible to acquiring healthcare-associated infections, while the perceived rate in another study was 51.43% [28]. These students over-estimated the WHO reported percentage of 0–15%. About a quarter of students did not have an idea of the perceived susceptibility of patients; these can affect hand hygiene performance and the drive to protect the vulnerable.

The majority of students (84%) feel the effort to perform HH is high. Though Mutanekelwa et al. [28] found only 58.1% agreeing to this, this may negatively affect compliance with HH practice.

There was a high perception that if patients develop healthcare-associated infections, these infections can really affect their prognosis and health outcomes, and hand hygiene can really play a role in preventing them. They feel it is given the right priority in their institution.

Student nurses believe they perform hand hygiene better than healthcare workers do; they believe they perform hand hygiene at 76–100% rate; this is rather the same with the study by Maria et al. [29] that found the self-reported hand hygiene performance among student nurses at 86.17%. Some students could not even estimate healthcare workers’ hand hygiene performance, which leads to questioning healthcare worker role modeling and supporting student nurses in performing hand hygiene during preceptorship.

Results of this study concur with WHO multimodal strategies aimed at improving hand hygiene compliance. The majority of students believe that leaders’ involvement, availability of necessary equipment like alcohol-based hand rub, display of reminders like posters and standard operating procedures, regularly conducting hand hygiene training, and healthcare workers performing hand hygiene can really help in fostering hand hygiene compliance, even though they less regard role modeling and patients’ involvement.

Between 52% and 84% of students attached being valued by colleagues, heads of departments, and patients when they perform hand hygiene as of high importance, their support can help promote compliance in healthcare settings.

This study found statistically significant association between hand hygiene knowledge and hand hygiene training, it concurs with Mutanekelwa et al. [28], though Tem et al. [19] did not find any significance between the groups. This proves that trainings, as one of the multimodal strategies to improve hand hygiene compliance, was effective in reducing the knowledge gap. When knowledge is improved, the intent to perform hand hygiene will improve, and likewise performance. There was no association found in this study in other demographic variables, though another study found an association (p = 0.015) in perceptions about the anticipated prevalence of hospital-acquired infections among hospitalized patients [28] and Zimmerman et al. [34] found a significant difference in year level and age. Knowledge level did not influence attitudes and perceptions, as they were good in all groups; this helps direct our focus to knowledge so that when they are all good, they can fuel the desire to perform hand hygiene.

5. Recommendations

There is a need for targeted interventions that address knowledge and training gaps, with a focus on critical points to foster hand hygiene compliance.

Resources can be targeted at creating awareness through frequent healthcare workers trainings, setting up reminders, and conducting campaigns, thereby reinforcing the importance of continuous education and training to promote effective hand hygiene practices and mitigate the spread of healthcare-associated infections.

Educational stakeholders to implement strategies that prioritize hand hygiene knowledge dissemination.

A review of nursing curriculum is needed to incorporate hand hygiene education as one of the first and basic trainings to be initiated before students start their practical; this will help establish infection prevention and control and hand hygiene culture early.

There is a need for further research that randomizes nursing students from all the nursing colleges.

6. Limitations

The cross-sectional design used was limited in establishing causality and affirming associated factors, and the change in variables over time cannot be measured.

Questionnaires were self-administered, which usually results in a low response rate. To address this, nurse educators were involved to make sure that the respondents understood the purpose of the study before they filed out the questionnaires.

The study was conducted during examinations, so the questionnaires were distributed and the participants were asked to fill them out at their convenience. This might have affected the quality of the data, as the participants might have sought unknown responses from each other or the Internet.

A bigger sample size, with nursing students from other nursing colleges, would have improved the reliability of the results.

The study was conducted in one nursing college; this limits the generalizability of findings to question the national teaching curriculum.

7. Conclusions

This study provides insight on knowledge, attitudes, and perceptions of hand hygiene. There was moderate knowledge and positive attitudes and perceptions among student nurses, with a significant difference in knowledge and hand hygiene training. These findings can be used as a mirror to see gaps and devise strategies to fill them during training sessions.