Dirt and disgust as key drivers in nurses' infection control behaviours: an interpretative, qualitative study

The combined application of hand hygiene and non-sterile gloves by nurses in a tertiary hospital: a multi methods study

BACKGROUND

The application of hand hygiene (HH) and the use of non-sterile gloves (NSG) in daily care is highly intertwined. We aimed (1) to assess the combined application of HH and NSG among nurses and (2) to explore determinants that influence their ability to combine both measures in their care.

METHODS

In a multi-methods study, we combined direct observations of care episodes with semi-structured interviews with nurses in two affiliated university hospitals. Topics were based on Flottorp's checklist of determinants of practice.

RESULTS

In total, we observed 205 care episodes and interviewed 10 nurses. Observations revealed that the combination of NSG and HH was correctly applied in 19% of care episodes in which a single procedure was executed, and in 2% of care episodes in which multiple procedures were performed. From the interviews, we found determinants that influenced compliance, covered mainly by three out of seven of Flottorp's checklist domains. Nurses indicated that their knowledge of protocols was limited to HH and protocols were hardly ever actively consulted; visual reminders within their workplace were used as sources of information. Nurses' behavior was primarily influenced by their ability to operationalize this information and their ability to integrate both infection prevention measures into their care. The intention to apply and combine HH and NSG use was influenced by their risk assessment of cross-contamination, by the urge to self-protect and gut feeling. The feasibility to execute HH and NSG protocols is influenced by the urgency and the complexity of the care episode.

CONCLUSIONS

The combined correct application with HH and NSG measures by nurses is low. Nurses are instructed in a fragmented way while in the day to day care HH and NSG use are highly intertwined. Operationalization and simplification of infection prevention protocols, in which instructions on both infection prevention measures are fused, should be considered. Strategies to improve practice should consider the power of habit and nurses urge to self-protect.

"Untold and unexpected clinical practice stress," nursing students' experience of disgust: A phenomenological approach

BACKGROUND

In the clinical learning environment, nursing students often face situations that cause physical disgust. Previous studies have shown that more than half of the students experienced disgust, and that high disgust sensitivity in students was related to negative results in terms of academic and caring behavior.

OBJECTIVES

This study aims to understand the experience of disgust felt by nursing students in a clinical learning environment.

DESIGN

A qualitative study using phenomenological method.

METHODS

In-depth, one-on-one interviews were conducted with 18 nursing students at a university in South Korea. The data obtained through the interviews were used to explore the essential structure and meaning of disgust using phenomenological analysis.

RESULTS

This study derived four categories, nine theme clusters, and twenty-one themes. The four categories were "fear that stimulates the senses," "untold and unexpected clinical practice stress," "ambivalence towards myself and patients," and "struggling to become a nursing professional."

CONCLUSIONS

Nurse educators must be aware that nursing students may feel disgust in clinical settings and are therefore under stress. They must also assist students so that their concerns caused by emotions that they cannot easily reveal do not affect their nursing careers.

Nurses' assessed self-efficacy levels to medical asepsis and their relation to structural empowerment, work engagement and work-related stress

BACKGROUND

Nurses' working conditions are important for their well-being at work and for their ability to provide patients with safe care. Self-efficacy can influence employees' behaviour at work. Therefore, it is valuable to study self-efficacy levels to medical asepsis in relation to working conditions.

OBJECTIVE

To investigate the relationship between nurses' assessed self-efficacy levels to medical asepsis in care situations and structural empowerment, work engagement and work-related stress.

METHODS

A cross-sectional study with a correlational design was conducted. A total of 417 registered nurses and licensed practical nurses at surgical and orthopaedic units responded to a questionnaire containing: the Infection Prevention Appraisal Scale, the Conditions of Work Effectiveness Questionnaire-II, the Utrecht Work Engagement Scale-9 and the Health & Safety Executive Management Standards Indicator Tool. Correlational analyses and group comparisons were performed.

RESULTS

The nurses rated high levels of self-efficacy to medical asepsis in care situations. The correlational analyses revealed that correlation coefficients between structural empowerment, work engagement, work-related stress and self-efficacy to medical asepsis were 0.254-0.268. Significant differences in self-efficacy were found in the grouped working conditions.

CONCLUSIONS

This study revealed that nurses rated high self-efficacy levels to medical asepsis and, to some extent, this seemed related to structural empowerment, work engagement and work-related stress. This valuable knowledge could enable improvements at the managerial and organisational levels, benefiting both nurses and patients in the long run.

Healthcare worker mental models of patient care tasks in the context of infection prevention and control

OBJECTIVE

Understanding the cognitive determinants of healthcare worker (HCW) behavior is important for improving the use of infection prevention and control (IPC) practices. Given a patient requiring only standard precautions, we examined the dimensions along which different populations of HCWs cognitively organize patient care tasks (ie, their mental models).

DESIGN

HCWs read a description of a patient and then rated the similarities of 25 patient care tasks from an infection prevention perspective. Using multidimensional scaling, we identified the dimensions (ie, characteristics of tasks) underlying these ratings and the salience of each dimension to HCWs.

SETTING

Adult inpatient hospitals across an academic hospital network.

PARTICIPANTS

In total, 40 HCWs, comprising infection preventionists and nurses from intensive care units, emergency departments, and medical-surgical floors rated the similarity of tasks. To identify the meaning of each dimension, another 6 nurses rated each task in terms of specific characteristics of tasks.

RESULTS

Each HCW population perceived patient care tasks to vary along 3 common dimensions; most salient was the perceived magnitude of infection risk to the patient in a task, followed by the perceived dirtiness and risk of HCW exposure to body fluids, and lastly, the relative importance of a task for preventing versus controlling an infection in a patient.

CONCLUSIONS

For a patient requiring only standard precautions, different populations of HCWs have similar mental models of how various patient care tasks relate to IPC. Techniques for eliciting mental models open new avenues for understanding and ultimately modifying the cognitive determinants of IPC behaviors.

The experience of disgust by nursing and midwifery students: An interpretative phenomenological approach study

Although disgust is recognized as a common and prominent emotion in healthcare, little is known about how healthcare professionals understand, experience and conceptualize disgust. The aim of the study was to gain an in-depth understanding of how nursing and midwifery students experience, understand and cope with disgust in their clinical work. Interviews were transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). Six participants (all women: two nursing students, four midwifery students) from a university in the South of England were interviewed. Four superordinate themes with eight subthemes were identified. Overall, findings suggest that participants experience both moral and physical disgust; however, they find it difficult to talk about and use other terms to describe their experience. Findings are discussed through the lens of social identity theory, to understand the relevance of professional identity and how this might further maintain the disgust taboo. The strategies participants have developed in order to cope with disgust are explored and understood within the current healthcare climate. Future research should focus on ways of addressing the experience of disgust by healthcare professionals in order to improve the quality of care provided, especially in the climate of the COVID-19 crisis.

Hand Hygiene Compliance at Critical Points of Care

BACKGROUND

Most articles on hand hygiene report either overall compliance or compliance with specific hand hygiene moments. These moments vary in the level of risk to patients if healthcare workers (HCWs) are noncompliant. We assessed how task type affected HCWs' hand hygiene compliance.

METHODS

We linked consecutive tasks individual HCWs performed during the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) study into care sequences and identified task pairs-2 consecutive tasks and the intervening hand hygiene opportunity. We defined tasks as critical and/or contaminating. We determined the odds of critical and contaminating tasks occurring, and the odds of hand hygiene compliance using logistic regression for transition with a random effect adjusting for isolation precautions, glove use, HCW type, and compliance at prior opportunities.

RESULTS

Healthcare workers were less likely to do hand hygiene before critical tasks than before other tasks (adjusted odds ratio [aOR], 0.97 [95% confidence interval {CI}, .95-.98]) and more likely to do hand hygiene after contaminating tasks than after other tasks (aOR, 1.12 [95% CI, 1.10-1.13]). Nurses were more likely to perform both critical and contaminating tasks, but nurses' hand hygiene compliance was better than physicians' (aOR, 0.94 [95% CI, .91-.97]) and other HCWs' compliance (aOR, 0.87 [95% CI, .87-.94]).

CONCLUSIONS

Healthcare workers were more likely to do hand hygiene after contaminating tasks than before critical tasks, suggesting that habits and a feeling of disgust may influence hand hygiene compliance. This information could be incorporated into interventions to improve hand hygiene practices, particularly before critical tasks and after contaminating tasks.

Development of a behaviour change intervention using a theory-based approach, Behaviour Centred Design, to increase nurses' hand hygiene compliance in the US hospitals

BACKGROUND

A behaviour change campaign is unlikely to be effective if its intervention is not carefully designed. While numerous frameworks are widely used to develop and evaluate interventions, the steps detailing how to create an intervention are not as clear because the process of linking behaviour analysis to the intervention design is seldom discussed. We document the application of the Behaviour Centred Design (BCD) approach to the development of an intervention to improve hand hygiene (HH) rates among nurses' hospital units in the USA.

METHODS

Intervention development is divided into the first three steps of the BCD approach: Assess, Build, and Create. The Assess step centres on understanding the target behaviour. The Build step expands the knowledge of the target behaviour and population through formative research which leads to a creative brief that explains the focus of the intervention. In the Create step, the creative brief guides the intervention design.

RESULTS

Drawing from the main findings of the Asses and Build steps, a focal insight was developed positing that nurses can rediscover the meaning and purpose of their role as a nurse and thus as a caregiver by practicing HH; in the process of cleaning their hands, nurses are living up to their ideal nurse-self. The focal insight was linked linguistically into a theory and change. The outcome was a simple intervention, called the Mainspring Intervention, which consisted of three major parts: a self-affirmation exercise to reduce defensiveness, a message that challenged nurses' perceptions about their HH practice, and an implementation intention activity to help nurses link HH behaviour to a cue.

CONCLUSIONS

We detailed the creation of an original HH intervention that used the BCD approach. The intervention is relatively simple compared to most HH initiatives in the literature, both in terms of having relatively few components to the intervention and relatively easy field implementation. This intervention will allow us to test how specific psychological processes contribute to the problem of low HH rates, how our proposed intervention changes these processes in the hospital setting, and how the expected change in nurses' cognition transforms over time because of the intervention.

Comparing infection control and ward nurses' views of the omission of infection control activities using the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey

Aim

To compare the perceptions of nurses with infection control expertise and ward nurses as to what infection control activities are missed and the reasons why these activities are omitted.

Background

Infection prevention activities are viewed as important for reducing health care‐acquired infections (HAIs) but are often poorly performed.

Methods

Data were collected through the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey delivered to 500 Australian nurses prior to COVID‐19.

Results

Significant differences were found on the mean scores between infection control and other nurses on ten items. In eight cases, five relating to hand hygiene, infection control specialists viewed the activity as more likely to be missed. Factors viewed as having greater contribution to omission of infection control prevention were as follows: 'Patients have to share bathrooms', 'Urgent patient situation' and 'Unexpected rise in patient volume and/or acuity on the ward/unit'. Infection control nurses were more likely to highlight the role of organisational and management factors in preventing effective infection control.

Conclusions

Differences in response between nurses suggest that the extent of omission of infection control precautions may be under‐estimated by ward nurses.

Implications for Nursing Management

Infection control specialists are more likely to identify organisational barriers to effective infection control than other nurses. Work demands arising from pandemic management may contribute to infection control precautions being missed.

Nurses' and midwives' cleaning knowledge, attitudes and practices: An Australian study

Background

As frontline providers of care, nurses and midwives play a critical role in controlling infections such as COVID-19, influenza, multi-drug resistant organisms and health care associated infections. Improved cleaning can reduce the incidence of infection and is cost effective but relies on healthcare personnel to correctly apply cleaning measures. As nurses and midwives have the most contact with patients and as an important first step in improving compliance, this study sought to explore nurses' and midwives’ knowledge on the role of the environment in infection prevention and control and identify challenges in maintaining clean patient environments.

Methods

Cross-sectional online survey of 96 nurses (RN/EN) and midwives (RW) employed in clinical settings (e.g. hospital, aged care, medical centre, clinic) in Australia.

Results

Nurses and midwives broadly stated that they understood the importance of cleaning. However, cleaning responsibilities varied and there was confusion regarding the application of different disinfectants when cleaning after patients with a suspected or diagnosed infection post-discharge. Most would not be confident being placed in a room where a previous patient had a diagnosed infection such as multi-drug resistant organism.

Conclusion

Greater organisational support and improving applied knowledge about infection control procedures is needed. This includes correct use of disinfectants, which disinfectant to use for various situations, and cleaning effectively following discharge of a patient with known infection. The cleanliness of shared medical equipment may also pose current risk due to lack of cleaning.

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Improved cleaning reduces incidence of healthcare associated infection but relies on correct application.

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Nurses and midwives expressed confusion regarding disinfectant use and cleaning responsibility.

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Most would not be confident being placed in a room where a previous patient had a diagnosed infection.

Use of non-sterile gloves in the ward environment: an evaluation of healthcare workers' perception of risk and decision making

Background

Studies have found that inappropriate use of non-sterile gloves (NSG) can affect hand hygiene compliance; the main risks are missing opportunities for hand hygiene and gloves being a vector for microbial transmission.

Aim

The aims of this study were to explore the accuracy of healthcare worker (HCW) risk assessment and decision making regarding the use of NSG.

Methods

The study was conducted in two acute NHS Trusts and a community social enterprise. A cross-sectional survey was carried out, followed by qualitative semi-structured interviews.

Findings

There were highly significant differences at the 95% probability level between staff groups, unqualified staff being significantly more likely than qualified staff to report NSG use when not indicated (P < 0.0001). The primary motivating factor for staff to wear NSG was for personal protection; the secondary factor being the protection of patients. Staff were also motivated by a desire to create an image of professionalism. Respondents were more likely to follow the lead of seniors in their own profession.

Discussion

The results suggest a necessity for change interventions aimed at unqualified staff such as healthcare assistants (HCAs). It would be beneficial to review the indications for glove use and amend organisational policies accordingly. Leaders in each professional staff group would be required to influence practice across organisations, taking into account motivating factors, and in association with multi-modal interventions to improve practice.

Evaluation of infection prevention and control policies, procedures, and practices: An ethnographic study

BACKGROUND

The intensive care unit (ICU) is considered the epicenter of infections, and patients in the ICU are at higher risk of infection because of their vulnerability, age, and lengthy hospitalization.

METHODS

The ethnographic design has been used to describe, examine, and evaluate the policies and procedures that are implemented to prevent and control hospital-acquired infections (HAIs) in the medical ICU in King Abdullah University Hospital. In-depth semi-structured interviews with 23 participants supported by nonparticipant observation and document analysis were carried out to collect triangulated data. The themes and subthemes were developed through a software package and hand-coding procedure.

RESULTS

Health care workers were aware but not fully engaged to prevent and control HAIs; nevertheless, they presented themselves as knowledgeable. Staff recognized the importance of involving family members and visitors. However, they had serious concern toward open visitation. The nurse to patient ratio was another challenge of infection prevention and control practices. The findings demonstrated that performing continuous prospective surveillance by highly qualified and trained staff can reduce the risk of endemic HAIs.

CONCLUSIONS

The study highlighted the importance of changing behaviors and practices of health care providers and visitors to improve adherence to infection prevention and control policies and practices.

Healthcare associated infection: good practices, knowledge and the locus of control in heatlhcare professionals

BACKGROUND AND AIM

The incidence of Healthcare Associated Infections (HAI) is an important indicator of the quality of care. The behaviors associated with the prevention of infections are not only supported by rational knowledge or motivation, but are mediated by social, emotional and often stereotyped behaviors. The awarness of the good practices related to HAI, may be a factor. Other studies, identify how the perception of the problem in healthcare professionals is often influenced by a tendency towards an external Locus of Control: the patient, the family, the other wards, other care settings. The aim of this study is to investigate the perception of healthcare professionals. In particular they have been measured their  awarness of the good practices, perceptions of the potential contamination level of some commonly used objects, knowledge about the management of invasive devices, Locus of Control.

METHOD

A cross-sectional correlational design was utilized.  An ad hoc questionnaire was interviewed by 222 health professionals nurses and physicians in a northern hospital of Italy.

RESULTS

The percentage of professionals who have attended training courses over the last 5 years was quite high, both for upgrades on HAI (78.7%) and Vascular Catheters (78.8%), while the percentage of professionals who updated on bladder catheterization (59.46%) was lower. The mean  score of good practice awareness towards HAI (5.06), is high. The perception of the potential level of contamination of some devices had a  mean ranging from 4.62 (for the drip) to 5.26 (for the door handle). The average value of the Locus of Control (43.54) indicates that participants demonstrated a value that is midway between External and Internal. The correlation test analysis revealed no significant relationships among professionals'age, knowledge about HAI, or infection related venus catheter. Also, results revealed that there were statistically significant positive relationships between professionals' Good Practices awareness about HAI , Knowledge, and Locus of Control.

CONCLUSION

The study findings demonstrated that good practice awareness towards HAI among nurse and physician was good but not completely optimal. Findings revealed that knowledge toward HAI prevention and HAI related device prevention were not completely adequate. The educational courses, according to our correlational findings, should definitely take into account the psycho-social aspects of this phenomenon.

Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care

BACKGROUND

Health care workers (HCWs) are recommended to wear nonsterile clinical gloves (NSCG) for direct contact with blood and body fluids. However, there is evidence of extensive inappropriate NSCG use.

METHODS

A mixed-methods study comprising observation of NSCG use in 2 acute hospitals and semistructured HCW interviews. Qualitative data were categorized using thematic analysis. Findings were mapped to the Systems Engineering Initiative for Patient Safety model and used to develop a strategy for improving NSCG use.

RESULTS

Two hundred seventy-eight procedures performed in 178 episodes of care involved the use of NSCG. NSCG were inappropriate for 59% of procedures (165 out of 278). Risk of cross-contamination occurred in 49% (87 out of 178) episodes. Twenty-six HCWs were interviewed; emotion and socialization were key factors influencing decisions to use NSCG. Data from observation and thematic analysis were mapped to 6 interacting components of the Systems Engineering Initiative for Patient Safety work system. Interventions targeting each component informed quality improvement strategies CONCLUSIONS: Despite intense promotion of hand hygiene as the key measure to protect patients from health care-associated infection, NSCG dominate routine clinical practice and potential cross-contamination occurs in 50% of care episodes. Such practice is associated with significant environmental and financial costs and adversely affects patient safety. The application of human factors and ergonomics to the complex drivers of inappropriate NSCG behavior may be more effective than conventional approaches of education and policy in achieving the goal of preventing health care-associated infection and improving patient safety.

Are we sending the wrong message when we ask health care workers to wash their hands?

When asking healthcare workers to wash their hands, perhaps a better message would be to ask them not to transmit diseases. This changes the emphasis from a single act of adherence to a concept of behavior change. Proper hand hygiene, proper use of personal protective equipment, and cough etiquette are the means to an end, to stop the transfer to organisms and disease, but not the ultimate goal itself. The ultimate goal is to stop the transmission of diseases and ultimately to decrease the occurrence of healthcare associated infections.

Nurses’ perceptions of dirt and contagion: Does the work environment pose a greater threat than one’s own home?

The aim of this study was to understand nurses’ infection prevention behaviours in the acute hospital setting by eliciting their explanations of observed behaviour. It sought to identify perceptions of risk from infection within their work environment and their homes, the practices carried out to avoid these risks, and the factors that influence behaviour. Twenty semi-structured interviews, using a topic guide and vignettes, were conducted with Registered Nurses. Interviews were audio recorded and transcribed verbatim. Three main themes of ‘Rationalising dirt related behaviour’, ‘Protection from dirt’ and ‘Transitions and journeys: no place like home’ emerged following data analysis using a framework method. This paper presents the theme ‘Transitions and journeys: no place like home’, which has two components: ‘Where is the dirt?’ and ‘Practice and rituals’. The findings demonstrate that dirt and germs present in hospitals represent a higher risk than those in the home. Healthcare workers can take measures to mitigate this risk; however, on leaving the workplace perception of self does not change significantly until they arrive home. At this point a transition occurs; they now recognise the risk they may pose and practices and rituals are required in order to protect the home . The findings demonstrate the multifaceted nature of infection prevention beliefs and behaviours. Behaviour is influenced by knowledge, belief systems and the circumstances of the situation. People see themselves positioned differently within the environment depending on the context of the risk; they can either be at risk or be the cause of the risk.

Failure analysis in the identification of synergies between cleaning monitoring methods

BACKGROUND

The 4 monitoring methods used to manage the quality assurance of cleaning outcomes within health care settings are visual inspection, microbial recovery, fluorescent marker assessment, and rapid ATP bioluminometry. These methods each generate different types of information, presenting a challenge to the successful integration of monitoring results. A systematic approach to safety and quality control can be used to interrogate the known qualities of cleaning monitoring methods and provide a prospective management tool for infection control professionals. We investigated the use of failure mode and effects analysis (FMEA) for measuring failure risk arising through each cleaning monitoring method.

METHODS

FMEA uses existing data in a structured risk assessment tool that identifies weaknesses in products or processes. Our FMEA approach used the literature and a small experienced team to construct a series of analyses to investigate the cleaning monitoring methods in a way that minimized identified failure risks.

RESULTS

FMEA applied to each of the cleaning monitoring methods revealed failure modes for each. The combined use of cleaning monitoring methods in sequence is preferable to their use in isolation.

CONCLUSIONS

When these 4 cleaning monitoring methods are used in combination in a logical sequence, the failure modes noted for any 1 can be complemented by the strengths of the alternatives, thereby circumventing the risk of failure of any individual cleaning monitoring method.