Infection control in clinical placements: experiences of nursing and midwifery students

How aseptic technique is taught to undergraduate student nurses: A qualitative study

BACKGROUND

Aseptic technique is essential to prevent healthcare-associated infection and reduce the risk of antimicrobial resistance but little research has explored how it is taught in undergraduate nursing curricula.

OBJECTIVE

Explore how undergraduate student nurses learn about aseptic technique in classroom and clinical settings and the contribution of key stakeholders in the educational process: nurse educators, mentors and infection prevention nurses.

DESIGN

Qualitative interview study with observation of teaching.

SETTING

Two contrasting sites, one reporting greater innovation in relation to the teaching and practice of aseptic technique than the other. Each site comprised a university nursing department and the organisations providing student placements.

PARTICIPANTS

Student nurses, university-based nurse educators, clinical mentors and infection prevention nurses.

METHODS

Telephone interviews, fieldwork and unstructured observation of teaching in the universities.

FINDINGS

Student nurses reported feeling poorly prepared to undertake aseptic technique. There were misunderstandings and confusion about its purpose and how it should be conducted among nurse educators and mentors. Suboptimal facilities, poor curriculum design and arrangements for competency assessment in both sites contributed to students' experiences. Reports of better innovation in one of the participating sites compared to standard practice in the other were not reflected in the data.

CONCLUSIONS

The findings of this study corroborate earlier research: student nurses do not feel well-prepared to undertake aseptic technique. Healthcare providers and universities need to investigate and address deficiencies in understanding among those responsible for teaching and performing this key nursing skill. University curricula should be revised to ensure that teaching takes place optimally in relation to clinical placements, improve arrangements for students' competency assessment, focus more on teaching the principles underpinning aseptic technique and promote transferability from the classroom to different types of clinical settings. Communication between university and clinical staff should be strengthened.

Assessment of neonatal intensive care unit nurses' compliance with standard precautions of infection control and identification of enabling factors

Background

Rigorous implementation of infection prevention and control practices by healthcare workers in different healthcare settings is of utmost importance. Neonates, particularly preterm babies in neonatal intensive care units, are a vulnerable population at high risk for developing nosocomial infections. Nurses have the greatest risk of spreading healthcare-associated infections among patients and healthcare workers. This study was conducted to assess the compliance of neonatal intensive care unit nurses with standard precautions of infection control and to identify the potential influencing factors.

Results

This was a cross-sectional study, whereby the compliance of a total of 58 neonatal intensive care unit nurses with standard precautions of infection control was assessed using the Arabic version of the Compliance with Standard Precautions Scale (CSPS-A). Student's t test, ANOVA test, and post hoc test were used for analysis.A suboptimal compliance rate (66.7%) was detected, with the highest for disposal of sharp articles into sharps boxes (86.2%) and the lowest for disposal of sharps box not only when full (27.6%). Significant differences were observed when participants were grouped according to their clinical experience and qualifications, where participants with longer clinical experience displayed higher mean scores for the use of protective devices score (P = 0.024), disposal of sharps score (P = 0.003), and total CSPS score (P = 0.006).

Conclusions

Clinical experience and educational qualifications are key factors that impact nurses' compliance with infection control practices. Nurses should receive up-to-date evidence-based educational and practical sessions that link theory to clinical practice and elucidate the importance of accurate implementation of proper infection prevention and control practices.

Undergraduate nursing students' education and training in aseptic technique: A mixed methods systematic review

AIM

To appraise and synthesize empirical studies exploring undergraduate nursing students' education and training in aseptic technique.

DESIGN

Mixed methods, systematic literature review adopting Joanna Briggs Institute methodology.

DATA SOURCES

Thirteen electronic databases were searched 1996-2020, followed by searches with a general browser, hand-searching key journals and reviewing reference lists of retrieved papers.

REVIEW METHODS

Potentially eligible papers were scrutinised by two reviewers. Those eligible were critically appraised and quality assessed using the Critical Appraisal Skills Programme and Specialist Unit for Review Evidence checklists.

RESULTS

Of 538 potentially eligible studies, 27 met the inclusion criteria. There was limited evidence of the effectiveness of different teaching methods. Students' knowledge, understanding and competency varied and were often poor, although they reported confidence in their ability to perform aseptic technique. Students and qualified nurses perceived that education and training in aseptic techniques might be improved.

CONCLUSION

Education and training in aseptic technique might be improved but the review findings should be viewed cautiously because the studies lacked methodological rigour.

IMPACT

This appears to be the first systematic review to explore undergraduate nursing students' education and training in relation to aseptic technique. There was limited evidence to support the effectiveness of different teaching methods and scope for improving nursing students' knowledge, understanding and competency in aseptic technique. Students and qualified nurses suggested that education and training might be enhanced. More robust studies are required to support education, practice and policy.

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.

National cross-sectional survey to explore preparation to undertake aseptic technique in pre-registration nursing curricula in the United Kingdom

BACKGROUND

Aseptic technique is a core nursing skill. Sound preparation is required during pre-registration nursing education to enable student nurses to acquire the knowledge and skills necessary to prevent and control healthcare-associated infection and promote patient safety. Few studies have explored nursing students' education and training in aseptic technique.

OBJECTIVES

To investigate what, when and how pre-registration nursing students are taught aseptic technique and how they are assessed in undergraduate, pre-registration nursing programmes in the United Kingdom.

DESIGN

National cross-sectional survey exploring preparation to undertake aseptic technique in pre-registration nursing curricula in the United Kingdom.

SETTING

Universities providing undergraduate, pre-registration adult nursing programmes in the United Kingdom.

PARTICIPANTS

Nurse educators.

METHODS

Structured telephone interviews were conducted with nurse educators. Descriptive and inferential statistical data analyses were undertaken.

RESULTS

Response rate was 70% (n = 49/70). A variety of different learning and teaching methods were reported to be in use. Teaching in relation to aseptic technique took place in conjunction with teaching in relation to different clinical procedures rather than placing emphasis on the principles of asepsis per se and how to transfer them to different procedures and situations. Wide variation in teaching time; use of multiple guidelines; inaccuracy in the principles identified by educators as taught to students; and limited opportunity for regular, criteria based competency assessment were apparent across programmes.

CONCLUSIONS

Pre-registration preparation in relation to aseptic technique requires improvement. There is a need to develop a working definition of aseptic technique. The generalisability of these findings in other healthcare students needs to be explored.

Factors influencing hand hygiene practice of nursing students: A descriptive, mixed-methods study

Developing nursing students' knowledge and practice of infection prevention and control (IPC) is fundamental to safe healthcare. A two-phase descriptive, mixed-method study conducted within a Bachelor of Nursing program at an Australian university aimed to explore: (i) theoretical knowledge of IPC, highlighting hand hygiene, of nursing students and; (ii) nursing students' and clinical facilitators' perceptions of factors influencing these practices during clinical placement. Phase One utilised an anonymous validated questionnaire assessing students' knowledge; identifying variables influencing students' IPC practices, subjected to descriptive and inferential analysis. Phase Two were semi-structured interviews exploring clinical facilitators' experiences/perceptions of students during clinical placement, analysed thematically. Students' demonstrated satisfactory knowledge of IPC in their second and third year, but clinical facilitators perceived that. students lacked awareness of the importance of these practices. Five themes arose from the interviews: (i) understanding workplace culture; (ii) students' modelling local behaviour; (iii) enhancing and consolidating knowledge for practice; (iv) adjusting to practice reality and; (v) accessing additional hand hygiene resources. Factors specific to workplace setting and culture were perceived to influence nursing students' socialisation. Future practice/education strategies could address these factors by ensuring students receive adequate supervision during clinical placement, and having strong advocates/role models present in the workplace.

Physiotherapy students as a partner for the prevention of healthcare associated infections

Background: Hand hygiene compliances of healthcare students have been examined extensively. However, there has been no study in this area for the students of the department of physiotherapy and rehabilitation. The aim was to evaluate hand hygiene compliance of the department of physiotherapy and rehabilitation students after a briefing on hand hygiene. Methods: Before the summer practice, the students were briefed on hand hygiene. Then their hand hygiene compliance were assessed. Their sociodemographic characteristics, clinical summer practice data, and hand hygiene compliance based on the recommendations commented in the Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health Care Settings were assessed with a questionnaire prepared by the researchers. Results: Of 53 students, 52 met inclusion criteria. The average correct answer rate was 82.69%. Students had inadequacies in selecting suitable hand hygiene techniques and in complying with hand hygiene indications in some situations related to their profession. Moreover, the students suggested that there was a great need for education (n = 24; 39.34%) and improvements in physical conditions (n = 21; 34.43%). Conclusions: As a conclusion, department of physiotherapy and rehabilitation students were aware of the importance of hand hygiene in terms of prevention of healthcare-associated infections. However, for department of physiotherapy and rehabilitation students, educational programs about hand hygiene is needed in order to gain optimal competence and to be able to protect and improve health care workers and patients safety.

Factors influencing nursing students' intention to comply with infection control practices

The purpose of this study was to examine how nursing students' intention to comply with infection control practices (ICPs) is affected by their awareness of ICPs and by their observations of staff nurses' noncompliance with ICPs. The subjects were 350 nursing students from 8 universities in Korea. Hierarchical multiple linear regression analysis was used to determine the predictive factors of compliance intention with ICPs. We found that nursing students' awareness of ICPs was the most significant influencing factor affecting their compliance with ICPs. Students' observation of staff nurses' noncompliance with ICPs was the second most significant influencing factor.

Survey to explore understanding of the principles of aseptic technique: Qualitative content analysis with descriptive analysis of confidence and training

BACKGROUND

In many countries, aseptic procedures are undertaken by nurses in the general ward setting, but variation in practice has been reported, and evidence indicates that the principles underpinning aseptic technique are not well understood.

METHODS

A survey was conducted, employing a brief, purpose-designed, self-reported questionnaire.

RESULTS

The response rate was 72%. Of those responding, 65% of nurses described aseptic technique in terms of the procedure used to undertake it, and 46% understood the principles of asepsis. The related concepts of cleanliness and sterilization were frequently confused with one another. Additionally, 72% reported that they not had received training for at least 5 years; 92% were confident of their ability to apply aseptic technique; and 90% reported that they had not been reassessed since their initial training. Qualitative analysis confirmed a lack of clarity about the meaning of aseptic technique.

CONCLUSION

Nurses' understanding of aseptic technique and the concepts of sterility and cleanliness is inadequate, a finding in line with results of previous studies. This knowledge gap potentially places patients at risk. Nurses' understanding of the principles of asepsis could be improved. Further studies should establish the generalizability of the study findings. Possible improvements include renewed emphasis during initial nurse education, greater opportunity for updating knowledge and skills post-qualification, and audit of practice.

'And you'll suddenly realise 'I've not washed my hands': medical students', junior doctors' and medical educators' narratives of hygiene behaviours

OBJECTIVE

Compliance to hygiene behaviours has long been recognised as important in the prevention and control of healthcare associated infections, but medical doctors still display some of the lowest rates of compliance of all healthcare workers. We aim to understand compliance to hygiene behaviours by analysing medical students', junior doctors' and medical educators' narratives of these behaviours to identify their respective attitudes and beliefs around compliance and how these are learnt during training. Such an understanding can inform future interventions to improve compliance targeted to areas of greatest need.

DESIGN

A qualitative study, using narrative interviews (nine focus groups and one individual interview). Data were analysed thematically using inductive framework analysis.

SETTING

Teaching hospitals in the UK.

PARTICIPANTS

Convenience sample of 25 participants: third-year medical students in their first clinical year (n=13), junior doctors (n=6) and medical educators (n=6).

RESULTS

We identified four main themes: (1) knowledge, (2) constraints, (3) role models/culture and (4) hygiene as an added extra. Knowledge varied across participant groups and appeared to influence behaviours; medical students relied on what they have been told by seniors, while medical educators relied on their own knowledge and experience. There was a strong belief that evidence for the effectiveness of good hygiene behaviours is lacking. Furthermore, medical educators' behaviour appears to strongly influence others. Finally, hygiene was predominately viewed as an added extra rather than an integral part of the process.

CONCLUSIONS

Awareness of the evidence around good hygiene needs to be improved at all levels. Medical students and junior doctors should be encouraged to consider why they are asked to perform certain hygiene behaviours in order to improve ownership of those behaviours. Medical educators need to recognise their responsibilities as role models for their junior counterparts, thereby understanding their role in developing the culture of hygiene practices within their clinical domains.

Compliance with standard precautions among baccalaureate nursing students in a Saudi university: A self-report study

Meticulous observance of standard infection control precautions by health care providers is strongly recommended for every patient encounter. Assessment of nursing students' compliance should be carried out regularly in order to ensure adherence to protocols. Thus, this study was conducted to assess self-reported compliance with standard precautions among baccalaureates in nursing students in a Saudi university. A convenience sample of 236 nursing students was surveyed in this cross-sectional, self-reported study, using the Compliance with Standard Precaution Scale Arabic version (CSPS-A). Independent t-test and one-way analyses of variance (ANOVA) were performed to examine the differences on compliance. A multiple regression analysis was performed to identify the factors affecting compliance. The overall compliance rate was 61.0%. The students reported highest compliance in disposing used sharp instruments and other sharp objects into sharps-only boxes, while the lowest compliance rate in using water only for hand washing. Significant differences in compliance were observed when respondents were grouped according to their demographic characteristics. Cultivating a supportive culture of adherence to infection control precautions among nursing students is of paramount importance. The clinical environment should be supportive of a culture where strict compliance with the control and prevention of infection is of prime importance.

Factors influencing student nurse decisions to report poor practice witnessed while on placement

BACKGROUND

While it is commonly accepted that nursing care is generally of a good standard, it would be naïve to think that this is always the case. Over recent years, concern about aspects of the quality of some nursing care has grown. In tandem with this, there is recognition that nurses do not always report poor practice. As future registrants, student nurses have a role to play in changing this culture. We know, however, relatively little about the factors that influence student decisions on whether or not to report. In the absence of a more nuanced understanding of this issue, we run the risk of assuming students will speak out simply because we say they should.

OBJECTIVES

To explore influences on student decisions about whether or not to report poor clinical practice, which is a result of deliberate action and which is witnessed while on placement.

METHODS

Qualitative interviews were conducted with thirteen pre-registration nursing students from the UK. Participants included both adult and mental health nurses with an age range from 20 to 47. Data were analysed to identify key themes. Category integrity and fit with data were confirmed by a team member following initial analysis.

RESULTS

Four themes. The first of these, 'I had no choice' described the personal and ethical drivers which influenced students to report. 'Consequences for self' and 'Living with ambiguity' provide an account of why some students struggle to report, while 'Being prepared' summarised arguments both for and against reporting concerns.

CONCLUSION

While there is a drive to promote openness in health care settings and an expectation that staff will raise concerns the reality is that the decision to do this can be very difficult. This is the case for some student nurses. Our results suggest ways in which educationalists might intervene to support students who witness poor practice to report.

Predictors for compliance of standard precautions among nursing students

BACKGROUND

We aimed to investigate the frequency of standard precautions (SPs) compliance and the factors affecting the compliance among nursing students (NSs).

METHODS

A cross-sectional survey study guided by the health belief model was conducted in 2009. The study questionnaire is valid (content validity index, 0.81) and reliable (Cronbach α range, 0.65-0.94).

RESULTS

There were 678 questionnaires analyzed, with a response rate of 68.9%. The mean frequency score of SPs compliance was 4.38 ± 0.40 out of 5. Tukey honest significant difference post hoc test indicated that year 2 and year 4 students had better SPs compliance than year 3 students. Further analysis using a univariate general linear model identified an interaction effect of perceived influence of nursing staff and year of study (F1,593 = 3.72; P < .05). The 5 following predictors for SPs compliance were identified: knowledge of SPs, perceived barriers, adequacy of training, management support, and influence of nursing staff.

CONCLUSION

Although the SPs compliance among NSs was high, the compliance varied by year of study and was affected by the nursing staff. Furthermore, SPs compliance among NSs can be enhanced by increasing SPs knowledge, providing more SPs training, promoting management support, reducing identified SPs barriers, and improving nursing staff compliance to SPs.

Factors influencing ceftriaxone use in community-acquired pneumonia: Emergency doctors' perspectives

OBJECTIVE

To explore the perceptions of ED doctors regarding the use of ceftriaxone in patients with community-acquired pneumonia (CAP).

METHODS

Face-to-face interviews were conducted with ED doctors in an Australian tertiary public hospital. A semi-structured interview method was used for collecting data and a framework analysis approach utilised to identify emerging themes regarding the influences on ED prescribers when using ceftriaxone for CAP.

RESULTS

Eight interviews were performed (two consultants, four registrars and two residents). Five main themes emerged as influencing decisions regarding the selection of ceftriaxone for patients with CAP: (i) clinical intuition versus structured evaluation of severity; (ii) clinical uncertainty; (iii) prior experience; (iv) source of guidance; and (v) prescribing etiquette.

CONCLUSION

As most cases of CAP are initially diagnosed and treated empirically in the ED, any interventions that aim to decrease inappropriate use of ceftriaxone for CAP should address the factors identified here that influence ED doctors' prescribing decisions.

How do university education and clinical experience influence pre-registration nursing students' infection control practice? A descriptive, cross sectional survey

AIMS

This study aims to explore nursing students' knowledge of infection control and investigate how university education and clinical experience influence their infection control practice.

BACKGROUND

In order to prevent and control healthcare associated infections all healthcare staff must be knowledgeable about infection control. However, knowledge and practice of infection control are often sub-optimal. Education has had variable results in improving the infection control knowledge of healthcare professionals yet, there have been few studies examining this issue in relation to pre-registration nursing students in the United Kingdom.

METHODS

This descriptive cross-sectional survey employed a questionnaire composed of predominantly closed questions for data collection. A non-probability, purposive sample of 354/444 (79.7%) nursing students from one university participated in the study.

FINDINGS

Knowledge was generally adequate in questions related to pathogen transmission, hand hygiene principles, glove use, immediate action following sharps' injuries, and risk reduction in relation to sharps and waste management. Topics that received less positive results related to the chain of infection, the use of alcohol gel and Clostridium difficile and the definition of inoculation injury. University education was the main influence on knowledge and practice (340/353, 96.3%), but mentors (322/354, 91.2%), nurses (316/353, 89.3%), doctors (175/353, 49.4%) and other members of the multi-disciplinary team (213/352, 60.2%) were also deemed influential. Workload, time, and availability of facilities and equipment also contributed to the adoption of infection control precautions. The findings illustrated the importance of both theoretical and practical knowledge, supported by competent role models.

CONCLUSION

The study identified the complexities of knowledge acquisition and application in a practice based discipline. The support of a competent role model to assist in applying theory to practice is vital. The study has identified that there are many variables that affect IPC practice, both positively and negatively.

Student nurses' experiences of infection prevention and control during clinical placements

BACKGROUND

Little is known about nursing students' experiences of infection control in the clinical setting despite its importance protecting patients and reducing risks of occupational exposure.

METHODS

We conducted an online survey involving a fixed choice Likert-type scale with 19 items and an open question to solicit more detailed information with a national sample of student nurses in the United Kingdom.

RESULTS

Four hundred eighty-eight student nurses completed questionnaires. All participants reported lack of compliance for every item on the Likert scale, most frequently from community settings and long-term care facilities for older people. Incidents most commonly witnessed were failure to comply with hand hygiene protocols, failure to comply with isolation precautions, poor standards of cleaning in the patient environment, not changing personal protective clothing between patients, and poor management of sharp instruments. Qualified nurses did not provide good role models. Medical staff were the occupational group most heavily criticized for poor compliance.

CONCLUSION

Students demonstrated sound understanding of infection control and were able to identify lack of compliance on the basis of preclinical classroom instruction. The study findings indicate that ensuring safe infection control practice remains a challenge in the United Kingdom despite its high priority.

The barriers and motivators to learning infection control in clinical placements: interviews with midwifery students

AIM

To investigate the barriers to and motivators for learning infection prevention and control as identified by midwifery students.

METHODS

Semi-structured interviews were undertaken with 15 undergraduate midwifery students within one large university. Data were analysed using Framework Analysis.

RESULTS

Barriers to good clinical practice were identified by students which were concordant with previous literature related to reasons for non-compliance with infection control precautions. Issues such as competing demands specific to midwifery were also identified. Factors which act as barriers to learning good practice in placements included conflicting information and practices from different staff and placement areas and staff attitudes towards students who tried to comply with precautions. Motivators to good practice included the perceived vulnerability of infants to infection, the role modelling of good practice to new mothers and the monitoring of practice.

CONCLUSIONS

This study demonstrated that midwifery students perceive barriers and motivators to learning infection prevention and control in their clinical placements. Many of the barriers identified are related to the attitudes and practices of qualified staff. Some of the motivators are related specifically to midwifery practice. Midwives need to be aware of the effects of what is observed in practice on midwifery students and how their practices and attitudes can influence learning both positively and negatively. As healthcare-associated infection and poor compliance with precautions are a global problem, this research should be of benefit to midwives and midwifery educators worldwide in terms of addressing barriers and ensuring better clinical education.

Using Framework Analysis in nursing research: a worked example

AIMS

To demonstrate Framework Analysis using a worked example and to illustrate how criticisms of qualitative data analysis including issues of clarity and transparency can be addressed.

BACKGROUND

Critics of the analysis of qualitative data sometimes cite lack of clarity and transparency about analytical procedures; this can deter nurse researchers from undertaking qualitative studies. Framework Analysis is flexible, systematic, and rigorous, offering clarity, transparency, an audit trail, an option for theme-based and case-based analysis and for readily retrievable data. This paper offers further explanation of the process undertaken which is illustrated with a worked example.

DATA SOURCE AND RESEARCH DESIGN

Data were collected from 31 nursing students in 2009 using semi-structured interviews.

DISCUSSION

The data collected are not reported directly here but used as a worked example for the five steps of Framework Analysis. Suggestions are provided to guide researchers through essential steps in undertaking Framework Analysis. The benefits and limitations of Framework Analysis are discussed.

IMPLICATIONS FOR NURSING

Nurses increasingly use qualitative research methods and need to use an analysis approach that offers transparency and rigour which Framework Analysis can provide. Nurse researchers may find the detailed critique of Framework Analysis presented in this paper a useful resource when designing and conducting qualitative studies.

CONCLUSION

Qualitative data analysis presents challenges in relation to the volume and complexity of data obtained and the need to present an 'audit trail' for those using the research findings. Framework Analysis is an appropriate, rigorous and systematic method for undertaking qualitative analysis.

Attitudes towards the Infection Prevention and Control Nurse: an interview study

AIM

A study was undertaken involving nursing students and nurse mentors to investigate the experiences and learning needs of nursing students in relation to infection prevention. One of the objectives was to consider the views of both nursing students and mentors towards the Infection Prevention and Control Nurse (IPCN) as an important staff member in infection prevention and control.

BACKGROUND

Infection prevention and control is a national and international priority but compliance with precautions can be low. One reason for this is staff attitudes. Infection Prevention and Control Nurses have an important role to play in the management of patient care through clinical staff and it is therefore important that they are seen as approachable and effective in their role.

METHODS

Using a qualitative approach, data were obtained through semistructured interviews with 31 nursing students and 32 nurse mentors. Interviews were recorded, transcribed and analysed using framework analysis.

FINDINGS

Three themes emerged: attitudes towards the IPCN, effects of the presence of the IPCN and preferred qualities in IPCNs.

CONCLUSIONS

Areas for future research are identified and recommendations made to address areas where attitudes may affect both clinical practice and the education of nursing students in clinical placements.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse specialists or practitioners, who are often seen within a management role, need to consider how they work with clinical staff in order to foster more collaborative relationships.