Hand hygiene among healthcare workers: A qualitative meta summary using the GRADE-CERQual process

BACKGROUND

Hand hygiene is considered an effective and potentially modifiable infection control behaviour among healthcare workers (HCW). Several meta-studies have been published that compare quantitatively expressed findings, but limited efforts have been made to synthesise qualitative research.

OBJECTIVES

This paper provides the first report of integrated findings from qualitative research reports on hand hygiene compliance among HCW worldwide that employs the GRADE-CERQual process of quality assessment.

METHODS

We conducted database searches and identified 36 reports in which authors conducted qualitative or mixed methods research on hand hygiene compliance among HCW. We used Dedoose analysis software to facilitate extraction of relevant excerpts. We applied the GRADE-CERQual process to describe relative confidence as high, moderate or low for nine aggregate findings.

FINDINGS

Highest confidence findings included that HCW believe they have access to adequate training, and that management and resource support are sometimes lacking. Individual, subjective criteria also influence hand hygiene.

DISCUSSION

These results suggest the need for further investigation into healthcare cultures that are perceived as supportive for infection control. Surveillance processes have potential, especially if information is perceived by HCW as timely and relevant.

Describing knowledge encounters in healthcare: a mixed studies systematic review and development of a classification

Background

Implementation science seeks to promote the uptake of research and other evidence-based findings into practice, but for healthcare professionals, this is complex as practice draws on, in addition to scientific principles, rules of thumb and a store of practical wisdom acquired from a range of informational and experiential sources. The aims of this review were to identify sources of information and professional experiences encountered by healthcare workers and from this to build a classification system, for use in future observational studies, that describes influences on how healthcare professionals acquire and use information in their clinical practice.

Methods

This was a mixed studies systematic review of observational studies. DATA SOURCES: OVID MEDLINE and Embase and Google Scholar were searched using terms around information, knowledge or evidence and sharing, searching and utilisation combined with terms relating to healthcare groups. ELIGIBILITY: Studies were eligible if one of the intentions was to identify information or experiential encounters by healthcare workers. DATA EXTRACTION: Data was extracted by one author after piloting with another. STUDY APPRAISAL: Studies were assessed using the Mixed Methods Appraisal Tool (MMAT). PRIMARY OUTCOME: The primary outcome extracted was the information source or professional experience encounter. ANALYSIS: Similar encounters were grouped together as single constructs. Our synthesis involved a mixed approach using the top-down logic of the Bliss Bibliographic Classification System (BC2) to generate classification categories and a bottom-up approach to develop descriptive codes (or “facets”) for each category, from the data. The generic terms of BC2 were customised by an iterative process of thematic content analysis. Facets were developed by using available theory and keeping in mind the pragmatic end use of the classification.

Results

Eighty studies were included from which 178 discreet knowledge encounters were extracted. Six classification categories were developed: what information or experience was encountered; how was the information or experience encountered; what was the mode of encounter; from whom did the information originate or with whom was the experience; how many participants were there; and where did the encounter take place. For each of these categories, relevant descriptive facets were identified.

Conclusions

We have sought to identify and classify all knowledge encounters, and we have developed a faceted description of key categories which will support richer descriptions and interrogations of knowledge encounters in healthcare research.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0564-1) contains supplementary material, which is available to authorized users.

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.

Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care--a cluster randomised study

BACKGROUND

Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention.

METHODS

The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention.

RESULTS

No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal.

CONCLUSIONS

The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44819426.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

MRSA-colonized persons' and healthcare personnel's experiences of patient-professional interactions in and responsibilities for infection prevention in Sweden

BACKGROUND

Patient-professional interactions and adherence to infection control measures are central to the quality of care and patient safety in healthcare. Persons colonized with methicillin-resistant Staphylococcus aureus (MRSA) describe insufficient support and unprofessional behavior among healthcare personnel.

METHODS

A descriptive qualitative study was conducted to investigate managers', physicians', registered nurses' and MRSA-colonized persons' experiences of patient-professional interactions in relation to and responsibilities for infection prevention in the care of colonized patients. Five persons with MRSA colonization and 20 healthcare personnel employed within infection, hematology, nephrology or primary healthcare settings participated. The data were collected using open-ended semi-structured individual interviews with the MRSA-colonized persons and semi-structured focus group interviews with the healthcare personnel.

RESULTS

The participants perceived MRSA as an indefinable threat and described that the responsibility for infection prevention is important, but such adherence was a neglected and negotiable issue. The described actions that were acknowledged as unprofessional and inappropriate adherence to infection prevention resulted in stigmatized patients.

CONCLUSION

Colonized persons' and healthcare personnel's understanding of MRSA determines whether the personnel's behavior is perceived as proper or improper. Individual responsibility for patient-professional interactions in relation to MRSA colonization and adherence to infection control measures should be more stringent.

Preventing transmission of MRSA: a qualitative study of health care workers' attitudes and suggestions

BACKGROUND

Health care workers' (HCWs) perceptions and attitudes affect implementation of precautions to prevent transmission of drug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA). Identification of challenges and barriers to recommended practices is a critical component of promoting a safe clinical environment of care.

METHODS

Semistructured interviews addressed how MRSA affects HCWs, prevention of transmission, and challenges and barriers HCWs experience when entering a MRSA isolation room and performing appropriate hand hygiene.

RESULTS

The purposive sample of 26 acute care HCWs (16 registered nurses; 1 physician; 6 allied health professionals; and 3 support staff) self-selected from 276 responding to a questionnaire on MRSA. Analysis identified 18 themes across seven categories. Most participants reported feeling responsible for preventing transmission, and having the knowledge and desire to do so. However, many also reported challenges to following consistent hand hygiene and use of contact precautions. Barriers included patient care demands, equipment and environmental issues such as availability of sinks, time pressures, the practices of other HCWs, and the need for additional signs indicating which patients require contact precautions.

CONCLUSIONS

The HCWs reported a need for improved clarity of isolation protocols throughout patients' hospital journey, additional rooms and staff for isolation patients, improved education and communication (including timely and appropriate signage), and an emphasis on involving all HCWs in reducing contamination.

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.

Infection prevention as "a show": a qualitative study of nurses' infection prevention behaviours

BACKGROUND

Control of infection and prevention of healthcare associated infections is an ongoing issue worldwide. Yet despite initiatives and strategies to reduce the burden that these infections cause, healthcare workers' practice is still reported as suboptimal and these infections persist. Much of the research to date has primarily focused on predicting infection prevention behaviours and factors associated with guideline compliance. While this has given valuable insight, an investigation aiming to understand and explain behaviours that occur in everyday practice from the perspective of the actors themselves may hold the key to the challenges of effecting behaviour change. This study questioned "How can nurses' infection prevention behaviour be explained?" This paper presents one of three identified themes 'Rationalising dirt-related behaviour'.

DESIGN

This interpretative qualitative study uses vignettes, developed from nurses' accounts of practice, to explore nurses' reported infection prevention behaviours.

PARTICIPANTS

Registered nurses working in an acute hospital setting and had been qualified for over a year. They were recruited while studying part-time at a London University.

METHODS

Twenty semi-structured interviews were undertaken using a topic guide and vignettes. Interviews were transcribed verbatim and analysed using the framework method.

RESULTS

The findings demonstrate that participants were keen to give a good impression and present themselves as knowledgeable practitioners, although it was evident that they did not always follow procedure and policy. They rationalised their own behaviour and logically justified any deviations from policy. Deviations in others were criticised as irrational and explained as superficial and part of a 'show' or display. However, participants also gave a presentation of themselves: a show or display that was influenced by the desire to protect self and satisfy patient scrutiny.

CONCLUSIONS

This study contributes to the identification and explanation of nurses' infection prevention behaviours which are considered inappropriate or harmful. Behaviour is multifaceted and complex, stemming from a response to factors that are outside a purely 'scientific' understanding of infection and not simply understood as a deficit in knowledge. This calls for educational interventions that consider beliefs, values and social understanding of dirt and infection.

Sustainable healthcare waste management: a qualitative investigation of its feasibility within a county in the south west of England

This paper aims to investigate the possibility of safely and lawfully employing a sustainable reduce, reuse, recycle philosophy in the management of waste within healthcare settings. Climate change presents significant threats to our wellbeing on a global scale and provides a new challenge for healthcare organisations. As the United Kingdom’s biggest public sector employer, the National Health Service has enormous power to mitigate the impact of climate change by implementing sustainable practices. One area in which sustainable practices could be employed is within healthcare waste management. The investigation used a qualitative approach using semi-structured interviews with 20 participants responsible for the safe management of healthcare waste in an English county.

Interviews indicated that topics such as knowledge, the environment, finance and legislation influence attitudes and behaviour in healthcare waste management. Participants were clear that from financial and environmental perspectives an aim to reduce, reuse and recycle waste in health care was desirable. Attempts to implement sustainable healthcare waste management practices, informed by a sustainable waste management philosophy are desirable both financially and environmentally. Research is needed to explore behaviour, attitudes, learning, knowledge and the role of the environment in healthcare waste management.

Infection prevention practice: how does experience affect knowledge and application?

The purpose of this study was to evaluate nurses’ knowledge of infection prevention procedures, the degree to which they were applied correctly, and whether length of service affected either knowledge or application. Nurses with over five years of experience had significantly increased understanding of infection prevention ( p=0.009) and significantly increased application of knowledge to practice ( p=0.001), compared to nurses with five years or less experience. In particular, understanding of hand hygiene and use of personal protective equipment (PPE) was poor although application was compliant, while knowledge of care of patients with meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile was poor, which was reflected by substandard application of knowledge to practice. The results of this study suggest that focusing infection prevention education around patients with specific infections, such as MRSA and C. difficile, rather than on individual standard precautions may more effectively increase knowledge and therefore application of infection prevention practices.

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.

The role of education in the prevention and control of infection: a review of the literature

This paper discusses a literature review which was undertaken prior to a research study about student nurses' and midwives' experiences of learning infection control in clinical practice. Its aim is to identify the role of education in the prevention and control of infection, with a specific focus on compliance with infection control precautions and reduction in infection rates. It also identifies the methods used for teaching infection control. The review concludes that there is no rigorous and convincing evidence that education improves compliance with infection control precautions or reduces rates of infection, particularly in the long-term. Areas for future research are identified.