Exploring determinants of hand hygiene compliance in LTCFs: a qualitative study using Flottorps' integrated checklist of determinants of practice

Fostering an aged care organizational culture that supports innovation

AIM

This study aimed to identify how aged care organizations can foster a culture that supports the implementation of innovation.

INTRODUCTION

The aged care sector must innovate to meet clients' evolving needs and increased regulatory requirements. Given the need to account for the values, beliefs, expectations, and assumptions held by a diverse range of stakeholders, implementing innovations within aged care can be exceptionally complex. Fostering a supportive organizational culture can facilitate the implementation of these critical innovations.

METHODS

Papers from a large scoping review that identified organizational culture as a barrier and/or enabler to implementing innovations in aged care were imported into NVivo. Data relating to how organizations fostered (or could foster) a culture that supported the implementation of innovations were then extracted, inductively coded, interpreted, and grouped into approaches.

RESULTS

Of the 193 papers from the original scoping review, 109 were included in this secondary analysis. From these 109 papers, we identified six key approaches: cultivating collaboration; valuing contributions; ensuring alignment between the organizational vision, culture, and innovation; demonstrating organizational commitment; developing and communicating the implementation plan; and accounting for stability.

CONCLUSIONS

Our study outlines effective approaches that can be used by aged care organizations to cultivate a culture that supports the implementation of innovations. However, these approaches should not be viewed in isolation; rather, they are interconnected and mutually reinforcing. Together, these insights offer practical guidance for aged care entities seeking to adapt and evolve through innovation implementation.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A264.

Leading the way: implementing aged care innovations

OBJECTIVES

The objective of this study was to identify the key characteristics of leaders that support the implementation of innovations in aged care settings.

METHODS

We conducted a secondary analysis of papers from a large scoping review that identified how leaders supported the implementation of innovations in aged care. Once imported into NVivo12, the findings were deductively coded using the domains of Bloom's taxonomy of learning. Each parent code was then inductively analyzed to identify key characteristics within each domain.

RESULTS

Our review identified four types of knowledge, five skills, and six attitudes that leaders should exhibit to better support the implementation of innovations within aged care settings. In addition to our findings regarding Bloom's learning domains, we identified nine leadership behaviors that participants in the included papers perceived as valuable for enhancing the implementation process. Furthermore, we identified four key organizational elements that support leaders in navigating and facilitating the implementation of innovations within aged care settings.

CONCLUSION

Our review identified the characteristics that leaders should demonstrate when supporting the implementation of innovations in aged care. Importantly, our findings also emphasized the changing role of leadership from a hierarchical approach to a more collaborative, supportive, and empowering style. The insights identified in this review will help to guide aged care leaders, stressing the significance of adaptable and relational leadership styles that will guide the implementation of innovations within the aged care sector.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A271.

Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area

BACKGROUND

Hand hygiene is known to reduce healthcare-associated infections. However, it remains suboptimal among healthcare providers. In this study, we used the Behaviour-centered Design approach to explore the facilitators and deterrents to hand hygiene among healthcare providers in the Kampala Metropolitan area, Uganda.

METHODS

We conducted a formative qualitative study as part of a cluster randomised trial in 19 healthcare facilities (HCFs). The study used 19 semi-structured and 18 key informant interviews to collect data on hand hygiene status and facilitators and deterrents of hand hygiene. Research assistants transcribed verbatim and used a thematic framework aided by Nvivo 14.0. to undertake analysis. We used thick descriptions and illustrative quotes to enhance the credibility and trustworthiness of our findings.

RESULTS

About 47.4% of the HCFs had sufficient hand hygiene infrastructure, and 57.9% did not report total compliance with hand hygiene during patient care. The physical facilitator for hand hygiene was the presence of constant reminders such as nudges, while the biological included the frequency of patient contact and the nature of clinical work. The only biological deterrent was the heavy workload in HCFs. The executive brain facilitators included knowledge of workplace health risks, infection prevention and control (IPC) guidelines, and a positive attitude. A negative attitude was the executive brain deterrent to hand hygiene. Recognition, rewards, and fear of infections were the only motivated brain facilitators. Behavioural setting facilitators included proximity to functional hand hygiene infrastructure, the existence of active IPC committees, good leadership, and the availability of a budget for hand hygiene supplies. Behavioural setting deterrents included the non-functionality and non-proximity to hand hygiene infrastructure and inadequate supplies.

CONCLUSIONS

The study revealed low compliance with hand hygiene during the critical moments of patient care and inadequacy of hand hygiene infrastructure. The deterrents to hand hygiene included a heavy workload, negative attitude, inadequate supplies, non-functionality, and long distance to hand washing stations. Facilitators included constant reminders, fear of infections, frequency of patient contact and nature of clinical work, positive attitude, knowledge of IPC guidelines, recognition and reward, good leadership, availability of budgets for hand hygiene supplies, availability and proximity to hand hygiene supplies and infrastructure and active IPC committees.

TRIAL REGISTRATION

ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

Hand hygiene compliance in nursing home wards: The effects of feedback with lights on alcohol-based hand rub dispensers

BACKGROUND

Hand hygiene (HH) among health care workers (HCWs) is crucial in preventing infections in nursing homes. However, HH compliance (HHC) among HCWs remains low. This study aimed to investigate the effect of feedback lights on HCWs' HHC.

METHODS

A 5-month interventional study was conducted in 3 wards in a nursing home in Denmark. During the intervention period, a green light with a smiley appeared on the alcohol-based hand rub (ABHR) dispensers when HCWs used the ABHR, acknowledging HCWs for using the ABHR. HHC was monitored using an automatic HH monitoring system (AHHMS).

RESULTS

A total of 64 HCWs were enrolled. The AHHMS collected 23,696 HH opportunities in apartments and dirty utility rooms. Overall, HHC in the apartments increased from 50% at baseline (95% CI: 48, 53) to 56% (95% CI: 54, 58) during the intervention. However, the increased HHC level was not sustained during follow-up.

CONCLUSIONS

The AHHMS enabled the assessment of the intervention. We found a significant effect of light-guided feedback in the apartments. However, the increased HHC was not sustained after the light was switched off.

Mind the gap: knowledge, attitudes and perceptions on antimicrobial resistance, antimicrobial stewardship and infection prevention and control in long-term care facilities for people with disabilities in the Netherlands

BACKGROUND

Antimicrobial resistance (AMR) has become one of the major public health threats worldwide, emphasizing the necessity of preventing the development and transmission of drug resistant microorganisms. This is particularly important for people with vulnerable health conditions, such as people with intellectual disabilities (ID) and long-term care residents. This study aimed to assess the current status of AMR, antimicrobial stewardship (AMS) and infection prevention and control (IPC) in Dutch long-term care facilities for people with intellectual disabilities (ID-LTCFs).

METHODS

A web-based cross-sectional survey distributed between July and November 2023, targeting (both nonmedically and medically trained) healthcare professionals working in ID-LTCFs in The Netherlands, to study knowledge, attitudes and perceptions regarding AMR, AMS and IPC.

RESULTS

In total, 109 participants working in 37 long-term care organizations for people with intellectual disabilities throughout the Netherlands completed the questionnaire. The knowledge levels of AMR and IPC among nonmedically trained professionals (e.g., social care professionals) were lower than those among medically trained professionals (p = 0.026). In particular regarding the perceived protective value of glove use, insufficient knowledge levels were found. Furthermore, there was a lack of easy-read resources and useful information regarding IPC and AMR, for both healthcare professionals as well as people with disabilities. The majority of the participants (> 90%) reported that AMR and IPC need more attention within the disability care sector, but paradoxically, only 38.5% mentioned that they would like to receive additional information and training about IPC, and 72.5% would like to receive additional information and training about AMR.

CONCLUSION

Although the importance of AMR and IPC is acknowledged by professionals working in ID-LTCFs, there is room for improvement in regards to appropriate glove use and setting-specific IPC and hygiene policies. As nonmedically trained professionals comprise most of the workforce within ID-LTCFs, it is also important to evaluate their needs. This can have a substantial impact on developing and implementing AMR, AMS and/or IPC guidelines and policies in ID-LTCFs.

Hand hygiene compliance in nursing home wards: the effect of increased accessibility of alcohol-based hand rub

BACKGROUND

Elderly nursing home residents are vulnerable to infection from micro-organisms. Hand hygiene is considered one of the most important measures to prevent transmission.

AIM

To determine the effect of increased accessibility to alcohol-based hand rub (ABHR) in nursing home wards by monitoring hand hygiene compliance (HHC) among healthcare workers (HCWs).

METHODS

An 11-month intervention study was conducted in a Danish six-ward nursing home. Data were collected using an automatic hand hygiene monitoring system (AHHMS). After a baseline period, one extra ABHR dispenser was placed in each of the 150 apartments. Baseline HHC was compared with the HHC during an immediate intervention period and a long-term intervention period.

FINDINGS

A total of 159 HCWs were included. The AHHMS registered 341,078 hand hygiene opportunities. Overall baseline HHC was 31% (95% confidence interval: 30-32). A significant +18% absolute immediate effect (first five months) (95% CI: 17-19; P < 0.0001) and +13 percentage points (95% CI: 11-14; P < 0.0001) long-term effect (another four months) were recorded. HCWs working day shifts and short-term employees had a higher baseline HHC than HCWs working evening/night shifts. However, HCWs working night shifts achieved the greatest long-term effect with a mean +27 percentage point difference (P < 0.0001).

CONCLUSION

Placing an additional ABHR dispenser strategically within staff workflow significantly increased HHC among HCWs, demonstrating a noteworthy effect. The study is the first to report the effect on nursing home dispenser accessibility as a single intervention and to show a significant unmet potential.

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.

Factors that influence the implementation of innovation in aged care: a scoping review

OBJECTIVE

The objective of this scoping review is to identify factors that influence the implementation of innovation in aged care.

INTRODUCTION

Aged care is a dynamic sector experiencing rapid change. Implementation of innovations in aged care has received relatively little research attention compared to health care.

INCLUSION CRITERIA

This review included studies of any design, that examined the implementation of innovations in aged care settings.

METHODS

Searches were conducted in MEDLINE, CINAHL, AgeLine, and ProQuest Social Sciences Premium Collection for studies published between January 1, 2012 and December 31, 2022. The titles and abstracts of retrieved citations were screened by two independent reviewers. Full-text articles were screened by one reviewer to determine inclusion. Data were extracted in NVivo using a tool developed by the research team. Factors that influenced implementation were inductively coded, interpreted, and grouped into categories in a series of workshops.

RESULTS

Of the 2530 studies that were screened, 193 were included. Of the included papers, the majority (74%) related to residential aged care, 28% used an implementation theory or framework, and 15% involved consumers. Five key categories of factors influencing implementation were identified: organizational context including resourcing and culture; people's attitudes and capabilities; relationships between people; the intervention and its appropriateness; and implementation actions such as stakeholder engagement and implementation strategies.

CONCLUSIONS

Our findings can be used to develop practical resources to support implementation efforts, and highlight the importance of resourcing for successful implementation. Attention to community-based aged care, and greater engagement with theory and community is needed to promote research rigor, relevance and applicability.

Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting

BACKGROUND

Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland.

METHODS

We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding.

RESULTS

Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment.

CONCLUSIONS

Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time.

Hand hygiene compliance and its drivers in long-term care facilities; observations and a survey

Background

Hand hygiene is an important measure to prevent healthcare-associated infections in long-term care facilities.

Objectives

To evaluate compliance with hand hygiene recommendations by different nursing professionals in long-term care facilities and to investigate determinants potentially influencing hand hygiene and whether these differed between the different cadres of staff.

Methods

We conducted two sub-studies: we measured hand hygiene compliance of 496 professionals in 14 long-term care facilities (23 wards) through direct observation using World Health Organisation’s ‘five moments of hand hygiene’ observation tool. In addition, we performed a survey to examine determinants that may influence hand hygiene and to determine differences between different cadres of staff. We used a principal component analysis approach with varimax rotation to explore the underlying factor structure of the determinants.

Results

We found an overall mean hand hygiene compliance of 17%. There was considerable variation between wards (5–38%) and between specific World Health Organization hand hygiene moments. In addition, hand hygiene compliance varied widely within and between different cadres of staff. The determinant analysis was conducted on 177 questionnaires. For all nursing professionals, we found multiple determinants in four domains: ‘social context and leadership’, ‘resources’, ‘individual healthcare professional factors’ and ‘risk perception’. In two domains, several barriers were perceived differently by nursing assistants and nurses. In the domain ‘social context and leadership’, this included (1) how the manager addresses barriers to enable hand hygiene as recommended and (2) how the manager pays attention to correct adherence to the hand hygiene guidelines. In the ‘risk perception’ domain, this included a resident's risk of acquiring an infection as a result of the nursing professional’s failure to comply with the hand hygiene guidelines.

Conclusion

Hand hygiene compliance was low and influenced by multiple factors, several of which varied among different cadres of staff. When designing interventions to improve hand hygiene performance in long-term care facilities, strategies should take into account these determinants and how they vary between different cadres of staff. We recommend exploring hand hygiene determinants at ward level and among different cadres of staff, for example by using our exploratory questionnaire.

Trial registration

Registration number 50-53000-98-113, ‘Compliance with hand hygiene in nursing homes: go for a sustainable effect’ on ClinicalTrials.gov. Date of registration 28-6-2016.

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.