Healthcare-associated infections (HCAI’s) are the ones resulting from medical care or treatment in any setting (hospital, in- or out-patient, nursing homes, patient's own home) (HPA, 2013). Therefore, differentiating community from hospital acquired infection is crucial to finding its cause. HCAI’s include urinary tract infections, respiratory tract infections like pneumonia, surgical site infection and gastrointestinal diseases (HPA, 2013).
During the last 20 years, HCAI have become a critical risk to patient safety (Pratt et al.,2007).In the current context of the rapidly changing healthcare system, the protection of patients, families/ visitors and healthcare workers from HCAI has become more challenging and vital (Chan et. al., 2008). Clearly, this remains a global problem for hospitals (Sheng et al., 2005), with more than 1.4 million people acquiring infections in hospital per year (Pittet and Donaldson, 2006). Due to the high incidence of HCAI in British hospitals the public interest has been aroused by the reporting of ‘superbugs’ in the media (Gould et al., 2007).
World-wide outbreaks of various infections has increased awareness on the protection of frontline clinical staff, especially nurses who provide 24 hour direct patient care (Lam, 2011). Nurses are particularly more highly exposed and at risk of acquiring occupational micro-organisms than other healthcare workers (Kosgeroglu et. al., 2004), which are potentially transmissible to patients if incorrect prevention is applied. Also, infection prevention and control (IPC) has been high on healthcare providers’ agenda, especially in acute trusts in England (Healthcare Commission, 2006, Department of Health, 2007).
More interestingly, UK has the second highest (9%) HCAI’s compared in other countries a study (NAO, 2009) which range from 3-11.4%. Unfortunately despite clear and simple guidelines several studies confirm low compliance among nurses (Efthanthiou et al., 2011).
In this regard, compliance can be defined as the degree of constancy and accuracy with which the nurses are able to follow infection control procedures so as not to affect the overall safety of patients and their overall health.
HCAI entails financial and personal cost to the NHS (NAO, 2009). In UK each HCAI costs the NHS about £3000 (Department of Health, 2000), contributing to £1 billion a year and at least 5000 deaths (Pittet, 2005). Patients and their relatives are physically, socially and psychologically adversely affected, with risks to organisational reputation and other services (National Audit Office, 2009).
HCAI’s also impact greatly on morbidity; mortality and length of hospital stay. Patients with infections are also more likely to need more nursing and medical care than those without infection (Plowman, 1999). Data show that £150 million could be saved by implementing good clinical practice, which shows that resources are required to be redirected more wisely (Parliamentary Office and Science and Technology, 2005).
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This methodology is based upon Cronin et al. (2008) and Aveyard’s (2010) research process with reflection. I selected the topic, keywords, and inclusion and exclusion criteria, searched the literature, assessed the quality and relevancy of each article then identified themes. End-note web and email to save references and searches were used. English language articles only were included due to time restrictions and ability to interpret and excluded other languages.
Cronin et al. (2008) stated that the maximum time frame of 5-10 years is usually included. Moreover I also realized that there was a presence of ample literature studies pertaining to my topic and also themes were quite extensive (Cronin et al., 2008). So due to time and word restriction I decided to remove articles being too old. Various areas have been analyzed to be in tune with the inclusion and exclusion criteria. There has been a usage of empirical primary research, mostly published in journals. These are up-to-date, first –hand sources to answer research question. Peer/ double- blind reviewed and original articles are also included to enhance quality (Aveyard, 2010).
Studies from perspectives of trained nurses, students, healthcare assistants which appeared valuable, were included. Other healthcare professions have been excluded as when causes of non-compliance are established amongst a professional group, the relevant strategies to enhance compliance can be targeted towards this specific group, which may not apply to other professions. Non-research sources i.e. grey literature (books, posters, opinions, supportive letter, and literature review) policies, peer reviewed journals by expert opinion on have been excluded as they formed weak forms of evidence and cannot be relied on (Heck et. al., 2000).
I initially searched internationally to establish the scope but then I realised the question of result transferability and comparison. This is because resources issues, attitudes and healthcare systems in less developed countries vary to United Kingdom setting. However, I still included from developed and less developed countries.
After careful consideration of a diverse set of alternative keywords enabled me to capture fully available literature on a chosen topic (Price, 2009), within a limited time frame (Aveyard, 2010). Mine were (see appendix 5). As there were too many keywords, my librarian suggested doing different searches with dissimilar keywords. Also, selecting keywords not just in title but also in whole article was useful to enhance chances of relevant articles. There were many false negatives, contributing to answering the research question but did not contain the keywords searched, hence my long list of various keywords. The use of appropriate Boolean commands helped my search (Walliman and Appleteon, 2009). Therefore, when I obtained no articles I kept changing the keywords until I got some response. When I had many articles I refocused the repeated searches from different databases.
Student central was my major electronic academic University resource consisting of the most common, fast, efficient and revolutionary nursing databases (Aveyard, 2010). I used CINHAL, Medline, Science direct, EBSCOHOST, Department of Health; Infection Prevention Society (IPS). Google scholar generated quick but overwhelming, free academic full text articles (Davies and Logan, 2012) which I was unable to obtain via student central in a timely manner. I also used Business source premier database and gathered the research done by medical professions, other healthcare professionals, managers and psychologists. To achieve more thoroughness I searched common authors and infection control journals (Aveyard, 2010).
Network search was used which means identifying recent papers and then they were searched at their reference list to trace the original article which seem relevant (Timmins and McCabe 2005). This was the most effective and rewarding but tedious search method (Cronin, Ryan, and Coughlan 2008). I obtained some articles via ordering in library, but mostly was available online in full text. However, contacting one author directly was unsuccessful.
There were certain conflicting research areas that were required to be handled with. For example, words like nurses compliance/ non-compliance, causes, reasons, were not easily found and I was unsure if nurses were included in sample. Therefore, I read whole article to gain a better understanding of the study and their link with research question.
The next step is a research critique of my selected articles so as to maintain the quality (in appendix 7). This aimed to judge the value of studies, journal, process of peer review, the standing of the author and its claims (Cronin et al., 2008). This helped to gain more understanding about the research topic to aid answering the question. However, no research is perfect, hence the purpose of a critical review. Surprisingly most studies did not state clearly the research design or rationale as critique frameworks criteria recommend. As my research question is mainly qualitative in nature, I expected most of my studies to be qualitative from observations as these are more accurate than survey interviews. Some were non-experimental (Aveyard, 2010) but nevertheless included as different study aims lends itself to different hierarchy of evidence.
Among the many methods of data analysis, mixed methodology studies was used that combined qualitative and quantitative methods and computer programs. The quantitative studies used descriptive and/or inferential statistics. Qualitative studies used ethnographic, phenomenological, grounded theory approach. These methods appeared appropriate, although some limitations acknowledged. Thematic analysis is used in the next chapter where common themes and sub themes emerged once I collated the results of each article (see appendix 12), (Aveyard, 2010). A brief overview is displayed in tables (appendix 13) which helped me collate a vast amount of interrelating sub-themes and to separate them into main themes.
This is the research thematic critique. A research critique is an objective assessment of a studies strengths and limitations and recommendations for helping in bringing improvements in the study (Polit and Beck, 2011). The aim is also to analyse and synthesise the literature.
Attitude, Beliefs and Individual concerns: These include Emotional/ Psychological, Memory/lapse, Habit/Routine, Attitude, Social/cultural
Education, Communication and Professional Status: These include Knowledge Skills, Experience, Risk Perception, Peer influence, Role models, Communication
Individual concerns, attitudes, beliefs and behaviour: Most of my studies arrived at the consensus that individual factors are found to influence acute care nurses’ non-compliance with infection control policies. They include individual concerns, attitudes, beliefs, habits, ritualistic practice and memory lapse/retention, allergies and different size of products.
This study was conducted in UK amongst 52 acute elderly medical wards and departments in 2007, 13 medical wards, 6 nursing control groups and 7 interventional random ward groups which had trainers. They aimed to determine whether the introduction of the 2 clinical skills trainers for 4 months improved compliance with infection prevention and control practice. The authors seem credible from infection control background
Korniewicz et al, 2010) concluded that nurse’s poor self-efficacy or negative attitude towards time barriers are factors associated with hand hygiene compliance during clinical practice. They undertook this study in South Florida, University Oncology Hospital with a sample of 58% invited participants. They mentioned giving some Centres for Disease Control and Prevention (CDC) guidelines to participants as part of the study aims to see impact of compliance but this was stated near the end of study (Korniewicz et al, 2010)
This explains why staff in my setting says that masks are too tight and they cannot breathe properly with masks on, despite having been fit tested well (Martel et. al., 2013).
Chor et al. (2012) concluded individual perception contributed to reasons of poor compliance, but did not explain this fully. The aim of the study was to explore the practice of infection control measures during 2009 pandemic of HNN1 infection among healthcare workers in 120 hospitals in Hong Kong, Singapore and UK in 2010, via a cross-sectional study of 2100/6318 self-administered anonymous questionnaires (Chor et al., 2012).
Dyson et al., (2011) study based in NHS Trust UK, (similar to my own setting) revealed many themes and sub-themes regarding barriers and levers to hand hygiene using psychological theory to evaluate these (Dyson et al., 2011). Motivation was a factor, participants expressed complacency and competing priorities as barriers to compliance. A negative attitude was cited as a barrier to hand hygiene compliance, rather than a lack of understanding by a matron’s statement. This highlighted my practice as I have seen nurses, especially trained who are aware of appropriate hand hygiene but adversely affected by occupational stress levels. In a way that they do not wash their hand long enough according to recommended guidelines, including myself (Sattar and et.al. 2002).
Hanna et al., (2009) studies psychological processes underlying nurses’ hand washing behaviour. They argue that perceived risk is influenced by training and occupational stress levels. Therefore this leads me nicely to the next theme of education, professional status and communication (Hanna et al., 2009). Despite limitations it adds some value on findings which are similar to my own healthcare setting and offers an explanation to my hunches in practice observation. However, I disagree with memory lapse mentioned by Charge Nurse. For example, in my setting staff with varying cultural and educational background and experience will perceive the risk of infection differently. HCA will be less able to risk assess properly than a trained nurse or even infection specialist nurses
Guided by articles’ themes, I have adapted them to suit my evaluation. The literature has answered my research question to my surprise either minimally directly or the majority indirectly and some coming from different perspectives. As these themes occur frequently and I relate to them in practice and due to restricted word limit, I have chosen them.
Individual concerns, attitudes, beliefs and behaviour
Most of my studies arrived at the consensus that individual factors are found to influence acute care nurses’ non-compliance with infection control policies. They include individual concerns, attitudes, beliefs, habits, ritualistic practice and memory lapse/retention, allergies and different size of products.
There is a notion among nurses that patients and relatives are fearful of their looks when wearing PPE. This disrupts the professional relationship with the patient and family. Staffs also consider their own vulnerability to catching infection i.e. those who rarely go off sick may not wear PPE. Other factors that lead to non-compliance are allergies, the inappropriate sixe of equipment which interferes with manual dexterity.
Education, knowledge and skills including professional status and authority with communication
Various reasons in terms of non compliant attitudes by nurses towards infection control have been identified. These are related to education, knowledge and skills, professional status in terms of mentoring and communication issues. The major ones have been discussed in the below mentioned paragraphs.
The very first reason is about staff ignoring policies. I relate these significantly to my practice because the opinion of staff about compliance is not meaningful. This aspect does apply in my setting in other circumstances, especially by managers (Spector and Brannick, 2010). For instance, in my setting on numerous occasions when the ward is closed due to infection, staffs are moved to another area. This is irrespective of the policy which states that contaminated area must have established numbers of staff to prevention cross infection and must not be moved within 48 hrs. Also, Site Managers permit admissions to ward despite being closed (Sattar and et.al. 2002). The Infection Control Team additionally ignores policy which states that if we have a patient with MRSA, catheter and open wounds should ideally be isolated. But due to no isolation facilities available, they are kept with others. The cycle of causes to non-compliance returns to lack of resources (Suing and Davis, 2009). This is turn co-relates to the theme reason of non-compliance whereby managers responsibility to ensure adequate facilities is lacking.
Another reason is Lack of knowledge in using infection control products. My experience is that staff, including myself do not view new products as safe or effective even despite being updated. Also, more importantly product representative come to the ward to show a brief demonstration but they are not really in touch with direct patient care. Hence their demonstration is futile to our understanding and application to practice. For example we recently had no swine flu masks and the current company collapsed, and there were no companies producing similar masks.
This created huge delays in effective communication. I expected to ensure my ward had enough stock, and educate them all with correct information in timely fashion (Smith and et.al, 2008). Now when they finally succeeded and the masks were delivered, more problems arose. The staff complained being unable to breathe well, extremely claustrophobic and being too tight (Stein, Makarawo and Ahmad, 2003) I realised only then that no size was indicated on mask. After the period of flu the mask representative came to our infection control meeting. He failed to give us basic application especially removal instructions. This further led to no passing of crucial information to colleagues to help prevention infection and ensure compliance. Even senior nurses do not have enough knowledge (Scheithauer and et.al. 2011).
I have experienced many overseas nurses who have settled here are very knowledgeable, practical skills and experienced. They are found to comply with all the infection control procedures. Yet due to some reasons they still are not promoted in a senior position, whereas less qualified with less experience are in senior positions. This relates to the themes of leadership issues. Who is most suitable to communicate infection control issues effectively? Those with experience, knowledge and skills? Or those lacking knowledge, skills and experience but who are in senior positions.
The fourth reason is lack of effective communication. This suggests a missing link of effective communication to staff on the floor. This is not surprising in my area as difficulty disseminating any change or even existing policy to staff persists. This is there despite staff being aware of an infection control communication folder to read and sign. Even when I remind staff, they say that there is no time for them to have a thorough reading of the procedure. There are times when I seem to them as a harassing bully. In my practice the time of training issues relate to new staff is that they have to wait for so many days for infection control training even after starting ward work.
This tendency poses a risk to the very safety due to knowledge communicated deficit (Stein, Makarawo and Ahmad, 2003). A problem with communication is that when I am unable to generate policies and protocols in a timely fashion then how I can expect other staff to do this? Therefore in order to resolve this problem I have had to print folders of mass infection control information. Here again, when do staff have time to thoroughly read more than 50 page per policy?
Management and Organisational Factors
Randle and Clark (2011) conclude that a number of management related issues are present which are acting as barriers to infection control compliance (Randle and Clark, 2011). For example lack of facilities, side rooms, non-engagement of financial authority, organisation, high staff turnover, high workload, even when professional training is good. More importantly the infection control nurses opinions were that intervention driven by senior NHS mangers necessitated organisational change and they believe the need to set an authority to enforce the much needed change (Smith and et.al, 2008).
However, these are professional opinions which are considered as low level of evidence, despite being professional. Have they analysed the data objectively? All these issues exist within my setting significantly. Yet no-one is trying to change this. Without money or attitude we cannot change anything. Hence I suggest cash injection into NHS.
Farrugia and Borg (2011) conclude that there is a poor communication between departments where authority and management as well as organisational responsibilities are not lived up to. Ward (2010) concludes that rushed for time, cutting corners, reduced staff implies increased workload (Ward, 2010). Due to this there is a creation of adverse working environment for nurses to comply with infection control mandates. This leads to making of infection control a low priority, in response to cost cutting by adopting less safe behaviour. Also there is lack of authority figures e.g. mentors, managers to ensure compliance. Even if present, they are not in a situation to guide the juniors. This is on account of time factor, ever changing policy and presence of a belief that the understanding for infection control practices comes only by experience and thus there is no need for any training.
Efstathiou et. al., 2011 conclude that organisational factors like resources, policies and time impact on compliance (Efstathiou et. al., 2011). More importantly due to professional hierarchy physicians influence nurses compliance, as nurses follow doctors orders even if wrong. Also significant reasons among others are that there is a tendency among juniors that if the senior nurses follow the compliance then only we would be following the measures (Schears, 2012). Other than this the organizaional factors related to high staff turnover leads to lack of team stability of nurses. This further leads to presence of a poor infection control mechanism on part of the concerned organization. It happens as a hospital may put significant amount of efforts to train the nurses but if they leave the organization then it beocmes very costly for them.
In the present research study I have discussed three themes. Methodologies in nursing research can be grouped into 2 sections –qualitative and quantitative (Martin and Thompson (2002). Nurses and nursing research play a vital role in the development of evidence –based NHS to improve and sustain high quality care and appropriate organisation of health services (Martin and Thompson, 2002).
However, as a newcomer to research I soon discovered that is was better to view research on a continuum rather than as a rigidly separate qualitative or quantitative as depicted by Clifford et. al (1996). This was because many studies can use mixed approaches to data collection.
Most commonly used data collection methods in qualitative research are in-depth interviews, focus groups, observations that are also reflecting my discovery (Boyton and Greenlaigh, 2004). However, the data collected through observation is especially limited when actual inspection is sought rather than participants’ interpretation (Boyton and Greenlaigh, 2004).
For e.g. the extent to which nurses comply with infection control practice can be measured more accurately through direct observation than other methods, as it is well known that participants, may not accurately self-report their behaviour. As per my professional practice as well as the studying the literature written by various authors it is clear that there is a presence of good practices by staff in terms of compliance towards infection control norms. However, some are in a need of attention. In this respect, several barriers have been identified in terms of handwashing (Tilmouth and Tilmouth, 2009).
Some of them are knowledge deficit of guidelines amongst healthcare professionals, insufficient facilities, lack of time, lack of hand washing facilities lack of good leadership, high quality guidelines and a culture shift.
Why are we still having problems with infection control compliance despite some facilities increased and greater understanding of non-compliance? Is it finance and attitude of managers, quality of products, constant change of policies, products, staff, companies, patient turnover; or lack of communication and understanding of polices as well as disseminating correct information. Working in isolation cannot prevent infections (Smith and et.al, 2008).
All healthcare professional are responsible. Moreover, existing significant litigation costs arising from clinical negligence claims involving HCAI’s are recognized to be largely, though not completely avoidable. Still they seem to be underappreciated by healthcare organizations (Goldenberg and French, 2012)
Hence, it is recommended that commitment is required from senior managers to change culture, apply measures to reduce risks if infection as well as enable provision of evidence-based guidelines. Furthermore whose responsibility is it to clean? The motto well established is that infection control is everyone’s business (Suing and Davis, 2009).
The causes of nurses’ non-compliance and solutions potentially in the literature have been assessed but some cannot be resolved as they are outside our control e.g. environmental causes, media coverage. However, I disagree with media coverage as it is the responsibility of hospital to protect staff and patients. Most studies have focussed on professional perception via interviews and compliance rates. Therefore there is a need for more observational studies to explore causes of non-compliance per profession, instead of mass population. Farrugia and Borg, 2011 suggest ICLF to bridge the gap, hence recognising complex challenges for extensive organisational change. Ward suggests need for clear student guidelines of good practice (Farrugia and Borg, 2011).
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