Abstract
Background
Hospital acquired infections (HAIs) increase length of hospital stay and lead to poorer clinical outcomes. HAIs are viewed as preventable through risk monitoring and prevention of transmission. These activities are frequently missed. This study explores missed infection control activities through the lens of missed or rationed care.
Aim
To determine the factors that contribute to infection control activities being missed.
Methods
Semi-structured interviews were conducted with eleven nurses with infection control expertise.
Findings
Four major factors were identified as contributing to infection control activities being missed. These are systemic factors such as poor staffing and skillmix which contribute to time constraints and difficulties with identifying signs of infection; environmental factors such as ward layout and access to Personal Protective Equipment (PPE); organisational factors including lack of managerial support and interprofessional relationships; and personal factors, primarily the priority given to infection control by the nurse and knowledge, understanding and application of the principles of infection control.
Discussion
Policy responses to HAI frequently focus upon surveillance and education however, resourcing, organisational and interprofessional support and hospital layout all contribute to infection control activities being missed.
Conclusion
Further research is required into the impact of systemic factors upon infection control activities being missed.
Keywords
Summary of Relevance
Problem or Issue
To determine the range of factors which contribute to infection control activities being missed.
What is Already Known
Hospital Acquired Infections are preventable but activities to prevent transmission are often poorly performed.
What this Paper Adds
Infection control activities are missed due to systemic and organisation factors, the physical layout of the ward, the priority placed on infection control by the nurse and their knowledge of and understanding of the reasons for infection control precautions.
1. Introduction
Restrictions on healthcare budgets, growing concerns about the impact of prolonged antibiotic use and emergence of new antibiotic resistant pathogens have increased government concerns with hospital acquired infections (HAI) (
Australian Commission on Safety and Quality in Healthcare (nd), 2019
). The extent of HAIs in Australia is difficult to determine due to underreporting but Mitchell et al., 2017
estimate that there may be as many as 165,000 HAI/year in Australian hospitals. The Australian Commission on Safety and Quality in Healthcare (nd), 2019
identify 180,000 patients as acquiring a HAI /year creating a considerable fiscal burden on health systems.HAIs are potentially preventable.
Russo et al., 2016
view surveillance as the primary means of preventing HAI, noting that surveillance is often implemented in response to government initiatives. Auditing and accreditation against standards have become a major feature of infection control in Australia. The Australian Guidelines for the Prevention and Control of Infection in Healthcare were developed conjointly by the Australian Commission on Safety and Quality in Healthcare and NHMRC and released in 2010. Underpinning the guidelines is the belief that HAI are preventable “through the implementation of practices that minimise the risk of transmission of infectious agents.” (Australian Government, 2010
: 7). Management of risk is dependent upon regular infection prevention risk assessment. The guidelines are accompanied by a toolkit for implementation. The Australian Commission on Safety and Quality in Healthcare has also commissioned Hand Hygiene Australia to implement the National Hand Hygiene Initiative (NHHI) from 2008. Hand Hygiene Australia list their responsibilities as: healthcare worker education; and auditing and performance feedback on hand hygiene compliance with the five moment of hand hygiene (Hand Hygiene Australia (Sabariego et al.) (n.d.), 2019
). A third national strategy is the Antimicrobial stewardship program which was established in 2013 by the Australian Commission on Safety and Quality in Healthcare to monitor antibiotic use (James et al., 2015
).This paper explores the perceptions of nurses with infection control expertise of the reasons why infection prevention activities are not performed. There are several studies in which infection control professionals and nurse managers identify barriers to infection prevention.
Randle and Clarke, 2011
view lack of facilities including side rooms and the attitude of medical staff as the primary barrier to implementation of the code of hygiene which establishes guidelines for infection prevention in the UK. Gurses et al., 2008
argue that reliance upon guidelines may fail to address some of the underlying systemic factors contributing to poor compliance. They note considerable differences between facilities in success in preventing infection associated with unfamiliarity with guidelines, ineffective inter-provider communication, workload and ward culture. Ider et al., 2012
conducted focus groups with clinical managers and infection control staff in Mongolia and found that systemic factors including lack of guidelines, poor monitoring and disincentives for reporting rates of HAI contribute to poor practice. These factors are exacerbated by organisational factors including lack of budgetary control, limited capacity for surveillance, limited infection control knowledge and performance of competing tasks by infection control clinicians. Halton et al., 2017
also note structural factors highlighting the impact of organisational resistance and lack of access to clinical leaders by Infection Preventionists as a key factor in poor infection control practice. There are fewer studies exploring ward nurses’ perception of why infection control activities are missed. Shah et al., 2015
interviewed a range of healthcare workers and associated poor performance of infection control activities with perception that these activities were the responsibility of other professions, most commonly nurses; the prioritisation of other activities and medical hierarchies. Jackson and Griffith, 2014
found that infection prevention is driven by self-protection, with nurses more likely to take precautions when coming into contact with body fluids or situations perceived to be dirty.This study adopted a systems approach to infection prevention. It sought to explore failure to perform infection control activities through the lens of missed or rationed care. Underpinning this approach is the belief that when time poor, nurses will ration care, delivering care which addresses imminent clinical concerns first over other issues such as patient emotional needs (
Papastavrou et al., 2014
; Patterson et al., 2011
), or perhaps infection control issues. This is not new. Experienced nurses have always rationed care according to patient need, resources and time (Schubert et al., 2009
). What is new in the last two decades is the extensive research on missed or rationed care in the light of the major health care budget cuts introduced in most developed economies in both public and private health care systems (Papastavrou et al., 2014
). Evidence suggests that essential care may be missed or incomplete because of lack of resources, or, because of austerity measures arising from the Global Financial Crisis (Palese et al., 2015
; Willis et al., 2017
). A number of researchers in this field have used the MISSCARE survey tool developed by Kalisch to make their argument (Kalisch et al., 2009
).Kalisch et al., 2009
: 1510) defined missed care as “required [nursing] patient care that is omitted (either in part or in whole) or delayed.” The majority of researchers using the Kalisch tool concur with her initial findings that nursing care is often missed due to too few staff (labour resource), time required for nursing interventions (time scarcity), poor use of existing staff resources, ‘it’s not my job’ syndrome, ineffective delegation, habit, and, sometimes, sheer denial (Kalisch, 2006
; Papastavrou and Panayiota, 2012
). Kalisch’s work has been replicated in several contexts within North American, Europe, Australia, and New Zealand (Blackman et al., 2015
; Dabney and Kalisch, 2015
; Harvey et al., 2017
). In many instances this work does not capture the difference between nurse expertise, care not done because of prioritisation, and as a consequence missed, that may compromise quality of patient care and cause harm such as infection prevention and control.This paper reports interviews conducted with nurse experts as part of a study to develop a tool to measure missed infection control activities replicating the methods utilised by Kalisch in developing previous MISSCARE surveys (Dabney & Kalish, 2014;
Kalisch and Williams, 2009
). An initial review of literature was undertaken to identify infection prevention activities which were perceived to be omitted or performed poorly. The literature review informed the development of an interview schedule. Interview data was then analysed for infection prevention activities that are missed and the reason these activities are missed. This data informed the development of a draft survey which was trialed with a small group of infection control experts who provided written feedback. The feedback was then incorporated into the final draft of the survey which was delivered online to a larger cohort of infection control experts. This paper reports on the themes that emerged in interviews conducted with the nurses.2. Methods
2.1 Data collection
Data for this paper is drawn from semi-structured interviews conducted with eleven nurses with expertise in infection control recruited through an expression of interest in the Australian College of Infection Prevention and Control (ACIPC) electronic newsletter. This newsletter enabled recruitment across a wide network of infection control practitioners across Australia. All participants had expertise in infection control with eight participants currently employed in infection control roles (see Table 1). The interviews were conducted by two interviewers (EW and JH) using an interview guide that addressed infection control activities that participants believed were missed; the reasons why these activities are missed; nurses’ capacity to recognise the signs of infection; and other care activities which if missed, may contribute to development of infection. The interviews were of 30 to 45 min duration and were transcribed verbatim by an independent transcription service.
Table 1Characteristics of interview participants.
| Pseudonym | Nursing Role | Workplace | State |
|---|---|---|---|
| Alice | Infection control/ quality assurance | Multi-site/ multi state role | South Australia |
| Bonnie | Infection control (16 years) | Private sector | New South Wales |
| Charlotte | Perioperative / previous infection control and quality assurance role in theatre | Private sector | South Australia |
| Donna | Clinical Nurse Manager (17 years) | Public sector | Victoria |
| Elise | Infection control | Rural public sector | Victoria |
| Frances | Infection control/ academic | Multi-site | New South Wales |
| Grant | Academic /casual nursing work | Multi-site | Queensland |
| Harriet | Infection control | Public sector | New South Wales |
| Isabelle | Casual/ previous infection control role | Multi-site | Western Australia |
| Jenny | Infection control | Public sector | Victoria |
| Kerry | Infection control | Public sector | Australian Capital Territory |
a Years in role documented if participants mentioned it, were not specifically asked.
2.2 Data analysis
The transcripts were analysed deductively and inductively. The initial framework for thematic analysis was provided by the interview schedule with a focus upon infection control activities which are missed and the reason why they are missed. Additional themes were added upon review of the transcripts (
Fereday and Muir-Cochrane, 2006
). Data were double coded by four members of the research team working independently of each other and managed in NVivo12.2.3 Ethics
Ethics approval for this project was obtained through the Flinders University Social and Behavioral Research Ethics Committee.
3. Results
This paper addresses infection control experts’ perceptions regarding factors contributing to missed care. Four subthemes emerged from the data relating to systemic factors; physical factors (eg: ward layout); organisational factors and personal factors.
3.1 Systemic factors
Systemic factors are related to the health system and include issues such as funding, staffing ratios and health policy. Systemic factors have been widely implicated in other nursing care activities being missed (
Blackman et al., 2015
; Dabney and Kalisch, 2015
; Kalisch et al., 2014
). Systemic factors were also identified by our respondents for infection control activities. A primary concern for many participants was lack of time which was related not only to capacity to undertake infection control precautions but also to perform basic nursing care to prevent infections. Alice notes for example, that:… they just don’t have time to wash their hands before they clean the person’s teeth or something like that. So it’s time but I think sometimes nurses are aware that what they are missing but they – because they’re so time poor they go ‘I know I’m not doing this as well as I should be but I either do this half as well or not at all’ (Alice).
Lack of time was also identified in failure to follow transmission-based precautions. Grant identifies the time taken to put on personal protective equipment (PPE)
…well, it takes time to put those on properly, it takes time to take those off properly and if you’ve forgotten something …and you go back in, then you’ve got to get all dressed up again and that all takes time and if you already – if we’re already busy, then that’s an onerous expectation for us to do (Grant)
Lack of time to undertake infection control precautions was related to staffing, with understaffing identified as a factor in missed infection control activities. Bonnie states that “sometimes it is a time thing, sometimes it’s a, just, I just can’t do it, because of staffing”. Likewise, Alice views infection control precautions as more likely to be missed when staffing is poor.
….it’s going to be worse when you’re under-staffed, when you’re busy things always get worse there and that’s when they think by cutting the corner of not putting on your PPE or doing the hand hygiene they’re saving time (Alice).
Skill mix was also implicated. Charlotte argues that skill mix may contribute to work intensification which in turn, leads to a task being missed. She states that a “lot of these things are based on poor skill mix of staff members because then you’re rushing and you tend to miss some opportunity that you could be undertaking” (Charlotte). For Elise, the employment of Assistants in Nursing may contribute to the development of infection due to lack of knowledge and expertise in recognising symptoms. She argues that “they’re expected to pick up if there’s an outbreak going. Not surprised that it doesn’t happen” (Elise).
Respondents identified funding shortfalls as a second systemic factor contributing to infection control activities being missed.
Mitchell et al., 2015
surveyed Australian infection control units to determine level of staffing and resourcing. They found an average of 1 FTE infection control nurse per 152 overnight patient beds, with the private sector having fewer infection control staff on average than the public sector. While the number of dedicated infection control staff was not identified by our participants, funding shortfalls are viewed as leading to difficulties in implementing programs. Elise reflects upon the impact of funding on antibiotic stewardship.Health is ridiculously underfunded but the – we need more, particularly around antimicrobial stewardship, that really needs a decent amount of money if they want to keep antibiotics for the future (Elise).
Lack of funding is also implicated in capacity to purchase equipment and programs to manage infection control. Harriet notes that the importance of:
….ensuring that we have adequate staffing … and then having enough of resources to be able to buy some of the latest developments that are available in infection control to make life easy but which we don’t buy in our hospitals because we don’t have the money.
3.2 Environmental factors
A second set of barriers to infection control relate to environmental factors such as ward layout and access to equipment.
Chagpar et al., 2010
view environmental design as impacting on perception that hand hygiene could be added to workflow and but also performance of hand hygiene. They found that infection control practice was often inhibited by poor access to hand basins and PPE. Similar trends were noted by our participants. Grant in describing one site he worked in states “the health facility has one sink[hand basin], it’s down the other way and they don’t provide alcohol-based hand wipes because of the risk of fire or … complication, those things … all impact on our ability to do it.” Consequently, infection control nurses have to be aware of access issues. Jenny indicates how she addresses issues of access to PPE through environmental audit.Gowns, … you do have to be in the know. I do think that’d be really tricky if you’re agency. But goggles can be quite difficult to find and that’s one of the things that we looked for in those environmental audits. We always ask somebody to show us where the PPE is and when the staff on the ward can’t find it then we know that it’s not in the right place.
Infection control management can also be inhibited by outdated ward layout. Elise notes the importance of ward layout to infection control.
[T]he future is actually the way we structure hospitals and the materials that we use and those sort of processes will, as infections get nastier and we’re running out of antibiotics, I think that sort of stuff will probably come a bit more to the fore
The use of multi-bed wards is a significant barrier to infection control. For Bonnie
…the way things are designed, it’s just really, really hard to isolate a person in a ten-bed room, and we use what we call magic curtains, so that means just pull the curtains around the bed, and then the poor person is stuck behind them.
Older hospital designs within the public sector can also involve the sharing of toilets and foyers. Harriet notes that her workplace has “very few single rooms. And then some of them – some of them have a shared – don’t even have an ensuite. So, all of these factors can make maintaining infection control really hard.”
A third environmental factor related to overstocking of rooms. Kerry states that
…nurses are bower birds and they like to have more equipment in their procedure rooms than they need and that’s all becoming contaminated with the person’s – and all their patient, of their own flora in a room.
This is viewed as problematic as noted by Jenny, the room is “not being cleaned properly between patients because there’s too much equipment in there for them to go to clean it properly.”
3.3 Organisational factors
A third set of barriers to infection control can be attributed to organisational factors.
Halton et al., 2017
surveyed Australian and New Zealand infection control prevention specialists who identified lack of leadership and organisational resistance to infection control as precipitating poor infection control practice. Lack of managerial support was identified as inhibiting good infection control practice by our participants. Bonnie notes for example that:….if you’ve got a management that’s engaged, you’ll generally find your staff are engaged. If your manager is not interested, then it’s very uphill work finding anyone who wants to be involved with infection control doing the right thing…
Managerial engagement with infection control is reflected in ward culture. Jenny argues that “leadership makes the difference [to ward culture] and there are some wards that have just really embraced – they’ve embraced infection control”. When the ward culture does not promote good infection control practice, nurses may modify their practice to reflect that culture. Grant views clinical role models as having an impact on the practice of nursing graduates while Frances notes that “for many nurses they will take on the culture of what they can see, … the culture of the ward, … ‘oh we don’t really need to do that’, [they] more likely will not do it.”
Lack of managerial support also contributes to lack of financial support and educational opportunities for infection control, lack of funding for information technology and research and limited access to infection control expertise (
Halton et al., 2017
). Mitchell et al., 2015
found while ratios of dedicated infection control staff to beds were consistent across the public sector in Australia, participants from smaller hospitals identified limited access to microbiologists and infectious disease specialists. Limited access to infection control specialists has been found to lead to poorer outcomes (James et al., 2015
). Participants in this study reflect upon the lack of investment in infection control technology and education. Harriet identifies the additional work created by not having access to information technology. “We don’t have a database or a proper system there – it can generate numbers to us or generate significant information… in a timely manner”. Charlotte bemoans the impact of limited professional development opportunities. “There has to be respect given to education, to monitoring practise and nurturing on the floor to build sound infection control principles in the staff coming through.”Interprofessional relationships can also hinder infection control. Dedicated infection control prevention positions are largely filled by nurses. This can be problematic when monitoring the practice of other professions.
Brown et al., 2008
argue that nurse management of infection control precautions can be disrupted by medical staff breaching boundaries established to prevent the spread of infection. For one respondent this arises from a focus upon task performance rather than considering how the task is performed. She states that:…a doctor may clean his or her hands with alcohol gel as he[she] approaches the patient, but when they actually gets to the patient’s bedside, they pull the curtains around the patient in order to examine them. So in their mind, they’ve done the alcohol gel before they’ve approached the patient… [They] might be quite shocked that touching curtains takes away from having just cleaned their hands (Frances).
In addition, nurse subordination to medicine can lead to difficulties in challenging poor hygiene practice, creating uncertainty as to when to challenge poor hygiene practice (
Brown et al., 2008
). Shah et al., 2015
note that senior medical staff may consider themselves as independent practitioners who are not subject to hospital policies they disagree with. Alice identified poor understanding of transmission-based precautions among medical staff that nurses are reluctant to address.Unfortunately, there’s a bit of that hierarchical system where people don’t want to tell doctors off and say that you’re doing the wrong thing and they never improve and they’re probably the worse when it comes to infection control practices
Another nurse working within a rural hospital argues that medical staff may not accept correction. She identifies difficulties in providing advice to the general practitioners staffing that hospital.
….we have GP’s here so we don’t have to deal with physicians….They’re very – sometimes they can be very difficult. That can be complex when I do all the antimicrobial stewardship audits, so when I’m critiquing a doctor on how they’re prescribing antibiotics, that can get very interesting. (Elise)
3.4 Personal factors
A final set of barriers to infection control relate to the individual nurse. While some respondents challenge an individual as opposed to systemic approach to infection control management, others argue for a focus upon the individual. Harriet states for example, that
If you want to maintain a high standard you will do everything properly. But others will do shortcuts – will take shortcuts. So that’s the frustrating part of infection control because it is so dependent on the individual who’s putting the practice into place.
A focus upon the role of the individual nurse is also evident in discussion of the omission of specific infection precautions. Table 2 outlines the types of care that respondents identified as being missed in their workplace. This table demonstrates that despite recognition of the impact of systemic and organisational factors, blame for the omission of activities is often attributed to the individual nurse.
Table 2Examples of missed infection prevention activities.
| Activity Missed | Demonstrative quote |
|---|---|
| Aseptic no touch technique -auditing or reviewing of practice -fetching additional equipment in middle of dressing - poor maintenance of sterile field | Inadvertently misplacing [items] onto the sterile field because the field is laid out and then the nurse needs to leave to get more equipment, because everything wasn’t assembled at the time (Frances) |
| Care of IV lines -not keeping system intact (eg detaching IV line to change clothing) - not checking IV site for signs of infection - not using aseptic technique when inserting lines - not capping IV sites | …it’s really easy to put a patient into an item of clothing and just disconnect the line and reconnect it through the sleeve. The better way to do it is to, actually undo it all and thread it through, because then you’re maintaining your continuous line (Bonnie) |
| Catheter care -perineal hygiene | I don’t think that people realise that having a catheter in and keeping it clean is important (Bonnie) |
| Coming to work unwell | One area that we nurses don’t do very well, is taking time out to recover themselves or knowing when they should be coming and shouldn’t be coming to work (Donna) |
| Disposing of clinical waste | Waste is one of my bug bears. Clinical waste and what is clinical waste because everywhere I go, everybody seems to interpret the guidelines differently (Elise) |
| Environmental cleaning -cleaning of patient areas -Cleaning of equipment between patients | I would have to say having been a perioperative nurse spanning over forty-seven years I think the environmental cleaning of our operating theatres… is less than adequate (Charlotte) |
| Five moments of hand hygiene | Well the data certainly shows that health care workers appear to get right the moments that are seen to protect them, so after a procedure and after touching a patient…they seem to be done more correctly than before touching a patient, or before undertaking a procedure. (Frances) |
| Patient hygiene -hand washing -mouth care -showering prior to theatre | A lot of people don’t realise that you can get really bad infections from not doing mouth care properly (Isabelle) |
| Recognising signs of infection | I think though, that there is a reliance these days on looking at the machine and the number on the machine, and not looking at the patient and saying, hang on, this makes no sense. (Bonnie) |
| Routine screening of patients | The protocol all around Australia if you come in from a long-term care facility…nursing homes or you know a disability house, you should be screened but that probably happens maybe if we’re lucky 50% of the time (Kerry) |
| Timely implementation of isolation procedures | People isolate [in] rooms…but then fail to actually implement isolation precautions i.e. the PPE (Donna) |
| Use of PPE inappropriate use of gloves -forgetting asepsis when wearing gloves - inappropriate order of disrobing | I’ve seen them very often go into … room and not wear the appropriate [PPE] simply because they don’t understand the implications of what they’re doing. (Harriet) |
| Wound care -replacement of dressings | …the dressing is not great, so we’ll just tape over it (Bonnie) |
Two central reasons are offered for poor individual practice: 1) the priority given to infection control by the nurse and 2) knowledge, understanding and application of the principles of infection control.
Ebright et al., 2003
argue that time pressure leads to ‘stacking’ which involves prioritising tasks in relation to work demands. In a later study, Patterson et al., 2011
found that when resources are limited or if demand is unpredictable nurses give priority to actions which address imminent clinical concerns over other tasks. Respondents to this study indicated that while nurses perform infection control precautions well when there is sufficient time, routine infection control activities are “low on the priority list” (Kerry) and may be sacrificed for other activities when time is poor. This is supported by Alice and Grant in the responses above regarding time restraints and was identified by other studies. Shah et al., 2015
interviewed British health care workers about non-compliance with infection control practices and found that while their respondents were aware of infection precautions, competing demands were often given higher priority due to workload demands. A decision to take short cuts with infection prevention activities was rationalised by clinician assessment of level of risk associated with omitting prevention activities. Risk assessment was also evident in this study. Grant associates the priority given to infection control activities to nurse perception of the risk of not undertaking preventative activities. He states that “I think there’s a lot that comes down to clinicians’ or health professionals’ believing the risk of either following or not following infection prevention guidelines” (Grant). Bonnie argues however, that the low priority given to infection control activities may be due to limited knowledge as to why these activities are expected. She argues that nurses may not perform precautionary activities as:“I don’t know the rationale for why I’m doing this, and I’ve got to cut something, because I just can’t do it all, so let’s stop doing whatever it is.” And that becomes a habit over time if you’re in a facility where that’s happening all the time.
A second factor is “lack of knowledge and lack of awareness” of infection control (Isabelle). While there is some concern with the currency and quality of university teaching of infection control, respondents were more likely to identify the application of this knowledge as contributing to poor infection control practice. Harriet argues that:
…they don’t understand ‘why’ the procedure is in place. So it then comes - boils down to okay here you are, here’s the guidelines, here’s the sign. The sign says that I need to do this, do that. That’s it, they’ll just follow that sign. But there’s no thinking applied, or no rationale applied or is there any way in which if something doesn’t suit the activity that they’re doing, can they think outside the box and take appropriate measures accordingly
Frances questions whether nurses understand their role in causing infections and argues that “they [nurses] often see infections as being like par for the course”. For other respondents, nurses fail to understand the impact of non-performance of the fundamentals of nursing care on infection control albeit mouth care, patient hygiene or changing the bed. Elise states that:
I don’t think they connect those dots, I really don’t. And even more basic than that, changing the bedsheets when patients have wounds and stuff, it’s like, well, once the patient has been in those sheets for 24 h, oh, they’re still clean, like … they look clean but microbiologically, change the sheets so we have a fresh set and we’re decreasing the bacterial load in the chances of that person getting an infection. They don’t connect the dots.
4. Discussion
This paper has applied a missed or rationed care framework to failure to perform infection prevention activities.
Kalisch and Williams, 2009
identify three antecedents to missed nursing care: lack of human resources (eg: number and skill mix of staff, work intensity and lack of time), lack of material resources and communication breakdown. These factors were evident in this study. Time restrictions were identified by our respondents as a major impediment to performance of infection prevention activities. The performance of infection prevention tasks, in particular, and use of personal protective equipment (PPE) was seen as time consuming. Kaba et al., 2017
found that nurses viewed the use of PPE as taking 20 min to 2 h per shift. Time restrictions are exacerbated by staffing levels and lack of senior staff. Previous research has identified a link between staffing levels, skillmix and rates of hospital acquired infection (Griffith et al., 2009
). Zingg et al., 2015
in their systematic review found no less than 10 key components for effective infection prevention, including the level of pool or agency nurse use, hospital bed occupancy, ergonomics of equipment, guidelines and education and behavioural change programs (Zingg et al., 2015
). Participants in this study argue that staffing levels are associated with the ‘cutting of corners’ and failure to recognise the signs and symptoms of infection.Poor funding for infection control activities was also identified at both a systemic and organisational level. At a systemic level, respondents identify insufficient staff and resources to implement programs such as antimicrobial stewardship while organisational funding is related to lack of investment in infection control technology and education for infection control staff. Organisational funding is related by participants to the extent to which hospital management engages with, and the importance placed on infection control. Participants in this study made a direct link between managerial support for infection control and ward culture.
Gurses et al., 2008
note that much of the variance in compliance with guidelines can be attributed to features of the facility. Griffith et al., 2009
view organisational support as promoting infection control on wards, improving communication between staff and clarifying responsibilities.Poor communication was also identified by our participants with management of interprofessional relationships, particularly with medical staff, identified as a major impediment to effective infection control.
Brown et al., 2008
argue that management and knowledge of infection control acts as a form of symbolic capital which challenges traditional healthcare hierarchies leading to uncertainty for nurses and the necessity to ‘choose their battles’ when challenging medical staff. This is evident in this study with participants identifying difficulties in confronting doctors.In addition to systemic and organisational factors, participants identified personal factors which contribute to poor performance of infection prevention tasks. Two primary themes were identified. The first was the priority given to infection control activities by the individual nurse. Factors which were identified as impacting the priority given to these tasks include: limited time and the importance placed on competing tasks; poor understanding of the reasons for precautions and perception of the level of risk involved in omitting these tasks. Risk in this case may be related to risk to the staff member as well as the patient. Respondents to this study also viewed lack of knowledge or poor application of knowledge as a factor in infection control activities being missed. This is contrary to previous studies which have found that while poor understanding of infection transmission may be a factor in poor compliance with infection prevention guidelines other issues such as perception of level of risk, peer pressure, perception of one’s practice and motivation may result in infection precautions being missed despite level of knowledge (
Jackson et al., 2014
). Our respondents argue that infection control activities can be missed due to poor understanding of guidelines, acceptance of HAI and failure to identify the risk associated with poor performance of the fundamentals of care.Our respondents also identify environmental factors as contributing to infection control activities being missed. The physical environment has not been widely considered in relation to missed care although distance to be travelled was identified as contributing to missed care in residential aged care (
Henderson et al., 2018
). Chagpar et al., 2010
identify ease of access to PPE and hand basins as contributing to a willingness to undertake hand hygiene. Access issues were also identified by our participants as were outdated ward layouts which make cross contamination more likely and over stocking is also a factor in managing the physical layout and cleaning. The impact of physical environment on missed care may require further exploration.4.1 Limitations
Data for this paper were drawn from exploratory interviews to develop a MISSCARE survey for infection control. As such, the interview guide incorporates assumptions about missed or rationed care. This was managed through keeping the questions broad (eg; What infection control activities do you believe are missed? Why do you believe these activities are missed?). Rigour in data analysis was ensured through double coding of transcripts and member checking through feedback on the draft survey. Further, the individual factors identified by the infection control experts may not reflect the experiences of ward nurses, which will be captured more fully by the future MISSCARE survey developed from these interviews.
5. Conclusion
The reasons for failure to perform infection prevention and control activities are complex and involve issues of resourcing, managerial and interprofessional support, ward layout and access to PPE as well as personal motivation and understanding of the rationale for activities. This is an area which requires further exploration.
Conflict of interest
None.
Ethical statement
The study received ethical approval from the Flinders University Social and Behavioural Research Ethics Committee (SBREC 7614). Approval was gained in July 2017.
Acknowledgements
This study was funded by a Flinders University Faculty of Nursing, Medicine and Health Science seeding grant. We also acknowledge the role of the Australasian College of Infection Prevention and Control who promoted this study to its members.
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Article info
Publication history
Published online: October 18, 2019
Accepted:
May 23,
2019
Received in revised form:
May 3,
2019
Received:
March 19,
2019
Identification
Copyright
© 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.
