Challenges undertaking procedures requiring asepsis: a qualitative interview study with nurses.

BACKGROUND: Invasive devices and breaches to skin and mucous membranes increase susceptibility to infection. Nurses frequently undertake procedures requiring asepsis (PRAs), but report challenges and unwarranted variations in practice. OBJECTIVE: To explore nurses' experiences, perceived gaps in information and support needed to conduct PRAs. METHODS: Qualitative interviews were undertaken with 20 nurses in the UK National Health Service between September 2021 and January 2022 employing approaches to sampling and data collection adopted in grounded theory. RESULTS: Informants were employed in diverse clinical settings. They thought that outside operating theatres, attempts to maintain asepsis would inevitably be compromised, but that much could still be done to contain the risk of contaminating susceptible sites irrespective of circumstances. Suboptimal practice was reported, and informants were unclear whether asepsis was needed to perform routine procedures (e.g. dressing chronic wounds, manipulating indwelling intravascular lines). Problems were attributed to inadequacies in nursing education, poor access to continuing professional development, and carelessness of junior nurses and medical staff. Informants wanted more detailed guidelines to conduct PRAs. Senior nurses wanted procedures to be conducted in the same way regardless of circumstance. Nurses who undertook PRAs regularly suggested that guidelines should be flexible. CONCLUSION: There is a need for detailed guidelines to inform PRAs, better access to clinical updating, and improvements in pre-registration nursing education. To meet contemporary standards, guideline generation should adopt recognized methodology. Student nurses should be introduced to the knowledge and skills required to undertake and adjust PRAs according to circumstance during simulated practice before contact with real patients.

How practice nurses engage with parents during their consultations about the MMR vaccine: a qualitative study.

AIM: We aimed to understand practice nurses' perceptions about how they engage with parents during consultations concerning the measles, mumps and rubella (MMR) vaccine. BACKGROUND: The incidence of measles is increasing globally. Immunisation is recognised as the most significant intervention to influence global health in modern times, although many factors are known to adversely affect immunisation uptake. Practice nurses are a key member of the primary care team responsible for delivering immunisation. However, little is known how practice nurses perceive this role. METHODS: Semi-structured interviews were undertaken with 15 practice nurses in England using a qualitative descriptive approach. Diversity in terms of years of experience and range of geographical practice settings were sought. These interviews were recorded, transcribed verbatim and open-coded using qualitative content analysis to manage, analyse and identify themes. FINDINGS: Three themes were derived from the data: engaging with parents, the informed practice nurse and dealing with parental concerns: strategies to promote MMR uptake. During their consultations, practice nurses encountered parents who held strong opinions about the MMR vaccine and perceived this to be related to the parents' socio-demographic background. Practice nurses sought to provide parents with tailored and accurate sources of information to apprise their immunisation decision-making about the MMR vaccine.

The Hawthorne effect on adherence to hand hygiene in patient care.

Numerous studies demonstrate that the Hawthorne effect (behaviour change caused by awareness of being observed) increases health workers' hand hygiene adherence but it is not clear whether they are methodologically robust, what the magnitude of the effect is, how long it persists or whether it is the same across clinical settings. The objective of this review was to determine the rigour of the methods used to assess the Hawthorne effect on hand hygiene, effect size estimation, variations between clinical settings and persistence. To this end, a systematic literature review with meta-analysis was conducted. Nine studies met the criteria for the review. Methodological quality was variable. The Hawthorne effect ranged from -6.9% to 65.3%. It was 4.2% in one study conducted in intensive care and 16.4% in transplant units. It was most marked when data were collected across an entire hospital and in a group of general hospitals. Differences between wards in the same hospital were apparent. In the two studies where duration was estimated, the Hawthorne effect appeared transient. Despite methodological shortcomings, the review indicates clear evidence of a Hawthorne effect on general wards. There is evidence that it may vary between clinical speciality and across departments. The review identifies a need for standardized methodologies to measure the Hawthorne effect to overcome the dilemma of reporting the potentially inflated rates of adherence obtained through overt audit. Occasional covert audit could give a better estimation of true hand hygiene adherence but its acceptability and feasibility to health workers need to be explored.

International approaches for delivery of positive newborn bloodspot screening results for CF.

BACKGROUND: Newborn bloodspot screening (NBS) for cystic fibrosis (CF) is a well-established public health strategy with international standards. A European survey demonstrated considerable variability in approach to delivering a positive NBS result. We used a mixed methods approach to explore healthcare systems and beliefs around this process. METHODS: We used semi-structured interviews and online questionnaires with a purposive, international sample of health professionals involved in communicating positive NBS results to parents. Data were analysed using thematic analysis and Qualtrics Survey Software. RESULTS: In total, 63 healthcare professionals were approached; 25 interviews were conducted with delegates at the 2017 ECFS conference, 4 online questionnaires were subsequently completed by participants in the EU, 1 from Australia and 33 from the US. Methods used to communicate positive NBS results to families varied considerably. This influenced the quality and quantity of information provided which had the potential to heighten anxiety and affect timely diagnostic testing. Participants identified positive practices including systems to improve the timeliness of screening and processing of results, as well as areas for improvement. Respondents stated that knowledge of CF and familiarity with the family were both important when deciding who should communicate positive NBS results. CONCLUSIONS: Guidance and practice regarding communication of positive NBS results for CF to families varies considerably internationally. Further research is needed to ensure information received is accurate, up-to-date and from the most appropriate person. Also, that all children are followed up in a timely manner to minimise potential negative outcomes for the child and family.

Impact of observing hand hygiene in practice and research: a methodological reconsideration.

The purpose of hand hygiene is to break the chain of healthcare-associated infection. In many countries hand hygiene is regularly audited as part of quality assurance based on recommendations from the World Health Organization. Direct observation is the recommended audit method but is associated with disadvantages, including potential for being observed to alter usual behaviour. The Hawthorne effect in relation to hand hygiene is analogous with productivity improvement by increasing the frequency with which hand hygiene is undertaken. Unobtrusive and/or frequent observation to accustom staff to the presence of observers is considered an acceptable way of reducing the Hawthorne effect, but few publications have discussed how to implement these techniques or examine their effectiveness. There is evidence that awareness of being watched can disrupt the usual behaviour of individuals in complex and unpredictable ways other than simple productivity effect. In the presence of auditors, health workers might defer or avoid activities that require hand hygiene, but these issues are not addressed in guidelines for practice or research studies. This oversight has implications for the validity of hand hygiene audit findings. Measuring hand hygiene product use overcomes avoidance tactics. It is cheaper and generates data continuously to assess the compliance of all clinicians without disrupting patient care. Disadvantages are the risk of overestimating uptake through spillage, wastage, or use by visitors and non-clinical staff entering patient care areas. Electronic devices may overcome the Hawthorne and avoidance effects but are costly and are not widely used outside research studies.

Interventions to improve hand hygiene compliance in patient care.

Healthcare-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as the most effective method of prevention but is poorly performed by health workers. We report a systematic review identifying studies which investigated the effectiveness of interventions to increase hand hygiene compliance short and longer term and to determine their success in terms of hand hygiene compliance and subsequent effect on rates of healthcare-associated infection. We employed the inclusion criteria employed by the Cochrane Effective Practice and Organisation of Care Group. Forty-eight studies and one thesis were identified. Only two met the stringent inclusion criteria. Overall studies remain small scale, poorly controlled and follow-up data collection is abandoned too soon to establish impact longer term. Furthermore, designs are insufficiently robust to attribute any observed changes to the intervention. Studies lack theoretical focus and seldom describe the intervention in sufficient detail, the change management process or contextual information about the organisation in the depth necessary to explain success or lack of it. The review concludes that interrupted time-series studies may offer the most rigorous approach to assessing the impact of interventions to increase hand hygiene compliance. In such study designs the number of new cases of healthcare-associated infection should be taken as an outcome measure, with data collection points at least 12 months before intervention and afterwards to allow for seasonal trends. Contextual factors at national and at local level should be carefully documented to take into consideration the influence of secular trends.

Measuring handwashing performance in health service audits and research studies.

Handwashing is regarded as the most effective way of controlling healthcare-associated infection. A search of the literature identified 42 intervention studies seeking to increase compliance in which the data were collected by directly observing practice. The methods used to undertake observation were so poorly described in most studies that it is difficult to accept the findings as reliable or as valid indicators of health worker behaviour. Most studies were limited in scope, assessing the frequency of handwashing in critical care units. The ethical implications of watching health workers during close patient contact were not considered, especially when observation was covert or health workers were misinformed about the purpose of the study. Future studies should take place in a range of clinical settings to increase the generalizability of findings. Observation should be timed to capture a complete picture of 24h activity and should include all health workers in contact with patients because all have the potential to contribute to cross-infection. Reported details of observation should include: vantage of data collectors; inter-rater reliability when more than one individual is involved; and attempts to overcome the impact of observation on usual health worker behaviour. Ideally an additional data collection method should be used to corroborate or refute the findings of observation, but no well-validated method is presently available.

Interventions to improve hand hygiene compliance in patient care.

BACKGROUND: Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. OBJECTIVES: To assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection. SEARCH STRATEGY: We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. All databases were searched to July 2006; MEDLINE was searched from 1980, CINAHL from its inception, and the remainder from 1990 until July 2006. SELECTION CRITERIA: Randomised controlled trials; controlled clinical trials; controlled before and after studies; and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group. Studies reporting proxy indicators of hand hygiene compliance were considered. Studies to promote compliance with universal precautions were included providing data relating specifically to hand hygiene were presented separately. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed data quality. MAIN RESULTS: Two studies met the criteria for review. One was a randomised controlled trial. The other was a controlled before and after study. Both were poorly controlled. Statistically significant post-intervention increase in hand washing was reported in one study up to four months after the intervention. In the other there was no post-intervention increase in hand hygiene compliance. AUTHORS' CONCLUSIONS: There is little robust evidence to inform the choice of interventions to improve hand hygiene. It appears that single interventions based on short, 'one off' teaching sessions are unlikely to be successful, even short-term. There is a need to undertake methodologically robust research to explore the effectiveness of soundly designed interventions to increase hand hygiene compliance.

The CleanYourHandsCampaign: critiquing policy and evidence base.

Handwashing is considered to be the most effective way of reducing cross-infection. Rates of healthcare-associated infection and the incidence of meticillin-resistant Staphylococcus aureus are higher in the UK than in many other European countries. The government has responded by introducing the 'CleanYourHandsCampaign' throughout England and Wales, based on the success of the approach employed in Geneva. Alcohol hand rub is placed at every bedside in acute hospitals, ward housekeepers should replenish supplies and feedback on compliance is provided to health workers. Posters and other promotional materials are used to remind health workers and visitors to use the hand rub. Patients are encouraged to ask health workers if they have cleaned their hands before contact. In this paper we argue that the evidence base underpinning the CleanYourHandsCampaign is incomplete. Alcohol hand rub is acknowledged as a useful adjunct to hand hygiene but it is not effective in all circumstances. There is some evidence to support the use of feedback on performance to encourage compliance but no evidence that promotional materials such as posters or patient reminders are effective. The ethics of encouraging hospital patients to take responsibility for their own safety is questioned. Much of the success in Geneva must be attributed to the attention given to contextual factors within the organization that encouraged hand rub use, especially hospital-wide 'ownership' of the initiative by managers and senior health professionals. A customized intervention from another country that fails to consider local organizational factors likely to influence the implementation of the campaign is unlikely to be effective. It is concluded that although hand hygiene is of undoubted importance, undue emphasis should not be placed on it as a 'quick fix' to solve the unacceptably high rates of healthcare-associated infection in National Health Service hospitals.

Infection control in neonatal intensive care units.

Healthcare-associated infection is a major problem in acute hospital settings. Hand decontamination is considered to be the most effective means of preventing healthcare-associated infection, but is poorly performed. Few studies have examined technique, which may be important in neonatal intensive care units (NICUs) where clinical procedures are intricate and could result in contamination of many areas of the hand, resulting in cross-infection. This study examined technique in six NICUs. Eighty-eight nurses were observed. A scoring system was developed so that technique could be quantified and subjected to statistical testing. The mean score was 6.29 out of 11 when hands were washed and 3.87 out of 7 when alcohol hand rub was used, indicating that performance was not optimal. Scores for technique were not significantly different in each NICU. Senior nurses achieved higher scores for handwashing (P<0.01), as did nurses holding positive feelings about the atmosphere in their NICU (P=0.04). Junior nurses scored less well on a knowledge questionnaire than senior nurses (P<0.01). Nurses who had been employed in the neonatal unit for less than one year also scored less well (P<0.01). Differences in technique were noted when comparing the beginning and end of long shifts. These differences were not noted at the beginning and end of standard shifts.

Infection control. Unhappy nappy-changing.

This study was conducted in a special care baby unit (SCBU) and concentrated on hand decontamination and glove-wearing during nappy-changing. The aims were to determine whether or not nurses were adhering to existing infection control policies and guidelines as well as determining the most appropriate product to use for hand decontamination. The study demonstrated that not all nurses were adhering to existing infection control policies and guidelines. On the majority of occasions, alcohol was significantly better than soap at removing bacteria from the hands, but gloves provided the best protection overall for both babies and nurses by preventing the acquisition of bacteria.