I’ve written this post in preparation for next Wednesday’s IPS Journal Club in partnership with the Infection Prevention Society (register here). (Please note, it will be a little earlier in the day than most previous Journal Clubs, so don’t miss it!) The paper that I have chosen for the Journal Club is this one in the Journal of Infection Prevention, exploring infection prevention behaviour in hospital nursing staff.

Before I get to the article, we need to talk homographs because of the chosen title for the Journal Club! We’ve gone with “Making infection prevention live for frontline healthcare workers”. But is this making infection prevention live (as in alive) or live (as in not recorded)? I think you could make a case for either, so I think we’ve decided we’re going to go with both.

Why I chose this article:

• This is a qualitative study, trying to get to the bottom of “why” people behave the way that I do. The further into my IPC career I get, the clearer it becomes that our role is fundamentally to change human behaviour. And we need to understand why people do what they do in order to encourage them to do something else!
• The behaviour of healthcare staff directly influences IPC risks in terms of hand hygiene, environmental hygiene, care of devices (“I’m putting this line in just in case…”), use of gloves, antimicrobial stewardship, diagnostic stewardship, and more.
• Several working conditions that affect the frequency of HCAI have been identified, such as bed occupancy, staffing levels, workload, use of pool or agency nurses, and availability of materials.

Design and methods:

• The aim was to describe nursing staff’s experiences and reflections on working conditions and infection prevention behaviours.
• This qualitative descriptive study was undertaken between April and December 2023 covering four surgical and two orthopaedic units in five Swedish hospitals.
• A semi-structured interview approach was undertaken in separate face-to-face focus groups for each of the six units.
• The interview covered: interruptions, patient room arrangements, psychosocial work environment, structural empowerment, work engagement, and work-related stress.

Key findings:

• A single theme was identified: navigating in a complex and shifting environment.
• This theme was sub-categorised as follows:
  • The influence of co-workers and the workplace climate.
  • Interruptions raise the risk of deviations in hygiene routines but are also a necessary part of work progress
  • Access to adequate premises, materials, and equipment is essential but no guarantee of compliance
  • Stress, high workload, and lack of time can lead to both conscious and unconscious deviations
• A few reflections on the findings:
  • Compliance was described as a ‘herd behaviour’, illustrating the importance of leadership to achieve strong performance.
  • It was sometimes easier to go along with a behaviour that the participants disagreed with, rather than challenge it.
  • The staff wanted to hear more about ‘the why’ as well as ‘the how’ during training and education.
  • Participants felt that nursing staff were especially prone to interruptions due to the nature of their work.
  • Participants describe a possible conflict between meeting urgent patient care needs and reducing the risk of cross-transmission.  
  • Stress, high workload, and lack of time were commonly cited reasons for non-compliance.
  • Participants noted that stress is handled differently by different people, and that some stress can be positive.

Strengths and limitations:

• Study participants were nursing staff selected from Swedish surgical units – how generalisable are these findings to other settings and staff groups?
• 27 participants isn’t bad from a sample size point of view, but this study really only represents a handful of views in the wider scheme of things.  

Points for discussion:

• It seems a little reductive to condense the entirety of this study down to a single theme.
• Providing staff with sufficient matPerials and resources is necessary but not sufficient to achieving safe IPC behaviours.
• Participants introduced the idea of ‘positive stress’. This may be controversial for some, and it depends on how you define ‘stress’. There is evidence that we need some degree of pressure to reach a ‘performance zone’.
• How much of an influence would the culture and context of IPC in an organisation influence the perceptions of frontline staff?
• The authors make some useful recommendations at the end of the article:
  • Implement team training with opportunities for reflection and peer learning
  • Discussing risk-based decision making to support staff when IPC may come into conflict with competing priorities
  • Consider the complexities of the work environment, and provide adequate resources and support
  • Organisational action to address workload, staff turnover, and the physical environment

What this means for IPC:

• We have more to learn about workplace factors that influence the behaviour of nursing staff.
• Don’t underestimate the importance of the workplace environment (both in terms of physical environment and human ecosystem) in influencing behaviours.

Finally, you can hear more about this article (plus another one from the Journal Infection Prevention that Phil will be covering) next Wednesday (register here).