key: cord-0870845-1esq6o0u
authors: Henderson, Julie; Willis, Eileen; Blackman, Ian; Verrall, Claire; McNeill, Liz
title: Comparing infection control and ward nurses' views of the omission of infection control activities using the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey
date: 2021-02-11
journal: J Nurs Manag
DOI: 10.1111/jonm.13261
sha: 2eb0c2d7ebaf66d515c3598d8b98f8fdbca56b1e
doc_id: 870845
cord_uid: 1esq6o0u

AIM: To compare the perceptions of nurses with infection control expertise and ward nurses as to what infection control activities are missed and the reasons why these activities are omitted. BACKGROUND: Infection prevention activities are viewed as important for reducing health care‐acquired infections (HAIs) but are often poorly performed. METHODS: Data were collected through the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey delivered to 500 Australian nurses prior to COVID‐19. RESULTS: Significant differences were found on the mean scores between infection control and other nurses on ten items. In eight cases, five relating to hand hygiene, infection control specialists viewed the activity as more likely to be missed. Factors viewed as having greater contribution to omission of infection control prevention were as follows: 'Patients have to share bathrooms', 'Urgent patient situation' and 'Unexpected rise in patient volume and/or acuity on the ward/unit'. Infection control nurses were more likely to highlight the role of organisational and management factors in preventing effective infection control. CONCLUSIONS: Differences in response between nurses suggest that the extent of omission of infection control precautions may be under‐estimated by ward nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Infection control specialists are more likely to identify organisational barriers to effective infection control than other nurses. Work demands arising from pandemic management may contribute to infection control precautions being missed.

The primary means of preventing HAI is seen as 'the implementation of practices that minimise the risk of transmission of infectious agents' (Australian Government, 2010:7) . The Australian

Commission on Safety and Quality in Healthcare (2018:2-3) associates best practice in prevention of HAI with surveillance; the use of transmission-based precautions; access to personal protective equipment (PPE); sterilization and/or cleaning of reusable equipment; environmental cleanliness; and antimicrobial stewardship.

There is evidence that clinicians perform these activities poorly or may omit them completely. This paper explores perceptions of the infection prevention and control activities that are missed and the reason why they are missed through analysis of findings from the administration of Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey to Australian nurses, comparing the views of infection control nurses with other (ward) nurses. A recent study of infection control experts identified four primary reasons for failure to undertake infection prevention activities. These are as follows: factors related to the health system; organisational factors; and issues concerned with the physical environment and personal factors including motivation and awareness of these precautions (Henderson et al., 2020) . Results will be explored via these categories.

Systemic factors relate to the wider health care system and may include issues of resourcing, staffing ratios and policies, and other policy initiatives, which impact on infection control practice or patient throughput and workload. Infection control specialists report that there is inadequate resourcing for infection control and prevention.

There is evidence that staffing levels and nurse workload are associated with HAIs. Aitken et al. (2014) found in a study of the impact of nurse staffing across nine European countries that an increase in nurse workload by one patient was associated with a 7% increase in the likelihood of surgical patients dying within 30 days of admission.

Likewise, Van et al. (2020) Time constraints arising from workload, staffing levels and skill mix have also been implicated in failure to perform infection prevention activities (Henderson et al., 2020) . The impact of time is confirmed by studies with clinicians. Sadule-Rios and Aguiera (2017) conducted survey research with 47 critical care nurses to identify barriers to hand hygiene. The most cited reasons for failure to perform hand hygiene among this cohort was 'high workload and understaffing' (n = 24). The donning of PPE is also viewed as time-consuming. Yanke et al. (2015) conducted observational research into failure to complete isolation precautions in the United States. They noted full compliance with the use of PPE added to the time taken before entering the room, while in the room and upon leaving, and argue that this may be a factor in lack of compliance.

Organisational factors relate to a specific organisation and may incorporate managerial support and style, interprofessional relationships, budgetary factors and access to the technology and resources to implement infection control programmes (Henderson et al., 2020) . There are several studies in which infection control professionals and/or nurse managers identify organisational barriers to infection prevention. 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. This is exacerbated by limited access to clinical leaders by infection preventionists. 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 to monitor infection control and limited access to infection control expertise (Halton et al., 2017; Henderson et al., 2020) . Ider et al. (2012) found that lack of budgetary control, limited capacity for surveillance, limited infection control knowledge and performance of competing tasks by infection control clinicians all contribute to poor infection control performance. Leadership style was identified as indirectly contributing to HAIs by Wong et al. (2013) . They argue that a relational leadership style typified by a focus upon working with people to achieve common goals reduced the incidence of adverse events including HAIs through improving staff retention and a resultant increase in expertise and reducing absenteeism and poorer staff/patient ratios.

Interprofessional relationships also contribute, with medical staff frequently identified as a barrier to effective infection control.

This may be related to ineffective interprofessional communication (Gurses et al., 2008) and professional relations between infection control specialists who are largely nurses and medical staff. Brown et al. (2008) note that nurse subordination to medicine can lead to difficulties in challenging poor hygiene practice and the breaching of boundaries established by nursing managers. Shah et al. (2015) in a study of British health care workers found that senior medical staff may consider themselves as independent practitioners who are not subject to hospital policies.

Environmental factors relate to features of the physical environment and may include ward layout including availability of single rooms for patients, availability of sinks and access to PPE (Henderson et al., 2020) . Park et al. (2020) explored the relationship between proportion of private rooms and incidence of health-acquired MRSA (HA-MRSA) in Texas and found that there were 0.8% fewer HA-MRSA infections for each 1% increase in private rooms as a proportion of all rooms. Randle and Clarke (2010) view lack of facilities including side rooms as a barrier to implementation of the code of hygiene, which establishes guidelines for infection prevention in the UK. Chagpar et al. (2010) found that infection control practice was often inhibited by poor access to hand basins and PPE impacting on perceptions that hand hygiene could add to workflow. 'Difficulty accessing sink locations' was also identified as a barrier to hand hygiene by 22 of 47 critical care nurses working in Florida hospitals (Sadule-Rios & Aguiera, 2017).

Personal factors relate to the motivation, beliefs and knowledge of the individual nurse about infection control. Smiddy et al. (2015) conducted a systematic literature review of clinician's compliance with hand hygiene. They identified two major themes relating to motivation and perception of work environment. Motivation to perform hand hygiene was impacted by organisational factors such as managerial and peer support for hand hygiene and role modelling by senior staff; by the prioritization of tasks and perceived risk to the patient; self-protection; and visual cues. Staff perceptions of work environment incorporate access to resources; knowledge; auditing and the feedback of results; and organisational culture. The prioritization of tasks was also identified by Shah et al. (2015) who found that while respondents were aware of infection precautions, competing demands were often given higher priority due to workload demands. This finding is in line with research by Patterson et al. (2011) who found that when resources are limited or if demand is unpredictable, nurses give priority to actions that address imminent clinical concerns over other tasks.

Failure to undertake infection control precaution is often viewed as arising from lack of knowledge about infection prevention. found that perception of level of risk to patients, peer pressure, perception of one's practice and motivation may result in infection precautions being missed despite level of knowledge. Level of personal risk was also a factor in a study by who found nurses were more likely to take precautions when encountering body fluids or situations perceived to be dirty. Russell et al. (2018) who surveyed 359 home health care nurses also found no association between knowledge of infection control precautions and compliance with these precautions, although nurses with infection control certification were significantly more likely to report compliance with precautions.

They found a significant positive association between positive attitudes towards infection prevention and self-reported compliance with precautions, suggesting that attitude is more important than knowledge.

This paper reports results from Australian respondents to the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey, which measures nurses' perceptions of what infection control activities are routinely missed and the reasons why these activities are not performed. A second aim is to compare the perceptions of nurses working in infection control roles and nurses working in other roles to determine differences in perceptions.

Data for this study were collected through the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey administered in late 2019 prior to COVID-19. This tool was developed by Henderson, Blackman, Willis and Roderick to explore the failure to perform infection control activities through the lens of missed or rationed care (Henderson et al., 2020) . Lam (2011) developed a survey to explore performance of infection control activities. The MNCIP Survey incorporates a measure of activities missed and reasons for why these activities are missed. Missed care has been defined by Kalisch et al. (2009:1,510) as 'required [nursing] patient care that is omitted (either in part or in whole) or delayed'. Kalisch and Williams (2009) identify three primary antecedents to missed nursing care: lack of human resources (e.g., number and skill mix of staff, work intensity and lack of time), lack of material resources and communication breakdown.

The MNCIPC tool consists of three sections. Part A provides background and other demographic information about the respondents. Section B (37 items) identifies infection control activities that may be missed and asks participants to identify how frequently they believe these activities are missed. Items are scored on a scale of 1 to 5 where 1 is 'never missed' and 5 is 'always missed'. Section C (24 items) asks the respondents to indicate why care might be missed with items rated on a scale of 1 to 4 where 1 is 'not important' and 4 'very important'. Section C concludes with two open question allowing respondents to (1) provide any additional reasons for omission of infection control activities and (2) any comments they wish to make about omitted infection control. These questions were included to identify causes of missed care not identified in the survey and/or to clarify causes that were included. The survey was developed replicating the methods utilized by Kalisch in developing previous MISSCARE surveys (Kalisch & Williams, 2009; Kalisch et al., 2014) .

Items were developed through a review of literature and eleven interviews with respondents with infection control expertise recruited through the Australian College of Infection Prevention and Control (Henderson et al., 2020) . These data informed the development of a draft survey, which was trialled with a small group of infection control experts who provided written feedback. The feedback was incorporated into the final draft of the survey, which was then delivered online.

Participants were recruited through advertisements in the electronic newsletters of two organisations: the Australian College of Infection Prevention and Control (ACIPC) and the Australian College of Nursing (ACN). Recruitment through ACIPC provided access to nurses with expertise in infection control, while recruitment through the ACN enabled access to nurses without specific expertise in infection control. The survey was undertaken by 500 respondents (see Table 1 ).

Quantitative data were analysed using SPSS Statistics version 25.

Descriptive statistics were used to compare respondents across selected demographic characteristics and to analyse the quantitative data on how frequently tasks are missed and why. Both the survey item and nurse respondent reliabilities were checked using the Rasch analysis and revealed very acceptable fit indices at 7.7 (reliability of 0.97) and 4.28 (reliability 0.95), respectively. These indices confirm that the survey items operate well individually and collectively, in estimating nursing staff's consensus (Bond & Fox, 2015; Boone & Vale, 2014) . The chi-squares and t tests were conducted to determine whether there were significant differences in the demographic characteristics of the two groups and the tasks perceived as missed and reasons for missed care by respondents identifying as having a specific infection control role and those who do not.

The qualitative data were drawn from responses to an open-ended question: 'Are there other reasons why infection control activities are missed?' These data were analysed using qualitative content analysis (Mayring, 2014) . Qualitative content analysis involves thematic coding using systematic rules and quantification to determine the importance and generalizability of the themes. In this case, coding was undertaken inductively by two researchers working independently. Data were read for statements addressing the causes of missed care. Each response was allocated a descriptor. Where more than one reason was offered within a response, multiple descriptors were allocated. The descriptors were then divided into four themes: systemic factors, organisational factors, environmental and access issues and personal factors, and were collated to determine the most frequently occurring issues.

Ethics approval for this project was obtained through the Flinders University Social and Behavioural Research Ethics Committee. Table 1 compares key demographic characteristics of the sample undertaking the survey. In keeping with workforce composition, the majority of respondents were female (91.2%). Most respondents were employed as registered nurses or midwives (93.6%), and the majority had worked in their current workplace for more than 5 years (56.8%). Statistically significant differences were noted between the two groups of respondents in relation to age and education but not in relation to years within that workplace. The infection control specialists were older and better educated than the other nurses (p ≤ .05). They were also significantly more likely to hold tertiary qualifications in infection prevention (p ≤ .001). No significant differences were evident in rates of attendance at in-service infection control education sessions with 90.1% of all respondents indicating that they had attended. Hand hygiene is performed after a procedure has been performed 2.43 ± 0.86 2.12 ± 1.06 2.25 * ± 0.99

Hand hygiene is performed after touching a patient 2.92 ± 0.92 2.65 ± 1.12 2.76 *** ± 1.05

Hand hygiene is completed before drug administration 3.33 ± 1.11 3.08 ± 1.28 3.19 ± 1.19

Equipment is cleaned before it touches each patient 3.37 ± 1.11 2.91 ± 1.24 3.10 ** ± 1.21

Appropriate personal protective equipments (PPEs) (such as gloves and gowns) are used when providing direct care to patients/residents who have a transmissible disease including multiresistant organisms (MROs).

2.58 ± 1.18 2.21 ± 1.16 2.36 * ± 1.18 PPE is donned in the correct order, for example putting on gown first and then gloves to ensure that they are pulled over the cuff of the gown so that no skin is exposed Score were rated on a scale from 1 to 5 with higher scores indicating a perception that this activity is missed more frequently. Activities that were reported as frequently missed include the following:

cleaning over-way tables prior to food delivery (mean = 4.11); preoperative showers (4.10); screening of new admissions for infection (3.97); and performance of catheter toilets every shift (3.77). Failure to perform hand hygiene received a mean score of 2.98, the highest score received by the 5 moments of hand hygiene (WHO, n.d.).

Significant differences were found on the mean scores between infection control and other nurses on ten items. In eight cases, the activity was viewed as more likely to be missed by infection control nurses. These items include five items related to hand hygiene being:

'Hand hygiene is performed before touching a patient'; 'Hand hygiene is performed after a procedure has been performed' (p ≤ .01);

'Hand hygiene is performed before a procedure is undertaken' (p ≤ .001); 'Hand hygiene is performed after touching a patient'; and 'Hand hygiene is performed after exposure to body fluids' (p ≤ .05).

The other activities that were statistically significant relate to cleaning equipment between patients and correct use of PPE. The documentation of infection status upon discharge (p ≤ .01) and storage of equipment to ensure sterility (p ≤ .05) were more highly rated by ward nurses as being missed. The most commonly identified organisational cause of missed infection control was poor practice by medical staff (n = 13), followed by poor access to resources and funding (n = 11) and limited management support for infection control (n = 6).

Staff decontaminate spills of blood and other body substances/fluids 2.07 ± 1.14 2.19 ± 1.50 2.14 ± 1.37

Instruments and equipment are stored to ensure sterility prior to use '4 bedded rooms mean that hand hygiene leaving a patient space overlaps with hand hygiene before touching the next patient. Or nurses believe 'non carded' patients within four bedded room allows for no hand hygiene between touching non-clinical items'.

Nurses who were not working in infection control roles were more likely to cite poor environmental cleaning as contributing to poor infection control practice. One respondent identified insufficient 'attention given to public areas in hospitals where cross-contamination can occur very easily', while another noted that the 'cleaning of the patient beds is a major issue'.

Thirteen responses highlighted knowledge deficits as a personal factor with 7 respondents identifying nurses as lazy and 6 high- to be missed than infection control nurses. These were as follows:

'the documentation of infection status upon discharge' and 'storage of equipment to ensure sterility'. As these tasks are both performed on the ward, these estimates are likely to reflect practice.

Respondents were also asked to indicate why they thought infection control precautions were missed. Similar scores were obtained for both groups on the quantitative items. Missed care is commonly associated with systemic factors such as staffing; workload; patient acuity; and unexpected changes in workload associated with an urgent patient situation (Blackman et al., 2015; Kalisch and Williams, 2009; Schubert et al., 2013) . This was evident in this study with respondents rating 'urgent patient situation' and 'unexpected rise in patient volume and/or acuity on the ward/unit' highly. 

There are two notable limitations to the current study. The survey tool had not been validated at time of administration, and subsequent testing has suggested that some items could be removed (Riklikiene et al., 2019) . Further, many respondents did not complete all questions meaning that the response rate for later questions is often less than the 500 respondents who commenced the survey. 

A study of Australian nurses conducted prior to COVID-19 found that many activities, notably hand hygiene, were perceived to be poorly performed. Infection control specialists were significantly more likely to identify deficits on eight items than other nurses.

Failure to perform infection control precautions was related to ward layout and cleaning; unexpected rise in workload; lack of managerial support for infection control; poor practice by medical officers; and failure to apply infection control principles to practice.

Few studies compare the views of infection control and other nurses in relation to performance of infection control precautions. This study demonstrates that infection control nurses identify higher levels of missed infection control activities. While similar scores were obtained in relation to the reasons for missed care, infection control nurses identify blockages in relation to funding and support from hospital management. Changes in workload were identified as leading to missed infection control precautions by both groups. Further, despite education, there is a perception that nurses do not always apply this knowledge in their practice.

The authors wish to acknowledge the role of Alison Roderick in developing the survey of the Australian College of Infection Prevention and Control (ACIPC) and the Australian College of Nursing (ACN) for assistance with recruitment and the nurses who were involved in the development and completion of the survey.

The authors declare no conflict of interest. 

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