Fact or infection: do surgical trainees know enough about infection control?

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Assessing methicillin-resistant Staphylococcusaureus knowledge among nursing students

MRSA is becoming more prevalent in healthcare settings and community settings. The purpose of the study is to assess MRSA knowledge among nursing students. A MRSA Survey was administered to nursing students to gauge their general knowledge about MRSA. The scores from the MRSA Survey indicated that nursing students had a knowledge deficit regarding MRSA. Nursing student's need specific MRSA content in the nursing curriculum and need role models in healthcare settings who are following infection control guidelines. A variety of teaching strategies may be used to effectively teach this topic to nursing students. The goal of this education is to prevent the spread of MRSA organisms and decrease the related costs of treating MRSA infections.

Do guidelines for the prevention and control of methicillin-resistant Staphylococcus aureus make a difference?

Many countries have national guidelines for the prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) that are similar in approach. The evidence base for many recommendations is variable, and often, in the drafting of such guidelines, the evidence is either not analysed or not specifically reviewed. Guidelines usually recommend screening and early detection, hand hygiene, patient isolation or cohorting, and decolonization. Although many components of a prevention and control programme appear to be self-evident, e.g. patient isolation, the scientific base underpinning these is poor, and scientifically rigorous studies are required. Nonetheless, where measures, based on what evidence there is and on common sense, are implemented, and where the necessary resources are provided, MRSA can be controlled. In The Netherlands and in other low-prevalence countries, these measures have largely kept healthcare facilities MRSA-free. In MRSA-endemic countries, such as Spain and Ireland, national guidelines are often not fully implemented, owing to apparently inadequate resources or a lack of will. However, recent studies from France and Australia demonstrate what is possible in high-prevalence countries when best practice is effectively implemented, with potentially major benefits for patients, the respective health services, and society.

UK healthcare workers' knowledge of meticillin-resistant Staphylococcus aureus practice guidelines; a questionnaire study

Effective infection control practice requires knowledge of and adherence to contemporary infection control guidelines. Utilising a novel questionnaire tool, we evaluated knowledge of recently published guidelines on meticillin-resistant Staphylococcus aureus (MRSA) precautions in a number of relevant healthcare worker (HCW) populations. The questionnaire was developed from national UK MRSA practice guidelines and consisted of 10 'true or false' statements. The questionnaire was utilised to assess knowledge in 293 participants from HCW and control populations. The participants included 188 doctors attending the British Medical Association's Annual Representatives Meeting, 52 trainee surgeons attending the Association of Surgeons in Training annual conference, 30 members of a non-clinical control population and 23 infection control nurses (ICNs). The mean (SD) score for knowledge levels obtained from doctors was 6.6 (1.68), for non-clinical control population was 4.7 (1.8) and for ICNs, 8.4 (1.12). There were significant differences in knowledge levels between different population groups (P<0.001), UK employment region of the participant (P=0.01) and the doctors' medical specialty (P=0.02). Career seniority and gender of the participant were not significantly associated with differences in levels of knowledge. This questionnaire study evaluates a novel discriminatory questionnaire tool which differentiates knowledge levels of MRSA practice guidelines among a non-clinical population, HCWs and specialist infection control staff, thus providing a means for the rapid assessment of MRSA educational interventions. We identify demographics within HCW target populations which are associated with low levels of such knowledge. Consideration towards revising current HCW educational programmes to improve knowledge and best practice in MRSA prevention is required.