Make doing the right thing easy

Source: NHE Sep/Oct 17

Kay Currie, professor of Nursing & Applied Healthcare Research, ‘Safeguarding Health through Infection Prevention’ (SHIP) research group, at Glasgow Caledonian University, outlines approaches to overcoming the challenges of engaging hospital staff in screening for antimicrobial-resistant and healthcare-associated infections (HCAIs).

The resistance of many microorganisms to a growing number of antimicrobial drugs is presented in apocalyptical terms, with the World Health Organization declaring that “antimicrobial resistance (AMR) threatens the very core of modern medicine and the sustainability of an effective, global public health response to the enduring threat from infectious diseases”. The potential scale of the problem of AMR is immense, with the O’Neill report estimating that by 2050, AMR will cause the death of over 10 million people worldwide every year – more than the current death rate from cancers. 

In response to this recognised global health challenge, UK AMR strategies acknowledge the importance of infection prevention and control (IPC) and surveillance to identify emerging threats. Admission screening for selected antimicrobial-resistant organisms is part of the hospital IPC policy to prevent HCAIs. Within Scotland, a Clinical Risk Assessment (CRA) guides the decision on whether a microbiological swab is necessary. Other countries, dependent on national epidemiology, may adopt a policy which targets only patients admitted to ‘high risk’ areas such as intensive care or orthopaedics.

Barriers and enablers to staff compliance 

Detailed national guidelines for admission screening are available and procedures may appear deceptively simple. However, what may appear straightforward from an IPC perspective may be considered a ‘complex intervention’ in the context of embedding the screening practice into the everyday work of healthcare practitioners. The attitudes and beliefs of individuals, as well as group dynamics and organisational contexts, may influence intentions and actual screening behaviours, thereby influencing compliance levels and the effectiveness of ‘routine’ screening policies.   

Our research group recently completed a national study across Scotland (the ‘AMR-BESH Study’), which identified key barriers and enablers to hospital staff compliance with routine HCAI screening. We found that compliance was likely to be higher when staff had knowledge of the hospital’s policy and processes for screening; believed the consequences of HCAI were severe; had feedback on their screening compliance rates; and screening was highly routinised in practice. Compliance was likely to be lower when acuity and patient flow pressures meant screening was perceived as less of a priority. 

These findings may not come as a surprise to healthcare managers; however, solutions remain elusive. How can we ensure all relevant staff are enabled to engage with training about the consequences of AMR and the importance of screening policies when the typical pattern of staff education is reported as ad hoc or opportunistic ‘just-in-time’ sessions from Infection Control Nurses (ICN) working at a local level, particularly when service models may not have a ‘walk-around’ function as part of the ICN role? Can we really expect under-pressure staff working in acute receiving units to prioritise a CRA for HCAI, and possibly take a swab, when they are dealing with high numbers of unstable patients and under constant pressure to meet patient flow targets?

Overcoming the challenges 

We asked a representative group of health service managers and infection control specialists to help generate solutions to overcome some of these challenges. Their recommendations focused on routinising HAI screening in the admission process; providing feedback of screening compliance to ward staff; and raising staff awareness of the consequences of AMR and screening policy recommendations. 

Implementing admission procedures, preferably computerised, which ensure that CRA is an integral, routinised part of the admission process is fundamental; we need to make it easy to ‘do the right thing’ and impossible for admitting staff to ‘miss out’ the CRA. Providing staff with feedback on screening compliance should focus on both what is going well and less well, with a quality improvement approach applied to enhance screening activity. 

Recognition of the constraints of releasing staff to attend AMR-related education resulted in a range of more creative suggestions for raising staff awareness, from targeting staff entering staff coffee rooms with ‘two-minute information bites’ to a major multi-method national campaign to get the AMR message to all relevant staff (e.g. emails, intranet, mandatory training). The pros, but also cons, of online learning were also highlighted. 

In summary, implementing organisational systems to enhance staff understanding of AMR and ‘Make doing the right thing easy’ in busy clinical contexts are key components to enhancing HCAI screening compliance.




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