Infection Control Guidelines - Essay Example

Lack of Compliance in the Infection Control Guidelines amongst some Nurses Introduction: Attention to infection control and concerns over transmission of infection to other patients or to a patient who is at risk of infection is very important in the healthcare setting. There is evidence dating back to the early part of the 19th Century of theories and practices designed to minimize infection risks associated with healthcare delivery. The nurses are in a unique position to practice strict followership of infection control techniques in the hospital setting since it is through them the major portions of care takes place. They are in constant touch and communication with the patients, and they are the final common pathway for delivery of evidence-based care. They undergo the threat of infection transmitted into themselves due to close proximity with the ailing patients in the hospital beds. They virtually cannot avoid contact physically or cannot avoid exposure to the bodily secretions of the patients. Even if actual infection contracted from the patients is rare, they can serve as an effective vehicle for transmission of many infections to patients who are not infected. This transmission of infection in the healthcare setting is such a problematic issue that this is termed as hospital-acquired infection that is very difficult to cure and that might result in extended stay in the hospital environment (Bischoff, W.E., Reynolds, T.M., Sessler, C.N., Edmond, M.B., and Wenzel, R.P., 2000). Aside from the economic and legal consequences, the health outcome consequences of the patients affected become perilous, and strict adherence to evidence-based guidelines would go a long way to prevent such catastrophe. These outlines were developed earlier from strategies based on observations in the hospitals or clinics. However, later on scientific researches and evidence from them laid down the guidelines of evidence-based practice for infection control. Nonetheless, the observational practices were successful to control transmission of infection in the clinical areas where care used to be delivered, and these evolved over time into principles of infection control. Over the past decade, guidelines for infection control have become evidence based, obviously as a result of advancement of research techniques. In the absence of evidence, assumptions based on experience and knowledge have driven recommendations. Unfortunately despite the fact that almost all providers have guidelines for the nurses to practice, still hospital acquired infections happen, and the blame is naturally on the nurses who handle the patients most. The nurses grow in experience and knowledge from the time they are inducted into the training programme, yet somehow some student nurses fail to comply with the guideline requirements (Boyce, J.M., 1999). Improvement of infection control practice is a very hard act to follow, and it demands very strong commitment to reduce the incidence of healthcare associated infection. All aspects of nursing interventions and care delivery should, in fact, underpin career-long involvement in promoting and practicing the guidelines gleaned from evidence. The role of nurses in prevention and transmission of infection is pivotal, and to have things right, they must practice the learning in the practice area. The existence of unfortunate gaps between the evidence base and reality despite high-quality research points to the fact of noncompliance of nurses, specially student nurses' deficits in the standards of care. This indicates a gap between the scholarship or development of knowledge in nursing training and activity in the real setting. As a result, scholarship of discovery does not match with scholarship of application. As highly experienced, intelligent healthcare professionals, the nurses would be constantly and automatically involved in perfecting their practice understanding fully well the implications of the infection control guidelines and thereby would be consistently involved in research by exercising these two types of scholarships, although often without realising it (Moralejo, D. and Jull, A., 2003). In actuality, the student nurses often fail to identify the practice issues that require attention, particularly in relation to the implementation of policies and guidelines, while they are in a position best equipped to recognise the aspects of healthcare practice that impact on the control of infection. Hand washing is one of the most effective ways to prevent the spread of common infections including some infections that pose a problem, such as, methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and/or resultant bacteriaemia. The nurses are not the only portals for the spread of such infections. The NHS guidelines enumerate that looks are very deceptive in terms of hand hygiene in that even if they look clean, they can still carry a lot of organisms that may be transmitted and are capable of causing an infection. This is why cleaning hands regularly is so important. The nursing staff is required to ensure the highest possible standards of care by following the guidelines. Detailed guideline can be gleaned into simple instructions that the nursing staff should clean their hands each time they have direct contact with the patients. Direct contact means here touching the skin or any body parts. The nursing staff should make it a point to wash hands between contacts with different patients. Food has been long known to be a carrier of different diseases, and therefore, whenever the nurse handles or serves food, she should wash hands. Excreta are well known carriers of bacteria, and the nurse is also involved in helping the patient toileting. As a result, after helping the patients to use the toilet, bathroom, or commode or after using bathroom facilities, the nurse is required to wash hands. In the ideal situation, the nurse would care to do that, but sometimes lack of facilities or even extreme pressure of work in the busy hospital setting and the perspective of other important jobs, such as, timely administration of medication would compel them to forget this apparently innocuous part of their job. The nurse should, particularly, be careful when using equipment or medicines on a given patient (Calil, R., Marba, S.T., von Nowakonski, A., and Tresoldi, A.T., 2001). Research has established the importance of person-to-person contact in spread of disease on the face of hospitalism in healthcare, and initiation of strict antiseptic hand washing would go a long way to reduce nosocomial infection. The incidence of such infections has been reduced greatly by compliance to guidelines. Nevertheless, nosocomial infections continue to be one of the major preventable, iatrogenic complications of hospitalization affecting at least 5% of the patients discharged from the hospital and costing, and nurses play a major role in its incidence, and approximately one-third of such cases may be preventable by simple compliance with guidelines that highlights hand washing. Therefore, it is pertinent to find out the reasons as to why this problem of noncompliance to guidelines continue in practice so make infections like MRSA or C Diff associated infections and septicaemia resultant out of such infections. Several observational studies have indicated that hand washing is the most effective prophylactic measure that a nurse can employ to reduce incidence of such infections. The student nurses and nursing staff alike are both trained on the rationale and technique of hand washing. Hands can be cleaned in several ways, all of which are effective in killing germs and bacteria and will help to prevent spread of infection. Even if antiseptic lotions are not available, traditional hand washing using soap and warm water is an easy and effective option since all the nurses would have access to a wash basin in the ward. Alcohol hand gel is another option that is more easy to use anywhere even on sensitive skin, and that is equally effective, just rubbing the gel and allowing it to evaporate (Hugonnet, S. and Pittet, D., 2000). The student nurses' training programme is such that the professionals' learning is grounded in unique caring. The knowledge acquired in the training programme of the student nurses refers to care guided by nursing knowledge and understanding that is embedded in practice, that embraces theory, and encompasses a variety of ways of knowing (Hugonnet, S., Perneger, T.V., and Pittet, D., 2002). The philosophy imparts value to lifelong learning by integration of critical inquiry into practice, and individually, the nurse would deploy learning as knowledge, learning as process, learning as attitude, and learning as understanding. Infection and its transmission has placed healthcare in turmoil, and nursing is on the fault line (Eggimann, P., Harbarth, S., Constantin, M.N., et al., 2000). If nursing students are to understand that they need to categorize the knowledge that they learn, and they need to remember the material not only for examination, but also in their practice. Carpers patterns of Knowing, expressed initially by Barbara Carper is an excellent method to frame nursing knowledge. In my clinical area, specifically those with respiratory problems and those with terminal illnesses, such as, cancer are vulnerable to infection, and these infections may cause the patient's condition to worsen leading to increased suffering, prolonged illness, and enhanced cost of care. If simple hand washing could reduce all these, the problem that the nursing students are failing to comply with guidelines would either indicate their deficiency in training or not being careful enough to apply learning or knowledge into practice. Due to fact that the numbers of MRSA and C diff infections and bacteriaemia cases are on the rise, as the nurse working in my clinical area, I needed to investigate and audit the care provided in order to know what exactly the cause is. It was observed that the student nurses are not compliant with the hand washing guidelines, and the audit revealed that they are not just questioning their actions and practice. In most of the cases where care involves handling patients' utensils, bed, direct or indirect touch, possible contact with excreta or secretions, the student nurses are omitting the very important guideline of washing the hands (Journal Watch, 2004). When asked as to why they are doing so, they replied that they are just not following the education, knowledge, and learning, and instead, their actions are guided by observational practices from the trained staff nurses or medical staff. The training has taught them that hand washing is mandatory, that failure to wash hands before and after any patient contact tantamount to deficiency of fitness to practice, and that the consequences of their deficiencies may be extremely detrimental to the patients' outcome, but in the practice they are not guided by the evidence based on existing knowledge, rather are guided by blind observations. It is true that many trained staff nurses and the medical stuff despite knowing the implications would not follow the guidelines, and the bad practice percolates (Girou, E., Loyeau, S., Legrand, P., Oppein, F., and Brun-Buisson, C., 2002). MRSA is a major nosocomial pathogen that has caused problems in the hospitals worldwide with the UK having one of the highest rates of MRSA in Europe. Clostridium difficile (CD) and MRSA are colonized commonly in elderly patients. The incidences of both in hospitals in UK have been rising, and epidemics necessitating ward closure to control them are common. Both the organisms are prone to be transmitted by direct contact, mainly by nurses. CD infection is associated with more than 7 days of broad-spectrum penicillin use, and both organisms would require cephalosporin therapy. Side-room isolation, barrier nursing, and thorough hand washing are mainstays of therapy and management of MRSA and CD. Guidelines emphasize handwashing between examining patients. If the patient contact is prolonged, hands would need to be washed with 4% chlorhexidine scrub. The student nurses' knowledge had actually no deficits. They admitted to know that after a less prolonged contact, the hands would need to be washed with alcoholic 0.5% chlorhexidine hand rub. To facilitate this, a dispenser was present in each bay and side room, and a similar dispenser is usually carried on the medical notes trolleys during doctors' rounds. The nurses of all grades are encouraged to remind doctors of all grades to wash their hands. In practice, however, this seldom happens. Ideally, the guidelines for infection control should be based on good evidence, and they should be constantly and consistently evaluated in clinical practice. It would be wise to accept the fact that environmental and administrative factors including inadequate handwashing facilities, insufficient side rooms, inadequate ward cleaning, avoidance of understaffing, and avoidance of overcrowding may all play their roles, and these factors, particularly increased work load and understaffing were cited as reasons for noncompliance (Kilbride, H.W., Powers, R., Wirtschafter, D.D., et al., 2003). Consequently, it became important to know the mechanism of such omission. The most important factor for the student nurses if failure to categorize the knowledge. The pattern of knowing consists of empirical data, actual factual knowledge. Personal knowing is the lived experience the student nurse brings to the nursing situation. Since all the students have learned theoretically the importance of handwashing in a clinical setting, specially in the vulnerable patient population, it seems there is no gap in it. However, aesthetic knowing is transformation of personal knowledge and application of it in the field. This happens through the use of intuition and empathy to understand the uniqueness of each client, and it bypasses the usual linear process of thinking (Moralejo, D. and Jull, A., 2003). Aesthetic knowledge challenges student nurses to seeing unique possibilities for each client. The ethical knowing allows each student nurse to look at the mortality embedded in each situation, and this knowledge would empower the student nurse to recognise that this may flavour her reactions to a situation, and this would drive an action. The action would direct the interventions and choice of the caring response. This with respect to noncompliance of hand washing guidelines this may be interpreted as a partial deficit of aesthetic knowledge or total lack of ethical knowing, and presence of personal knowledge about contamination and prevalence of MRSA and CD and its effects makes it extremely unethical for these students to lack ethical knowledge. Despite having a theoretical knowledge, they just failed to impart care that is up to the mark (Pittet, D., 2000). There is a definite role of hierarchy in persuasion of best practices. This springs from the concept of experiential learning. This means the ideal condition of application of knowledge from personal learning can only be converted to aesthetic knowledge and ethical knowing when learning or knowledge at work setting is mentored by staff that strictly follows guidelines at work. By application of Eraut's framework, and the key to recognizing work-based learning is to find a way of providing the evidence and showing that the learning is as valid as learning acquired through other means. Thus, to be able to inspire the student nurses to follow their learning, it is important to establish transparent and explicit intended learning outcomes of the learning process. Thus, study of the particular course is rendered invalid unless the learning is applied in practice, and work experience would review and validate the current knowledge and synthesize a new practice guided to the care of the patients. The curriculum frameworks should be, hence, investigated and moderated to facilitate the planning and realization of experience-led work-based learning. The senior staff nurses have extremely important roles to play in the position of a mentor and leader who would lead by example so that the student nurses can experience their learning vividly applied in the field and be inspired to apply hand washing techniques rigorously while handling a patient. It is to be accepted that the benefits of supervised work experiences are unique in the sense that those are identifiable and are not accomplished by any other means. This leads to practical application of knowledge gathered in the classroom and development of general work and operational skills. The student nurse, thus, is exposed to a situation where general personal development of the care professional happens, and her critical and analytical powers are sharpened in the sense that she can relate between practice and its rationale learned earlier (Larson, E.L., 1995). Ultimately, this process would be expected to lead to specific skill development which in this case is compliance to handwashing guidelines and practices imbibed in the professional. According to Eraut's framework, most professional education involve both transmission of propositional knowledge in the college setting and acquisition of process knowledge by work-based learning. Thus a combination of propositional knowledge and process knowledge would generate professional knowledge and professional competence. For the student nurse to become a professional nurse in practice, it is of utmost importance that the staff nurse demonstrates and leads by action in the hospital setting, and they would create an environment where process knowledge is acquired by action (Larson, E., 1989). From the perspective of student nurses in a caring profession like nursing, the educational process is based around a partnership between the individual learner, the employment context, and the higher education institution. The other way of looking at this problem can best be elicited by problem-based learning described by Parker and Wiltshire. This concept emanates from the fact that there is considerable gap between the practice and learning for the new entrants. Nursing is just not about creating nurses, this is about creating professionals with a social mandate, and the teaching and work environment should contribute to this mandate by scholarship and doctoral education. The failure of the student nurses to comply with a reasonable guideline that involves a simple activity of handwashing that has larger significance. This hurts the mandate to such an extent that it is always timely to stop reflect upon this issue because it is very easy for the intellectual enterprise involved in conventional education so that the main activities may be stripped away from this mandate. Nursing has entered successfully into academy, but the problems are graver so that there are concerns about tensions, rifts, and gaps between theory and practice. Taking the example in my clinical area where student nurses equipped with more modern education based on evidence-based research are just failing to deliver what was supposed to be. Obviously, the imperatives of the university and healthcare agency did not match leading to a 'town-gown tension'. There is a constant improvement in healthcare services and access to services for the cared, and for the caregivers, the student nurses, the learning environments are improving. In this rapid change and turmoil associated with the package, the end result appears to be despairing mainly due to the fact that the focus on the ends or purpose with a social mandate is often put at bay (Pittet, D., Hugonnet, S., Harbarth, S., et al., 2000). Given the need of the hour, the student would need to be trained and taught in a scholarly place where truth is pursued through reasoned disciplined enquiry and knowledge valued, preserved, transmitted, advanced, and applied. This demands a move towards workplace learning where trained staff nurses play major role in building experiential knowledge that can be converted to ethical and aesthetic knowing. Historically, nursing practice has been portrayed as essentially practical, and this has resulted in a split or fragmentation between nursing knowledge and nursing practice. Thus the knowledge embedded in practice and the shifting and changing relationships between nursing knowledge and nursing practice enable that the discipline of nursing practice is first practice and then nursing knowledge, and the knowledge would better be practice based. This calls for review if the knowledge gathered is concurrently and harmoniously synthesized with practice. This needs collection of evidence by research and its deployment in practice (Sharek, P.J. et al., 2002). Evidence-based practice has evolved as a dominant theme of practice, policy, management, and education within the National Health Services. The ultimate rationale for developing nursing practice based on research is the contribution it can make to enhancing patient care in terms of prevention of nosocomial infection by MRSA and/or CD through creation of an evidence base to inform, review, and evaluate practice of the student nurses who will begin to comply with the guidelines enumerated above. Unfortunately, there has been little evidence-based research conducted into the best ways to manage hospital acquired infection or to lower the incidence where existing knowledge suggest that even apparently small activity like handwashing counts a lot. Such a research involving the student nurses and improvement of their practice is an urgent necessity. Nursing as a discipline is still developing its research acumen, and there is an ongoing debate and tendency towards qualitative research methods to be adopted best to achieve this goal. Qualitative research shares its philosophical underpinning with the naturalistic paradigm that describes and explains a person's experiences, behaviours, interactions, and social contexts without the use of statistical procedures or quantification. This considers the multiplicity of reality (Pittet, D., Dharan, S., Touveneau, S., Sauvan, V., and Perneger, T.V., 1999). The interrelation of this deficit of the student nurses can be examined and determined within the context that the trained staff nurses fail to behave as a role model. A student's willingness to follow handwashing guidelines and opinion in relation to the usefulness of hand hygiene to prevent cross infection hence would be the most appropriate research question. A rating scale could be introduced into a carefully designed questionnaire to aid analysis and presentation of the results. Most students accepted that handwashing is an important means of preventing infection. Apart from that, the attitude, motivation, behaviour, intention, knowledge, and abilities of the students can be measured, and it must be stated that in all counts, the student nurses were remarkable (Stone, S.P., 2001). It needs a special mention that healthcare workers are more aware of the threat posed by hospital-acquired infection through improved resources that they can utilize while being educated. Surprisingly in this case, there seems to be little correlation between what people know and what they do. It could be argues that those who have greater knowledge have greater insight about the breach in practice and violation in guidelines. In other words, the student nurses better trained theoretically have better awareness about their limitations and better knowledge about what they were failing to do. Most of the nurses, however, claimed that they believed that they washed hands as often as their peers, and most believed that the rewards for hand washing would have no effect on their practice. Almost all claimed that they followed their mentors in the ward who did not care to wash hands in most occasions, and they were vocal about the fact that they have observed that the doctors would never wash the hands in between examining two patients even if the patient or nurse would remind them. Some of them reported that questions about why hands are not washed to both the staff nurse and the doctor have raised grievance. Few reported that punishment for noncompliance would have no effect. Most, however, accepted that one of the reasons of noncompliance to guidelines is difficult access to sinks and unavailability of washing facilities, and availability would increase the frequency of hand washing. For the trained staff nurses, the workload and overcrowding in the clinical area is an important factor for their noncompliance since there is hardly enough time for a thorough warm soap water hand washing because rounds and administration of medication takes priority over hand washing. Few considered that an effective risk management and adverse event reporting system and retribution system would force the students to apply their knowledge in the work arena. These results indicate that the student nurses understand the importance of handwashing but tend to overestimate their own compliance to guidelines. They are not in favour of interventions involving rewards and punishments but are more in favour of interventions that make handwashing convenient. As the speciality of infection control increasingly recognise the complex behavioural issues that affect practice, the steps to ensure compliance to guidelines would involve means to modify the behaviour of the student nurses (Worsley, M.A, 1998). The interventions can be designed based on the assumption that a model nurse is aware of the fact that the patients are at risk from infections. The role model would need to imbibe the idea that knowingly putting the patient at risk of harm from nosocomial infections that can be life threatening would be surmounted to be an act of malevolence and thus morally reprehensible, and to get rid of such a situation, one should comply with infection control policy and guidelines. The context of nursing activities should be taking all possible measures to bridge the theory/practice divide, and the students should be motivated to synchronize between required knowledge and activities in the practice setting. The nurses should need to be made adequately knowledgeable about infection control issues. The audit has revealed that the student nurses could generally provide evidence of their comprehension of MRSA and CD infection control principles by articulating appropriate preventative measures when presented with a theoretical scenario. Clinical audits in my practice area, however, indicate that the student nurses do not always apply the principles they espouse. The NMC code of professional conduct (2002) states that all nurses have a responsibility to deliver care based on evidence-based practice and validated research. Nurses must keep their knowledge and skills abreast and must also participate in activities that will develop their competence or performance. The senior and experienced staff nurses has important responsibility to behave as role models for the student nurses (RCN Guidelines Infection Control, 2002). They should demonstrate in every possible occasion when to wash and how long to wash. They should explain the choice of an antiseptic agent and demonstrate the usage for antisepsis. The staff should be motivated to use demonstration of correct techniques, such as, pairing of nails, banning of artificial nails, promote the first wash to remove as much as particulate matters as possible. They should promote alcohol-based hand rubs as an effective method of handwashing. An attempt to behavioural modification of the nurses through educational campaign and supervised forced practice by the more seniors in the hierarchy can serve the purpose of percolation of practice among the students. Such ventures would need to be aided by documented incidence of poor compliance as a motivator to help staff adopt a higher level of commitment. The results of the baseline studies could be disseminated through educational in-service sessions, e-mails, handouts, and demonstrations. The behaviour can be indirectly influenced by reinforcement of the rationale for complying with the existing policies but also can be capitalized on the discussions generated by negative results to introduce change in policy. The change in management would involve techniques to improve the frequency of handwashing while addressing concerns regarding skin breakdown and sensitivity to antispesis agents. In this mode, repeated assessment of compliance after the initial campaign would need to be done usually in the form of small audits performed in front of the staff to serve as reminders for the staff. Conclusion: The audits of handwashing compliance perhaps are the most common and most important tool for changing behaviour. This is a well established technique in the clinical setting and would serve to improve compliance of the student nurses and of course would serve to reduce the contact transmission of MRSA and CD to lead to a spread of nosocomial infections. Reference List Bischoff, W.E., Reynolds, T.M., Sessler, C.N., Edmond, M.B., and Wenzel, R.P., (2000). Handwashing Compliance by Health Care Workers: The Impact of Introducing an Accessible, Alcohol-Based Hand Antiseptic. Archives of Internal Medicine; 160: pp. 1017 - 1021. Boyce, J.M., (1999). It is time for action: improving hand hygiene in hospitals. Annals of Internal Medicine; 130: pp. 153-155. 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