The Socio-Cultural Norms Influencing Hand Decontamination - Dissertation Example

A mini-ethnography: Illuminating the socio-cultural norms influencing the decision to perform hand decontamination Aim: The papers provides illumination on the decision to undertake hand decontamination by health care workers from the care home setting, and how these are informed by socio-cultural norms. Background: The use of hand washing (now termed decontamination), as a single technique to combat cross infection in health care has often been cited as a basic element of nursing practice. Healthcare acquired infection is estimated to cause five thousand deaths per year in England and Wales. There is general consensus that hand hygiene is the most effective means of preventing the transmission of infection in health care settings. Increased awareness of hand hygiene could cause reduction of pathogenic microorganisms carried on the hands of health care workers and as a consequence reduce morbidity and mortality from these infections in health care settings. Methods: An ethnographic approach was the basis of the research undertaken. This approach allows an understanding from an insider’s perspective that focuses on the interactions that occur and lead to the assessment of hand washing. In keeping with the requirements of the approach a sampling plan was devised. Intrusive data collection methods were eliminated from use. Four care homes from within two primary care trusts were selected from the care homes that volunteered for the study. The sampling process for participants was the same for each of the four participating care homes. The participants included both qualified nursing staff and care assistants. Observation and interviews were the means by which data was collected. Domain analysis, taxonomic analysis, componential analysis and theme analysis was used to analyse the data collected. Findings: Management styles had a significant impact on the socio-cultural influence on the decisions with regard to hand washing. Where management styles were authoritative and interfered in all aspects of the functioning, thus reducing the autonomy of the nursing staff there was a negative impact on the socio-cultural influences and thereby a negative attitude towards hand washing. Where the management styles offered greater autonomy in the functioning of the nursing staff and encouraged discussions on hand washing a positive impact on the socio-cultural influences was clearly visible and accordingly a higher importance given to hand washing. Conclusions: Lack of motivation is not the reason for health care workers not performing hand decontamination risk assessment. It is the social and cultural environment that the health care worker is in that decides the performance of hand decontamination risk assessment. The more amenable the environment the more favourable the impact upon the ability to perform the decision making process of hand decontamination risk assessment. The study also recommends that these conclusions be looked into deeper by studies in other health care environments. Key Words: hand washing/hand decontamination, health care workers, socio-cultural, ethnographic approach, observations, interviews, autonomy, management styles. SUMMARY What is already known about this topic: Hand washing or hand decontamination plays a significant role in controlling of transmission of infections within a health care setting. Many approaches are used to encourage hand washing or hand decontamination among health care workers within health care settings. Motivational aspects were considered as the most appropriate in encouraging hand washing or hand decontamination among health care workers. What this paper adds: Motivation remains an element in encouraging the use of hand washing or hand decontamination among health care workers, but the most significant factor is the socio-cultural aspects of the health care environment. Management styles have an important role to play in encouraging the use of hand washing or hand decontamination in a health care environment. The greater the autonomy in the matters of work and encouragement provided by the management for discussions on hand washing or hand decontamination, the more the positive impact on the performance on hand washing or hand decontamination risk assessment by the health acre workers. Introduction: The role of hand washing has been known as a means of preventing illness for over one and a half centuries; yet hand hygiene can be traced back to the early eleventh century, as a professional expectation for medical practitioners. During the later half of the twentieth century the use of chemical antiseptics, to reduce the numbers of microbes upon the hands of health professionals, has led to a great reduction in the incidence of infection being transmitted by this route. (Ayliffe et al 2000; Earl et al 2001). Characteristic improvements have been made to the many preparations now available for performing hand decontamination, including the use of alcohol. These improvements have led to worldwide improvement in infection prevention (Wilson et al 1999) and are viewed as an essential part of infection control programmes across Europe. (Plowman et al 2000). It is an undisputed fact that infection causes severe mortality and morbidity throughout the world’s population. (Mayon–White et al, 1988). Even after the advent of antibiotics and vaccinations as a front line measure to treat infection, the socio-economic costs of healthcare associated infections have continued to rise. (Plowman et al, 1997). The National Audit Office in 2000 had stated that 5’000 death per year in England and Wales could be attributed to healthcare associated infections, and this was considered to be a conservative estimation. Background: At any one time, approximately, one in ten patients in acute hospitals have a hospital-acquired infection (Pratt et al 2001), and an unspecified number of patients in the community have an infection related to a recent hospital admission.  These infections impose a burden on the health sector, patients and their carers. Plowman et al (2000) conducted one of the largest studies into the economic costs associated with health care related infection. They estimate that the largest identifiable costs of infection in hospitals, related to nursing care (42%) and management of patients (33%). They also estimate that this costs the National Health Service in England 1 billion pounds per year. This can be further quantified as an extra 3.6 million hospital days per year in England due to hospital acquired infection (Plowman et al 2000). After discharge of patients into the community this cost can only be increased, as we add the numbers of people claiming sickness related benefits and lost workdays, not to mention the way having an infectious disease can affect an individual, family and community. The role therefore, of the hand washing in transmission of infection has been well recognised (Pellowe et al 2003), and health care acquired infection remains one of the principle reasons behind morbidity and mortality in those receiving healthcare (Ayliffe et al 1992; Horton 1995). Hand washing it would seem, remains the simplest yet the most elusive means for controlling the transmission of infection. Hand washing is a basic skill taught to health professionals during training and induction into health and social care workplaces (Wilson 1999), and this education tends to be continued throughout that health care workers employment (Hobson 1998). Pratt et al (2001), highlights a number of actions that could increase compliance in hand hygiene and also cites some of the reasons for non-compliance. Factors that have an influence upon hand washing have been explored by a number of researchers (Cochrane, 2003; Earl et al, 2001; Ward 2003). The literature tends to reflect the common reasons given in the practice situation. Again, when asking health care workers ‘why do you not wash your hands?’, the degree of physiological and psychological stress of working in healthcare is discussed, along with lack of time, lack of education, insufficient or inappropriate physical resources (Cochrane 2003). Do life experiences, peer groups and settings where hand hygiene is performed affect the likely hood of hand decontamination assessment being made? If so, the issues, as addressed above, must also play their role. The lack of facilities, inappropriate equipment and the need for appropriate training has some effect upon the assessment decision, as has been shown (Cochrane 2003; Gould 2000; Naikoba et al 2001). Should these issues be considered in isolation, and hypothetically addressed as Elliott (1992) has done, or should nursing reconsider the role social and cultural issues have to play in this decision. Data Collection: The planned study took place in the natural care setting, embracing the research paradigm of naturalism. Not only were ethical issues, truthfulness, consistency and transferability of the study, considered prior to entering the field, but also in the sampling approach and data collection methods. Focus groups are a good strategy for acquiring data (Webb and Kevern 2001), concerning what happens in the natural day to day environment, they also provide an ideal situation for recording both audio and visual data to aid, and thus increase, the consistency of the data. However, participant observation that allows for the capturing of data in the workers own environment was one of the chosen means for data collection. An assumption was made that the effect that the observer has upon the participant’s behaviour will be self-limiting, once the initial stages of entering the field have worn off (Mulhall 2003) Interviews were an important method of data collection and within the study was the other preferred method. Interviews were used as data collection means formally in semi-structured interviews and informally throughout the period of participant observation. The participant groups were drawn from four care homes within the two primary care trust regions. The sampling process for participants was the same for each of the four participating care homes. Two health care workers from each home, one day and one night worker, were interviewed post observation. The participants included both qualified nursing staff and care assistants. All participants were chosen at the time of observation and were asked to complete tape-recorded interviews. They were given at least twenty minutes notice, in an effort to minimise the intrusion into the workplace The four principles of simplicity, acceptability, permissibleness and unobtrusiveness, as identified by Spradley (1979,1980), were the corner stones of the data collection in the study conducted. The data obtained through these methodologies provided a high quality resource. Ethical Considerations: There have been suggested that approaches like ethnography do not need to give consideration to the ethics of research, due to the closeness they have with real life situations (Hammersley 1992). However, due consideration to the ethics of consent were addressed within the research approach. Subsequent to the completion of the project’s research proposal, undertaken with guidance from the Royal College of Nursing Institute, a process of ethical clearance was launched and received from the Local Research Ethics Committee. Care homes from within two primary care trust geographical boundaries, were approached for participation. Administrative sanction was received from the acre homes that volunteered and were selected for the research study. Health care workers who wished to participate in the study needed to sign a consent form relating to the ethics and confidentiality of participation. This outlined a number of key points; agreement that the intellectual property of the research findings were to remain the property of the researcher, that participation is voluntary, and as long as there are no major objections the observation will commence without further consultation, unless significant numbers of staff do not wish to take part; therefore, making the observation impractical at this setting. The consent form also outlined the participant’s agreement to take part in the study and to undertake a tape recorded interview if requested, although this could be declined at any time, it also confirmed that the participant had read and understood the client information sheet. Conceptual Framework: The research was conducted using an ethnographic approach. Ethnography is derived from the ancient Greek terms of ‘Ethnos’ meaning people / culture, and ‘Graphe’ meaning a writing. Ethnographic research has been used within anthropology for many years. Leininger’s (1985) describes ethnography as ‘The systematic process of observing, detailing, describing, documenting, and analysing the life ways or particular patterns of a culture (or subculture), in order to grasp the life ways or patterns of people in their familiar environment.’ (Leininger 1985.) Historically, the approach has been used within the study of exotic peoples, to derive an understanding of the origins of civilisation. Anthropology uses a fieldwork approach, e.g. participatory observations and open interviews to enable this (Skeggs 1994). The ethnographic method focuses upon descriptions within cultural groups, be these populations or health care workers. The approach aims to gain understanding of the natives’ view of their world i.e. the insiders view, focusing upon the interactions that take place that lead to hand washing assessment. Atkinson & Hammersley (1988) traced the beginnings of this approach during the renaissance to the late twentieth century. Boyle (1989) favoured the term ‘field research’. Atkinson & Hammersley (1988) viewed ethnographic research, as a method, or set of methods, with which to describe people’s interactions. They surmise that ethnography has two set characteristics, that the researcher observes the activities, as opposed to relying upon experimentation, and gains an understanding of the perspective. The nature of reality is that meanings and perceptions help to construct the reality of hand washing assessment, as opposed to objective measurements. Thus allowing the study of meaning, that leads to the hand washing assessment, rather than quantification of the reasons for hand washing. The Study Aim: The purpose of the research is to uncover / illuminate the decision to undertake hand decontamination by health care workers from the care home setting, and how these are informed by socio-cultural norms. Design: The study was designed to take place in the natural care setting, embracing the research paradigm of naturalism. Unobtrusive observation and interviews were designed as the data gathering tools of the study. Participants: The study was designed to observe healthcare workers functioning in their natural settings and hence four volunteer care homes from within two primary care trusts were selected. The inclusion criteria required that the care homes be providers of nursing care. Care homes that provided both nursing and residential care were excluded, as they did not meet the sampling criteria. Volunteer healthcare workers from within these chosen care homes were selected as participants and consisted of two health care workers from each home, one day and one night worker. These participants included both qualified nursing staff and care assistants. Validity and Reliability: Reliability and validity of the data collected was expected, as the primary means of data collection was through unobtrusive observations. Field notes were used to record the observations and conversations were committed to memory for later recording. The recording of events reflected the reality of any speech event that took place. The journal notes that recorded the observations formed part of the ethnographic record and helped to identify thoughts and feelings, which became an introspective record of the journey that the study had taken by immersion into the field. Findings: Each of the four care homes studied had similar care practices and levels of dependent clients; however, the leadership / management hierarchies did differ. As the study progressed, differences between how practices were viewed, the morale of the workers and management styles of the matron / manager became more obvious. These had implications that could be seen as informing the practice of hand decontamination assessment at varying levels. From the study’s theme analysis it appears that the level of impact the socio-cultural norms identified here, have affected the decision to perform hand decontamination assessment both positively and negatively. This does alter the health care workers feelings and the levels of respect the workers hold for the matron / manager and the degree of self-autonomy the workers hold. The Culture at the Care Homes: The first care home, in the study, had a number of care workers who worked in teams; in these groups they managed the care provision for clients, without the direct supervision of the manager or matron. The home’s staff appeared accepting and happy in their work, with little complaint about conditions or morale of the workforce. The manager facilitated the care experience but remained distant, thereby freeing up time for her own duties and fostered a sense of belief that the staff were capable of undertaking their roles independently and were trusted to do so. The second care home, in contrast, had a far more authoritarian leader in the role of home matron / manager, who favoured the task allocation approach to care activities for her workforce, and was not prepared to involve the team in the direct care decisions. This resulted in a lack of opportunity for the staff to talk through their own care concerns. Little discussion took place regarding the care interventions and hygiene approaches used by the workers. The health care workers in this group appeared less at ease with the tasks they were being asked to perform. The main observed worker interactions seemed to focus upon providing the care task and ‘gossiping’ related to the management of the care home and how unhappy they, as individuals, were. The third care home, however, created a new anomaly, where the management style of the matron / manager similarly emphasised her role as an expert, providing task allocation of duties to the workforce. However, she was prepared to embrace the concept of team working, and showed preparedness to accept that the health care workers could have valuable input into providing care, being autonomous in their own right for judgement decisions in relation to the daily tasks required for the successful management of the day’s duties. However, these activities were soon altered and restructured, once the manager had left the building and had no visual control or checking methods to ascertain that her instructions had been completed. Discussions about the care needs and collaboration with the other health care workers became the norm. It was during these interactions that discussions took place, which affected the decisions to perform hand decontamination and teaching / training or learning experience, seemed to be occurring as a natural phenomenon between the health care workers. Once self-autonomy for actions and a mutual respect developed, an increase in positive feeling was generated within the home. This directly affected the health care workers ability to reach the decision to perform hand decontamination; as was witnessed in practice. The final care home resembled closely the experience of the first, where the care manger / matron authorised care to be delivered, but took little part in the task allocation of roles and duties. However, a high degree of delegated leadership was provided to key health care workers in the home, which resulted in a more authoritarian approach being created through the delegation of power over others actions. This resulted in less self autonomy of practice for the individual care worker and, subsequently, the respect held for these individual workers was palpably less than had been experienced in the other settings. These experiences reinforce the belief that the ‘management style domain’ identified affects the cultural norms seen in practice. It does influence the decisions to perform hand decontamination. Far from this being an individual phenomenon the pattern is a cultural norm, which affected the majority of staff to a higher or lesser degree, even when hand hygiene compliance training and education had been provided within all of the homes. This cultural phenomena, coupled with the ability of health care workers to discuss the hygiene implications of care, impacts upon the collective ability of the employees to perform the hand decontamination assessment in the practice setting. Theme Analysis: To begin with two examples of cross-cultural statements emphasize the foundations of the theme analysis. Carer A has walked into the manager’s office and asked for her duties for the morning shift. The manager has given her a list of patient focused tasks to complete and Carer A asked “can I bath Mrs E, as she is going out later”. The manager replied “you have had your list of duties; I will review them once I have allocated everybody else’s work, run along now”. The same carer some time later explained that the manager often did not let her ‘take the initiative’ and blamed her for having a ‘stroppy attitude’. The same carer expressed concerns regarding her own abilities to continue practicing, when such ‘interference’ prevents her from doing her ‘duty’. It became clear through the processes of participant observation, that this was not an isolated theme. Carer B from the first care home says “I love working here, we have so much fun. Ever since I started they have let me do the job, the last place I worked was so shit I quit”. I questioned this worker further whilst she was performing some cleaning duties, “it’s just really nice to have the respect of the other staff, they let you know when you have done things right…yesterday I wanted to do some dusting, so I did and the senior carer said it showed real initiative…if that had been my old place I would have been given a verbal for trying to get out of the work”. These two examples demonstrate how Management style and talking about hygiene were to emerge as central themes to be uncovered within the analysis of the data. The componential analysis of talking about hygiene is provided in the table below. It is the very nature of being able to provide autonomous practice, and discuss with others the processes of care that will impact upon an individual’s ability to perform hand decontamination upon an assessment of risks in their practice. Take this freedom away from the health care worker and the decision to perform hand hygiene is also reduced. The socio-cultural influences of ‘management style’ and the ‘ability to talk about hygiene in relation to care practice’ do have a role to play in how health care workers decide to perform hand decontamination in practice. Discussion: Historically, hand washing has been used as a means for preventing the spread of disease for over one and a half centuries (Hobson 1998). ). The role of hand decontamination has never been disputed (Mulhall 1997). The socio-economic burden of infection as a serious cause of mortality and morbidity throughout the world continues to rise (Mayon-White et al 1988). There have been many technological advances made in hand decontamination products such as soaps and alcohols (Ziomek 1998), yet here in the England and Wales, 5’000 deaths per year can still be attributed to health care acquired infection (National Audit Office 2001). The Centres for Disease Control (1986) produced guidance for health professionals regarding hand decontamination, which has failed to perceptibility increase compliance with hand decontamination practices (Ziomek 1998). In the UK, the government have endorsed guidelines on the prevention of infection (Pratt et al 2001, Pellowe et al 2003); however, neither of these major works identifies socio-cultural influences that could affect the decision of health care workers to undertake a hand decontamination risk assessment. The health care workers are engaged in practice, it is important to understand the culture of care provision and, that this culture is maintained to allow the forming of the group’s identity (Cavanagh 1997; Johnson 1995;). With nursing embracing holism (Carper 1978), as a concept for care practice, it stands to reason that the process involved in determining the hand washing need will incorporate a more holistic appreciation of the multiple factors involved, as opposed to purely measurable facts, quantifications of the reasons, how, why and when healthcare workers fail to perform hand decontamination. The process of reviewing the many factors that influence the decision to undertake hand decontamination, and the realities of this in practice, has remained the focus of this approach throughout the study. Using manifold methods (Slevin and Sines 1999) for data collection has, not only allowed for the triangulation of methodological data, but also increased the credibility of the findings, which have been achieved through the identification of socio-cultural themes from four unrelated care home settings, where elements of the cultural domains have been identified within each study base. This demonstrates that the phenomenon uncovered, although tacit in its nature, is shared across the four groups of health care workers; with each group having different levels of the norm influencing their own reality of the hand decontamination assessment. Conclusion: The research findings suggest that the resource argument has a much lesser impact than the cultural environment of the healthcare worker in the issue of hand decontamination and the employer has significant role to play in providing such an environment. From the studies findings it is clear that a recurrent theme of providing an environment, that allows health care workers to respect each other and perform their practice duties autonomously; that allows for the freedom of discussion about the hygiene needs carers need to consider, and enhances the ability of these workers to undertake the decision to perform hand decontamination. 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