Ipc West Study Guide
Healthcare-associated infections, while preventable, result in increased morbidity and mortality in nursing home (NH) residents. Frontline personnel, such as certified nursing assistants (CNAs), are crucial to successful implementation of infection prevention and control (IPC) practices. The purpose of this study was to explore barriers to implementing and maintaining IPC practices for NH CNAs as well as to describe strategies used to overcome these barriers. We conducted a multi-site qualitative study of NH personnel important to infection control. Audio-recorded interviews were transcribed verbatim and transcripts were analyzed using conventional content analysis. Five key themes emerged as perceived barriers to effective IPC for CNAs: 1) language/culture; 2) knowledge/training; 3) per-diem/part-time staff; 4) workload; and 5) accountability. Strategies used to overcome these barriers included: translating in-services, hands on training, on-the-spot training for per-diem/part-time staff, increased staffing ratios, and inclusion/empowerment of CNAs.
Understanding IPC barriers and strategies to overcome these barriers may better enable NHs to achieve infection reduction goals. Introduction Healthcare-associated infections (HAIs) in nursing homes (NHs) are an increasingly important concern resulting in increased hospital admissions, morbidity, and mortality among NH residents. There are an estimated 1.4 to 5.2 infections per 1,000 resident-care days in NHs and skilled nursing facilities, costing the US healthcare system an additional $673 million., The Department of Health and Human Services has declared HAI prevention in NHs a national priority, and the Centers for Disease Control and Prevention provides toolkits to reduce the number of HAIs occurring in this vulnerable population. HAIs are thought to be largely avoidable through adherence to infection prevention and control (IPC) practices. Furthermore, education and training of frontline personnel is key to ensuring compliance and successful implementation of those practices.
Certified nursing assistants (CNAs) comprise the majority of frontline personnel in NHs and are increasingly responsible for the identification and reporting of residents presenting with signs and symptoms of infection., When not performed effectively, activities primarily carried out by CNAs such as feeding, hydrating, hygienic care, toileting, ambulation, and resident turning and positioning, may increase the risk of infection transmission. Despite the potentially significant role CNAs play in reducing infection transmission, to our knowledge, there are no studies that explore the challenges to IPC compliance for NH CNAs. Therefore, the purposes of this study were to explore barriers to instituting and maintaining IPC practices for NH CNAs as well as to describe strategies utilized by NH personnel to overcome these barriers. Study Sample & Design This study was part of a larger, mixed-method, multi-site study designed to describe the phenomena of infection control in NHs (NINR R01 NR013687). The methods utilized in this study are described in detail elsewhere. Briefly, NHs were purposively sampled to obtain variation in geographic distribution, bed size, and ownership status.
At each NH, we interviewed personnel important to IPC including: CNAs, infection preventionists (IP), directors and assistant directors of nursing, NH administrators, advanced clinicians, environmental services workers, staff development/risk managers/quality improvement coordinators, minimum data set (MDS) coordinators, and staff nurses. Participants were English-speaking staff that worked in the facility for approximately one year or longer. Written informed consent was obtained from all participants. The Institutional Review Boards of Columbia University Medical Center, University of Pittsburgh, and the RAND Corporation approved the study. Data Collection & Analysis Between May and September 2013, we enrolled facilities and conducted site visits at 10 NHs located across the country (Northeast: n = 3; South: n= 4; West/Midwest: n= 3). NH size ranged from approximately 40 to 200 beds. Additional details about NH demographics are described elsewhere.
Semi-structured in-person interviews were conducted by a team of eight interviewers. All interviewers used topic guides tailored to the respondents’ roles and interview methods were reviewed to ensure consistent data collection procedures. The interview guides (available upon request) were informed by Donabedian’s conceptual framework of healthcare quality, that includes structures, processes, and outcomes, and published guidelines for infection prevention in NHs. Questions were open-ended and specific to infection prevention. Specific questions that were the focus of this sub-study included: “What are some of the barriers to effective infection control in your facility?”, “What are the facilitators in your facility that have helped you prevent or control infections?”, and “Tell me about the challenges related to infection control in your facility.” All interviews were digitally recorded, transcribed verbatim, and de-identified. Data were coded using a conventional content analysis in NVivo 10 data analysis software (QSR International Pty Ltd. Version 10, 2012).
This analysis allows for codes to flow from the data and is ideal when exploring a phenomenon that is poorly understood. Three members of the research team (PKS, RIB, CCC) coded all transcripts and, subsequently, data specific to the CNA’s role were analyzed for themes related to barriers and facilitators of IPC.
Coding discrepancies were reconciled during weekly team meetings. Emerging themes were also discussed in these meetings to ensure consensus of all interpretations.
Analysis concluded when no new themes emerged from the data. Results In total, 73 interviews were conducted and averaged approximately 45 minutes in length. Many of the personnel interviewed, including all of the IPs (n=9), had multiple roles.
For example, a participant may have been interviewed for their role as an IP, but may have also served as the Director of Nursing/Assistant Director of Nursing, Staff Nurse, or Staff Development Coordinator. These characteristics are further described in detail elsewhere. Five key themes emerged describing perceived barriers to implementing and maintaining IPC practices for CNAs: 1) language and culture; 2) knowledge and training; 3) per-diem and part-time staff; 4) workload; and 5) accountability. Descriptions of each theme with exemplar quotes of the barriers and strategies used to overcome the barriers can be found in.
Theme Description Exemplar Quotes Language and Culture CNAs were often described as non-native English speakers with diverse cultural backgrounds and this impacted the manner in which IPC information was delivered. Barrier: “when you’re dealing with elderly people and the majority of the elderly people are native English speakers there is a big language barrier I think that’s something we could really improve.” Admin NH 2 Strategy: “We also use symbols that alert the CNAWe use little yellow smileys on the door and yellow armbands if someone is at risk for aspirationIf you look on the inside of the armoire, you will see aspiration precautions with pictures.” RM NH 3 Knowledge and Training Education and training of CNAs impeded information delivery and the implementation and adherence to IPC processes. Barrier: “ one of the things I want to add is having an actual orientation for new personnel, and in that orientation I would like to have a session for infection control where we talk about hand washing and educate on the flu. So that’s something that I am working towards because if you’re a new CNA or a new nurse you really don’t know because you haven’t been taught and you haven’t been educated.” IP NH 5 Strategy: “ when we first get hired we go through a big orientation, and we go through more orientation than other NH staff because we deal more with the residentswe are taught how we do it at this facility. This is how we want our aides to work.” CNA NH4 Per-Diem and Part-Time Staff The infrequent work schedules of per-diem and part-time staff posed difficulties for IPC communication and resulted in IPC breakdown.
Barrier: “we do brief infection control training, but again if it’s once a year it’s very hard there’s such an influx of private duty aides and it could be three private duty aides per one resident because of the different shifts and the times. So, it’s very hard to isolateand catch everybody.” IP NH 2 Strategy: “Once I can identify per-diem and part-time staff and in-service them, there’s more compliance.” Nurse NH 2 Workload Time constraints and understaffing impeded effective IPC practices. Barrier: “I think a lack of staff and a lack of time make you cut corners.
I’m not saying that the aides don’t want to do it right or don’t know how to do it right. They don’t have the time to do it right.” Nurse NH 8 Strategy: “the only real way that the state addresses inadequate staffing is if they come in and see that there is just a total lack of careIf they see that the patients are being taken care of, even though there are seventeen residents for one CNA, then they kind of overlook it and say it’s okay.” Nurse NH 8 Accountability Lack of ownership of IPC created breakdown in infection control practices and communication.
Barrier: “When we talk about CNAs and infection control sometimes CNAs think it doesn’t relate to them. For example, CNAs wear gloves when they shouldn’t.
When we talk about IPC just in general, CNAs think there is no relevance to them.” DON NH 10 Strategy: “I think when you empower people, when you really make people realize that it’s so important what they’re doing, and you give praise to people. The person that you see taking off their robe before leaving the room, washing their hands and coming outyou tell them ’You know I can always count on you.’” QIC NH 1. Language and culture Language and culture were perceived as common barriers to ensuring effective implementation of IPC practices. Participants noted that many of the CNAs came from diverse cultural backgrounds and were often non-native English speakers. These characteristics were perceived to limit the CNAs’ ability to understand and, therefore, effectively adhere to routine IPC practices. For example, a risk manager responsible for resident and staff safety at NH 3 realized that a tool developed to help CNAs care for the resident, “really was not effective because some of the CNAs could not read it.” In addition to language, the diverse cultures of CNAs were perceived to present challenges to IPC practices.
An administrator from NH 2 described this as an issue of particular importance, “if you come from a culture where you don’t really discuss medical issues sometimes that could be a barrier.” To address barriers associated with language and culture, NHs provided translated in-services and rules and regulations. The same administrator from NH 2 stated that because of “an overwhelming number of nursing staff that are non-native English speakers when you do education in both languages, we’re making sure that everyone is grasping the concept.” Pictures and color-coding of messages were also described by participants as beneficial when working with diverse languages and cultures.
Knowledge and training Lack of knowledge and training were perceived by participants to impede information delivery and limit the CNA’s ability to effectively implement and adhere to IPC processes. Specifically, the lower educational requirements of CNAs, compared to those of other health professions, were perceived as a barrier when providing instruction on IPC practices. While discussing in-service trainings at the facility, a participant responsible for quality improvement from NH 1 noted, “I’m very aware that I’m sitting with a graduate person and I may be talking in the same session to somebody who has a GED General Education Development certification. Both people need what I have to say.
Both people are going to view it differently, but the outcome must be the same. So I have to hope that the graduate person recognizes I’m certainly not talking down, but I’m putting it in language that can be understood. And that’s my challenge.” A registered nurse in charge of staff development at NH 4 discussed the varying educational levels of NH personnel and the importance of stressing the process of hand washing to the CNAs because, “when you’re talking blood borne pathogens and things like that, sometimes that’s not well-understood, but hand-washing is.” In other circumstances, even if it was perceived that CNAs were educated appropriately on IPC practices, lapses still existed when it came to CNAs applying what they had learned to their everyday resident care. An administrator from NH 6 noted, “It could be that we’re trying to roll out a certain program and we educate; we in-service the CNAs. Thirty days later, there is one person always in the group that still does it the old way.” Barriers in IPC knowledge and training were also described as being influenced by the length of time a CNA had been employed at the facility or tenure in the profession. In particular, a CNA from NH 5 described the challenges of knowledge and training as it relates to newer staff, “we have new staff that come in and they’re maybe not aware of certain things when they first start.” One suggested solution to overcoming these barriers was to examine how infection control policies and practices were taught to CNAs.
A nurse from NH 3 noted, “The CNAs learned the procedure, but not necessarily the why. Those in charge of IPC education are going to teach you how to do it and maybe the emphasis is not enough on the why and the consequences of what could happen if you do not comply. And I think once you know that, then you can think a little more. “ Using signs outside the residents’ rooms to provide knowledge about infection control was reported as helpful by a CNA from NH 6. Participants also reported the use of many techniques to address issues related to training including hands on training with CNAs as a way to ensure comprehension. Dedicating specific trainings for the CNAs and education on urinary tract infection, perineal care, and pneumonia prevention (e.g., providing adequate hydration, hand washing) were additional approaches offered. Personnel from several facilities described the importance of alerting CNAs if they were not doing something correctly as the circumstance occurred, as opposed to after the fact.
Tenure of the CNAs was described as a facilitator to overcoming barriers created by lack of training and constant reiterations of the policies and reminders were described as key to ensuring compliance. Per-diem and part-time staff Participants reported a reliance on per-diem and part-time CNA staff to fill the voids created by sick calls, turnover, and staffing shortages. However, they also reported limited opportunities to educate this group on IPC practices, thus creating barriers to effective IPC. An IP from NH 2 explained this barrier as being, “really tricky.
It’s not like I can schedule an in-service and gather everybody together because the next day I could have more private duty aides.” Additionally, after surveillance revealed unacceptable practice patterns (e.g., poor trash disposal habits), the same IP stated, “I’ll identify very quickly that it’s not necessarily our permanent staff per-diem staff are putting things in the garbage inadvertently, for instance. So I need to stop the private duty aides and in-service them as well.” Participants described various approaches to training per-diem and part-time CNA staff on IPC policies and practices. These included utilizing current staff to intervene and educating individuals who were unfamiliar with the facility’s protocols. Additional approaches were annual meetings with per-diem and part-time staff, identifying and in-servicing those staff when they first started working at the facility, and providing one-on-one in-services when feasible. Having more permanent staff, lower turnover, and an infection control coordinator at the NH facility were described as facilitators to IPC compliance.
Workload Many discussed how workload prevented CNAs from effectively carrying out every day IPC practices. A director of nursing from NH 10 described that, despite CNAs’ awareness of IPC practices, adherence was low because of increased workload and being in a hurry to finish one task and move on to another.
When asked for reasons why CNAs might not follow an infection control policy a CNA from NH 1 stated, “ I would say multitasking.” An IP from NH 10 discussed an example of workload resulting in poor hydration, “if a CNA is in a hurry maybe they get to work late, they have an extra resident today, so now they have nine residents instead of eight. And they came late so they’re a little bit rushed Or if they don’t offer enough fluids and then the urine just gets concentrated “ Solutions to overcoming barriers created by increased workload involved hiring more staff.
However, respondents noted that this approach would likely not result from a state inspection as a nurse from NH 8 stated, “the only real way that the state addresses inadequate staffing is if they come in and see that there is just a total lack of careIf they see that the residents are being taken care of, even though there are seventeen residents for one CNA, then they kind of overlook it and say it’s okay.”. Accountability Gaps in CNA accountability related to IPC were reported by many participants.
A director of nursing from NH 8 indicated that CNAs have the ability to effectively implement IPC, however, she went on to say: “I think you have to stay on top of the CNAs, making sure that they’re providing their care because they are not used to accounting for their behavior.” Additionally, an IP from NH 2 noted issues related to teamwork and being accountable for communicating about IPC, “I think CNAs have to understand that everybody is here to complement each other, but I don’t see them communicating. I know my charge nurses will communicate to environmental services. I’d like to see my nurse’s aide communicate a little bit more. I think they rely on the uppers to do that” In order to increase accountability, empowerment and inclusion activities were frequently discussed as key approaches to ensure that CNAs felt they were part of IPC initiatives. For instance, an administrator from NH 2 described the importance of providing CNAs with the tools and training to execute IPC practices, “from an administrative standpoint you want your staff to know what your policy and your system is so that they can put it into play when your nursing management is not in the building.” Additionally, a physician assistant from NH 1 discussed the importance of including CNAs in IPC “because they’re the ones that are doing the hands on care.”. Discussion In this study, CNAs were described as a diverse group whose challenges to implementing IPC effectively centered on language and culture, lack of knowledge and training, reliance on per-diem and part-time staff, high workload, and limited accountability.
While existing studies have described barriers to implementing quality care practices and maintaining compliance among CNAs, – none have examined barriers to IPC specifically. Our work explored IPC barriers qualitatively, allowing participants to give an account of the barriers they encountered and the strategies participants were using. There is a growing national trend toward diversity among CNAs and, compared to what was seen in the 1990s, this group is now less likely to be US-born., Furthermore, the demographics of CNAs have shifted from primarily non-Hispanic White to primarily Black, Hispanic, or other races/ethnicities. Our findings indicate that the diverse workforce of CNAs presented challenges to IPC and that additional resources/trainings were useful in improving IPC practices.
Steps that NH administrators have taken to respond to these challenges (i.e., translation of in-services and educational material) align with recommendations by the American Medical Directors Association (AMDA) to implement teaching methods that are sensitive to language and culture, yet such methods may still fall short of ensuring that CNAs understand IPC processes. In most states CNAs are required to hold a high school diploma or pass a GED equivalency exam as well as take an exam for CNA certification and to participate in on the job CNA training that covers infection control and the importance of hand washing. These credentials require reading and writing in English. However, based on what was described by participants in this study, a deficit still remains with regard to language and culture when CNAs are placed in NH settings. A review of current minimum educational requirements for CNAs may be warranted to ensure that CNAs are best prepared educationally, linguistically, and culturally to satisfy the requirements of their position. Further, it is important to take into account the variations of terminology and meanings across different cultures and the challenges that accompany comprehension of foreign terms and practices. This is critical, particularly as effective infection control also involves delivering communication (e.g., relaying health concerns to the correct personnel and addressing resident concerns).
The reiteration of important messages to CNAs was described as an important strategy to overcome such challenges. This may take the form of posting important reminders and messages in areas where CNAs can see them, providing CNAs with information cards that can be placed in work ID holders, and incorporating CNAs into team huddles.
While these extended activities can assist with CNAs’ ability to assess and deliver important information appropriately, addressing the CNAs’ communication responsibilities was only minimally discussed in this study. Therefore, additional research is needed to better understand the mechanisms CNAs can use to communicate resident assessments and needs. Lack of knowledge and training can also impact IPC practices among all NH personnel., In this study, knowledge was influenced not only by how much experience one had working in a particular facility, but also by the educational requirements of the position. Providing effective education for personnel who have differing educational backgrounds was a challenge. In another study investigating the educational needs of licensed NH nursing staff and CNAs who provide end-of-life care, lack of knowledge and skills and communication difficulties were also cited as major needs areas. AMDA recommends employing teaching methods that are sensitive to workforce personnel with varying educational levels.
Because IPs are key players in IPC education, including these personnel in cultural competency and sensitivity activities may be beneficial in addressing challenges in CNA knowledge and training. Additionally, IPC compliance related to training was particularly problematic when CNA staff were newer to the facility. In one study, CNAs reported that initial training only provided them with half of what they needed to know and they learned the remainder informally on the job.
Therefore, it may be beneficial for IP staff to develop CNA-focused IPC programs that span longer periods of time. However, despite reported IPC training that did focus on CNAs, compliance was said to have varied in this study, suggesting the need for further research on which mode(s) of teaching and preparation would be most effective for this group. Inability to maintain adequate staffing levels also affected CNA IPC practices.
Unfortunately, limited staffing is a prevalent issue in the nursing professions and is only expected to worsen in the future., This is particularly true in long-term care settings. Individuals over the age of 65 will make up 20% of the US population by the year 2050 compared to 13.7% in the year 2012. Therefore, the need for long-term care services is expected to grow with the increasingly large elderly population, thereby increasing the demand for more CNAs. CNAs who do not hold full-time status within NH facilities are instrumental in filling staffing gaps. However, providing this group with the tools, knowledge, and training necessary to carry out expected IPC practices has been a challenge. One strategy for connecting with per-diem and part-time CNAs includes engaging them immediately when they begin their day/night at the facility. For instance, per-diem and part-time staff may be provided with IPC updates, in-services, and trainings at a central location 15 minutes prior to the start of their shift.
Another important finding in our study was the suggestion to equip other staff with the ability to deliver IPC education as opposed to having IPs primarily responsible for this task. This approach can be particularly useful as IPs regularly work hours that do not fully align with the start of the CNA shift and those CNAs working off-shift. Moreover, additional attention to meeting the needs of CNAs and reaching them despite their sporadic schedules is necessary, as is holding per-diem and part-time staff to the same standards of full-time CNAs.
These strategies are important for maintaining consistent IPC practices. Without adequate staffing and sufficient per-diem and part-time personnel to fill staffing gaps, CNAs work in less than optimum conditions with increasing workloads. Given this reality, it is important to acknowledge that overworked staff pose a threat to resident safety and quality of care as the attention of CNAs can be diverted from important care areas related to infection control.
Studies have shown that inadequate CNA staffing is associated with poorer quality measures such as increased infection rates, increased deficiency citations, and decreased rates of resident influenza and pneumococcal vaccination. Despite quality care concerns found both in our study and others, – minimum staffing ratios for direct care staff are present in only 36 states and still fall short of Centers for Medicare and Medicaid Services recommended staffing ratios. Strengths and Limitations NHs were purposively sampled to achieve variation in location, size, and ownership status in our participant selection. Recruitment in this study continued until data saturation was reached across the entire NH sample for infection-related topics posed by the interview guides.
Confirmability was achieved through documentation of field notes upon completion of interviews. Credibility was achieved through peer debriefings and reflexivity, thus increasing the rigor and trustworthiness of our results. Important to note, CNA responses to questions about barriers and facilitators to effective IPC were limited compared with how other NH personnel responded. Despite being informed that all responses would remain confidential, CNA reluctance to discuss IPC barriers may have been due to fear of repercussions. Transferability of these results to other CNAs should be made with caution as a result. Additionally, although CNAs are required to speak, read, and write in English, there were limitations with language during the interviews which impeded communication. Last, because this was a secondary data analysis and the purpose of the primary study was to explore the overall phenomena of IPC, and not just as it relates to the CNAs, we were limited to the methods and design of the primary study and the study guides were not piloted with CNAs.
Future researchers investigating these phenomena more fully should consider piloting interview guides with CNAs and/or incorporating focus groups to facilitate CNA responses to questions about barriers of IPC. Conclusions These findings provide necessary information to guide the implementation of successful IPC policies and programs in NHs.
CNAs are in the frontlines of providing direct care in NHs and, therefore, they are key to implementing effective IPC activities in practice. CNAs in our study were described as being a highly diverse group. High turnover and understaffing increased the need for per-diem and part-time staff and also increased CNA workload.
Furthermore, holding CNAs accountable for IPC was deemed important. It is necessary to implement strategies designed for this diverse workforce to improve CNA work performance and overcome IPC barriers. Our findings provide information to guide the implementation of IPC policies and programs in NHs. Further research is needed to better understand IPC barriers that CNAs face and how these barriers may be effectively overcome.
Such studies will enable NHs to achieve reduction in HAI among their residents. Funding sources: This study was funded by the National Institute of Nursing Research (NINR) (R01NR013687, T32NR013454, F31NR015176). Received additional support from the Jonas Center for Nursing and Veterans Healthcare. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Jonas Center for Nursing and Veterans Healthcare. The authors would like to thank the research team (Nicholas Castle, Laurie Conway, Andrew Dick, John Engberg, Elaine Larson, Victoria Raveis, and Mayuko Uchida-Nakakoji) and our advisory board (Steven Schweon, Philip Smith, and Nimalie Stone) for their contributions to this study. Conflict of Interest: M.
Pogorzelska-Maziarz serves as a paid consultant to Becton, Dickinson and Company. The consulting work was not related to the research presented in this article. The remaining authors have no conflicts of interest to disclose. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript.
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Methods We conducted an uncontrolled, before and after, mixed-methods study in eight health facilities in Bo and Kenema Districts during December 2014 and January 2015. Quantitative methods administered to HCWs at baseline and follow-up included a survey on attitudes and self-efficacy towards IPC, and structured observations of behaviours. The intervention involved a workshop for HCWs to develop improvement plans for their facility. We analysed the changes between rounds in survey responses and behaviours.
We used interviews to explore attitudes and self-efficacy throughout the study period. Results HCWs described IPC as ‘life-saving’ and personal protective equipment (PPE) as uncomfortable for providers and frightening for patients. At baseline, self-efficacy was high (median=4/strongly agree). Responses reflecting unfavourable attitudes were low for glove use (median=1/strongly disagree, IQR, 1–2) and PPE use with ill family members (median=1, IQR, 1–2), and mixed for PPE use with ill HCWs (median=2/disagree, IQR, 1–4). Observations demonstrated consistent glove reuse and poor HCW handwashing.
The maintenance of distance (RR 1.09, 95% CI 1.02 to 1.16) and patient handwashing (RR 1.19, 95% CI 1.3 to 1.25) improved to 90%. Introduction Sierra Leone was profoundly impacted by the Ebola virus disease (EVD) epidemic in West Africa, documenting 14 122 cases and 3955 deaths.
Its first confirmed case in May 2014 led to the initial outbreak in the eastern districts of Kailahun and Kenema. From June to December, transmission spread to all districts and peaked at 600 confirmed cases weekly.
The incidence among healthcare workers (HCWs) became 100 times that of the general population, leading to the deaths of nearly 10% of the workforce. Poor infection prevention and control (IPC) serves as an efficient amplifier of transmission of viral haemorrhagic fevers (VHF). In primary healthcare facilities, also called peripheral health units (PHUs), HCWs lacked the supplies and training to apply rigorous symptom screening and IPC practices recommended for Ebola treatment units (ETU). Such deficits increased the risk of occupational and nosocomial infection for HCWs and non-EVD patients, respectively. The majority (66%) of HCW infections occurred in PHUs and hospitals.
As HCWs became infected, colleagues became frightened and demoralised, and the community's trust of the health system was further eroded. By August, grossly insufficient IPC led to the infection of 43 HCWs in Kenema district, mainly in Kenema Government Hospital, which had become a de facto ETU. To prevent EVD transmission in PHUs, the International Rescue Committee (IRC), WHO and Kenema's District Health Management Team provided IPC supplies including light personal protective equipment (PPE), and training to Kenema's PHUs near the peak of the district's outbreak in August 2014.
The training covered screening, isolation, referral, hand hygiene, use of light PPE, sharps management, environmental cleaning and waste disposal. The epidemic continued to spread rapidly and geographically. Nearly all PHUs remained open, albeit with substantially reduced staffing and services. A rapid assessment of PHUs in six districts found deficiencies in the identification and isolation of suspected cases, scarcity of supplies (PPE, chlorine, water and incinerators) and delays in referral of suspected cases to ETUs.
This led the Ministry of Health and Sanitation, the IRC-led Ebola Response Consortium, UNICEF and the US Centers for Disease Control and Prevention (CDC) to train HCWs in IPC in all 1180 PHUs across 14 districts nationally, between October and December 2014. The effort was paired with a quality assurance programme to monitor inventory, structures and practices on an ongoing basis.
To learn from this experience and evaluate attitudes, experiences and the effects of an improvement workshop on behaviours, we conducted a mixed-methods study with multiple objectives. The primary objective was to generate insights into how IPC behaviours can be improved in a short time frame during an EVD outbreak. A secondary objective was to assess HCW attitudes, self-efficacy and experiences with IPC practice. Another secondary objective was to evaluate the effectiveness of participatory workshops to develop improvement plans, through the measurement of changes in adherence to IPC protocols. The primary outcome measures of effectiveness were the proportion of correct IPC behaviours within the domains of prescreening, donning, screening, doffing and consultation. Study design, setting and participants Using a participatory action framework and a mixed-methods approach, we conducted a single group, pretest post-test study (also called an uncontrolled before and after intervention study) in Bo and Kenema districts in December 2014 and January 2015. The districts were at different phases of the epidemic.
In Kenema, the epidemic had peaked, and by December, there were fewer than two cases per week. Bo's first cases were reported in July 2014, and by December, transmission dropped from 20 to 40 cases to 10 cases per week. The national IPC trainings led by the Ministry of Health and Sanitation and the Ebola Response Consortium were completed ∼1 week before the data collection for this study began in December 2014. There were two phases of the study where data were collected: a baseline period (10–20 December 2014) and a follow-up period 3 weeks later (7–16 January 2015). The study's intervention consisted of a participatory workshop in each district immediately following the baseline period and attended by HCWs, district health officials, community health officers (CHOs, who are main healthcare provider at the PHU level) and community representatives.
At this workshop, participants reviewed baseline data on IPC practices, attitudes and risk perception, and they developed improvement plans for each PHU. At baseline and follow-up, we conducted self-administered surveys with HCWs exposed to the intervention and who were present at the PHUs to assess demographics, attitudes and self-efficacy towards IPC. Also, at baseline and follow-up, we measured HCW's adherence to IPC protocols using structured observations of patient encounters. During both periods, in-depth interviews (IDIs) were conducted to explore attitudes and self-efficacy towards IPC, and experiences with IPC (without attempts to compare periods). This included vignettes where HCWs were asked how they would act in three situations related to IPC in their professional and personal lives.
We used stratified random sampling to select PHUs from a sampling frame of 121 PHUs in Kenema district and of 110 PHUs in Bo district. We stratified by urban/rural setting and any/no suspected cases at the PHU level, to maximise variation. One facility was randomly chosen from each stratum in each district resulting in a total of eight participating PHUs. At least four HCWs across a range of roles were included in the IDIs at each facility as most facilities had no more than four staff. This formed the purposive sample for the survey. Sample sizes for the observations were not calculated a priori due to the fact that observers could be present in PHUs for a limited time period and therefore could capture a limited number of observations. A timeline of the methods is presented in.
Data collection and measurement Two observers and eight qualitative interviewers per district were trained for 2 and 3 days, respectively. Three co-investigators trained the interviewers and supervised data collection (LSH, RA and HB). Research tools were piloted in PHUs that were not selected for study. The survey was self-administered to the HCWs available on that day.
Ipc West Study Guide Pdf
For the structured observations, teams of two observers watched HCW–patient encounters for 5 hours on a single day at each PHU. Behaviours were recorded for each domain in the national protocol (patient screening, donning and doffing of PPE, patient consultation, isolation of patients screened positive, donning and doffing of PPE for isolation, and dead body management). Data were collected with smartphones using Magpi software (Datadyne, Washington, DC, USA). If a behaviour was clearly a hazard (ie, HCW attempts to touch the patient without gloves), observers were instructed to intervene. IDIs were conducted in Krio and Mende by one supervisor and three interviewers per district, digitally recorded and typed verbatim in Krio or Mende. They lasted for 30–60 min. The transcripts were translated from Krio and Mende to English.
Data analysis Data were analysed and interpreted concurrently using a convergent-parallel design to integrate findings across methods. Quantitative analysis of the survey and structured observations was conducted using Stata V.14 (StataCorp LP, College Station, Texas, USA). For the survey, responses on a four-point Likert item scale were summarised using the median and the IQR. Since HCWs were selected based on their availability, some HCWs may have changed between rounds.
Since pairing was not possible, distributions of responses at baseline and at follow-up were compared using the Wilcoxon rank-sum test. For the structured observations, the proportion of correct behaviours for each task and the changes between rounds were computed. The main exposure and outcome were the time period (baseline vs follow-up) and the proportion of correct behaviours, respectively. A log-binomial model was used to estimate risk ratios (RR) for each correct behaviour at baseline and follow-up. Generalised estimating equations (GEE) with robust SEs accounted for repeated measures among HCWs and clustering within PHUs. An exchangeable working correlation structure was assumed. For all statistical tests, a significance level of p.
Results The survey was administered to 35 HCWs at baseline and 33 HCWs at follow-up in 8 PHUs. Twenty-two (63%) of the 35 HCWs were the same between rounds, based on profession, age and sex. There were no confirmed cases among HCWs in the sampled PHUs during the study period. Participants included CHOs, community health nurses (CHNs), maternal child health aides (MCHAs) and community health assistants (CHA). Half were below 40 years of age, and half were women.
The majority (77%) were trained through the national IPC training, and 43% had already screened patients. In total, 54 IDIs were analysed.
Three recordings were lost, but saturation had been reached before completion of the available transcripts. All field notes were reviewed to ensure no new themes emerged.
Implementation of the workshop intervention Each district conducted a daylong workshop. HCWs, health authorities and community members identified key themes in the data. They developed causal diagrams and matrices, to link IPC challenges to potential solutions, and improvement plans for each PHU that aimed to improve IPC within 3 weeks. Solutions ranged from specific and attainable (eg, obtaining PPE for safe deliveries) to broad and more distal (eg, improving the water supply).
Owing to the competing priorities of the emergency response, improvement plans were not always completed within 3 weeks. Risk perception, attitudes and self-efficacy Survey results did not change significantly between rounds; we report the baseline results in the text and the full results in. Respondents believed that they had an increased risk of infection compared to the public (median=4 (strongly agree), IQR, 3–4). There was slight disagreement with the false statement that children posed a lesser risk of transmission as adults (median=2 (disagree), IQR, 2–3). HCWs described difficulty in recognising how the risks of infection for EVD and other diseases differed. As EVD was described as an epidemic, ‘it would not last for long and that maybe after one or 2 months it will all be over and gone’ (Female state enrolled nurse, Bo). When asked if they would avoid the use of gloves to treat ‘non-Ebola’ patients and PPE to treat family members for any condition, HCWs indicated strong disagreement with these statements (median=1 (strongly disagree), IQR, 1–2).
Overall Bo Kenema Baseline 35 Follow-up 33 Baseline 16 Follow-up 16 Baseline 19 Follow-up 17 No. Of respondents Median.
(IQR) Median (IQR) p Value† Median (IQR) Median (IQR) Median (IQR) Median (IQR) Self-efficacy I can correctly identify suspected Ebola cases using the screening flow chart. 4 (3–4) 3 (3–4) 0.35 4 (3–4) 4 (3–4) 4 (3–4) 4 (3–4) I can remove PPE after isolating a suspected Ebola case without infecting myself. 4 (3–4) 3 (3–4) 0.52 4 (3–4) 3 (3–4) 4 (3–4) 3 (3–4) I can safely disinfect a room where a suspected Ebola case has been isolated to remove any risk of infection to myself or other. 4 (3–4) 4 (3–4) 0.25 4 (3–4) 4 (3–4) 4 (3–4) 3 (3–4) There is enough PPE at my facility to protect us from being infected with Ebola. 4 (3–4) 3 (2–4) 0.21 3 (3–4) 3 (2–4) 4 (3–4) 4 (3–4) Attitudes and risk perception I am at higher risk of becoming infected with Ebola because I work in a health facility.
4 (3–4) 4 (3–4) 0.51 4 (3–4) 4 (3–4) 4 (3–4) 4 (3–4) I am less likely to become infected with Ebola when taking care of children than adults. 2 (2–3) 2 (1–3) 0.87 2 (2–3) 2 (2–4) 2 (1–2) 2 (1–3) If my colleague is sick it would be cruel to use PPE when treating him/her.
2 (1–4) 1 (1–3) 0.4 2 (1–4) 1 (1–2) 2 (1–4) 2 (1–4) I do not need to use PPE when taking care of a family member with a fever, headache, diarrhoea and nausea. 1 (1–2) 1 (1–2) 0.87 1 (1–2) 1 (1–2) 1 (1–4) 1 (1–2) I do not need to wear gloves when I take care of non-Ebola patients. 1 (1–2) 2 (1–2) 0.29 1 (1–2) 1 (1–2) 2 (1–2) 2 (1–2). HCW, healthcare worker; IQR, interquartile range; PPE, personal protective equipment. HCWs described PPE as uncomfortable, hot and causing sweating and itching, yet at the same time, ‘precious, lifesaving, necessary for protecting oneself and one's family’. On balance, “it's better that you overheat but are protected than that you get fresh air and become contaminated.
I choose to be hot but protected” (Female CHO, Bo). A recurrent theme was that HCWs regretted the physical distance with their patients caused by PPE. There was disagreement among HCWs regarding the statement, ‘it would be cruel to use PPE when treating a sick colleague’ (median=2 (disagree), IQR, 1–4). However, a vignette to elicit perspectives on the management of an ill HCW suggested correct behaviours. HCWs most often reported that they would tell an infected colleague to isolate herself (‘put her in observation’, ‘don't touch her’, ‘tell her not to touch anybody’) or they would refer her to an ETU (‘call the emergency line’, ‘get that ambulance to take her away’, ‘encourage her with kind words while she is being referred’).
While acknowledging that it would be an upsetting experience (‘she will feel the stigma of the Ebola, she will be shedding tears, as will we’), most insisted on isolating or using PPE to treat her: “She is my colleague and friend and when the Ebola finishesI will apologize to her, but (for now) I will not touch her, I won't do it, before all of us die, let one die so that others can live” (Female MCHA, Kenema). Most HCWs expressed self-efficacy in identifying cases, removing PPE, and disinfecting a room after identification of a suspected case (see ). HCWs described five prevailing emotions that influenced the maintenance of care: disbelief, dread, fear, sadness and determination. Fear was described with the most depth and nuance, followed by sadness. Their self-efficacy developed after a gradual acceptance of the threat and after receiving training, supplies and undergoing practice. HCWs described how their own attitude or knowledge has changed after the training saying, for instance, ‘Now I feel like I have to be careful in everything I do’ (Female CHN Bo). Several HCWs, particularly those engaged in childbirth, described discontinuing work at the outset, but resuming services with confidence once they received training and PPE stocks: Let me say the truth, before Ebola, we were working hard but we were careless in terms of IPC.
As for me, the only time I used to wear gloves was during deliverythe use of chlorine for hand washing was not commonWe had no idea about the use of wearing of goggles, facemasks, PPE and gownsNow with the epidemic of Ebola, hand washing is widely practiced. (Female MCHA, Kenema) Most HCWs mentioned that for their IPC to be effective, community sensitisation was essential. PPE induced fear among patients, evoking images of burial teams and ‘memories of brothers and sisters taken by Ebola’ and ‘buried by these people’. Sensitisation by HCWs was reportedly impeded by restrictions on their movement, inaccessibility of communities, finances and a resistance from community members: They are really been panicked to comethey will stand at the gate and start to talk to themselves in fear of the booths that we have constructed. But we are still sensitizing them to continue coming. (Female MCHA, Kenema) HCWs tried to counteract patients’ fears by counselling them individually to understand the rationale behind the use of PPE: When the patients come, they sit down. Before we start our work, we talk to them, “Now, you see me as I am, I am alright.
I am going to dress in order to protect myself, and protect you. May be I am sick but you are not aware. I would be talking to you may be the spit from my mouth jumps to your face or whatsoever or your nose or your eye being that they are closer to me, if I had the disease, you will have it.
Or in case I am asking you questions then your child throws up or coughs, I will be infected. So for this reason I am going to put on these dressings. Don't see me and be afraid.
I am trying to protect myself and protect you so that I won't infect you and you also will not infect me. (Male MCHA, Bo) HCWs mentioned three further threats to self-efficacy. First, HCWs doubted the differential diagnosis for suspect cases: “typhoidmalariaLassa have signs of Ebola” (Female CHO, Bo).
Second, respondents at follow-up remained concerned about PPE shortages (median=3 (agree), IQR, 2–3). Third, HCWs emphasised that while conducting IPC, they continued to deal with a disrupted health system: There is no toilet, no water well, no network coverage, no means of transportation these are our problems. And you tell a person to wash their hands at the facility, but this is not easy without water. Adherence to IPC behaviours The proportions of correct behaviours and RRs comparing the proportion of correct behaviours between baseline (90 screenings and 54 consultations) and follow-up (131 screenings and 32 consultations) are shown in (see online (Final annexratnayake.pdf) for results stratified by district). No suspected cases or dead bodies were observed; therefore, all observations relate to the screening of patients and subsequent consultations. During prescreenings, only one instance of HCW handwashing was observed. The proportion of HCWs asking patients to wash their hands (RR 1.45, 95% CI 1.16 to 1.8) and patients doing so on prompting from the HCW (1.49, 1.19 to 1.86) increased.
Patient handwashing, with or without HCW prompting, increased though not significantly from 82% to 99% (RR 1.21, 95% CI 0.95 to 1.71). HCWs frequently mentioned patient handwashing as straining on the HCW–patient relationship: When they come and you tell them to wash their hands, they make comments like, “What about you, do you wash your hands every day?”the concept that behaviour should be changed, it is not really easy, it is difficult. (Female CHO, Kenema).
Supplementary data HCWs wore boots and face masks more than 60% of the time at baseline and more than 80% at follow-up (boots, RR 1.51, 95% CI 1.14 to 1.99; face masks, RR 1.27, 95% CI 1.03 to 1.58). Donning in the correct order increased ninefold from baseline (3%) to follow-up (56%) (RR 8.94, 95% CI 0.84 to 95.61). In 20% of screenings at follow-up, additional HCWs were present in the screening area (which is not recommended; RR 0.86, 95% CI 0.69 to 1.07). Virtually all HCWs stood 1.5 m from patients, increasing from 91% to 99% at follow-up (RR 1.11, 95% CI 0.83 to 1.48). Twice as many HCWs sat sideways towards patients to avoid bodily fluids (23% vs 57%, RR 2.3, 95% CI 1.34 to 3.95). There was a marked decrease from 91% to 12% of HCWs holding thermometers at the recommended distance of 5–6 cm from patients (RR 0.23, 95% CI 0.12 to 0.43). Across rounds, the temperature check was applied without questioning for symptoms and risk factors if afebrile.
In no case did a screener ask a patient about all symptoms and risk factors. HCWs described questioning as necessary to ‘determine the epidemiological link’ for case identification. Still, questioning patients was not viewed as particularly effective because individuals could ‘deny and hide the (link)’. Some differences between baseline and follow-up regarding the doffing procedure were significant, including removing light PPE and gloves (light PPE, RR 2.54, 95% CI 1.32 to 4.88 and gloves, RR 4.09, 95% CI 1.34 to 12.49) and completion in correct order (RR 6.64, 95% CI 2.09 to 21.14). Doffing was compromised by the fact that a low proportion of HCWs removed PPE between screenings (14% at baseline and 32% at follow-up).
Proportions of glove removal postscreening increased, but remained low (10% at baseline, 22% at follow-up). This was accompanied by a lack of handwashing of gloved or ungloved hands between screenings (11% at baseline, 19% at follow-up). HCWs expressed concern about PPE stock-outs, as well as the strain on incinerators that frequent glove and PPE disposal would cause. Among the 29 HCWs that removed gloves, all completed doffing in the correct order at follow-up.
For consultations, low proportions of HCWs washed their hands before treating a patient (15% at baseline, 10% at follow-up) or after (39% at baseline, 16% at follow-up). Most HCWs put on a new pair of gloves at baseline (93%) and follow-up (91%), and a few kept the gloves on after treating the patient. Most HCWs stayed 1.5 m from patients (65% at baseline, 91% at follow-up). HCWs, healthcare workers; IPC, infection prevention and control; PHUs, peripheral health units; PPE, personal protective equipment. As Sierra Leone's recovery plan intends to make all PHUs compliant with national IPC protocol, understanding how behaviours can be optimised will be paramount in achieving this goal. EVD's re-emergence in Sierra Leone in January 2016 may have led to nosocomial transmission due to the patient's treatment seeking at a hospital.
This underlines that the international community must continue to develop and support IPC in West Africa, in addition to surveillance and outbreak response mechanisms, to address future epidemics. Handling editor: Valery Ridde. Twitter: Follow Lara Ho at Contributors: LSH, LM and RR developed the research idea.
LSH, RR, HB, MB, RA and TK designed the study. HB, RA, LSH and LM undertook the implementation and data collection. RR, SM and LSH analysed the data.
All authors interpreted the data, drafted or revised the paper and gave final approval for the paper to be published. Funding: This work was supported by the Research for Health in Humanitarian Crises (R2HC) Programme, managed by ELRHA (SCUK—accountable grant number 13488). The Research for Health in Humanitarian Crises (R2HC) programme aims to improve health outcomes by strengthening the evidence base for public health interventions in humanitarian crises. Visit for more information. The £8 million R2HC programme is funded equally by the Wellcome Trust and DFID, with Enhancing Learning and Research for. Humanitarian Assistance (ELRHA) overseeing the programme's execution and management. The funder had no role in study design, data collection, analysis, interpretation or writing.
Competing interests: MB reports grants from the International Rescue Committee (IRC), during the conduct of the study. SM reports personal fees for conducting analysis from the IRC, during the conduct of the study. Patient consent: Written consent was obtained from healthcare workers.
Ethics approval: The study received ethics approval from Durham University's Institutional Review Board and the Sierra Leone Ethics and Scientific Research Committee. Provenance and peer review: Not commissioned; externally peer reviewed. Data sharing statement: Owing to ethical restrictions related to confidentiality, data are available on request by contacting Ruwan Ratnayake (ruwan.ratnayake@rescue.org).