Paul Elliott (Editor) - Julie Storr (Editor) - Annette Jeanes (Editor) - Infection Prevention and Control - Perceptions and Perspectives-CRC Press (2016)

Infection Prevention and Control
PERCEPTIONS AND PERSPECTIVES

Edited by
PAUL ELLIOTT
RGN, BSc, MA, PGCEA, FHEA
Senior Lecturer in Adult Nursing and Infection Control
School o f Nursing, Faculty o f Health and Wellbeing
Canterbury Christ Church University, Kent
JULIE STORR
BN (Hons), RGN, MBA
Director, S3 Global
Consultant, World Health Organization
Past President, Infection Prevention Society
S3 Global, London
ANNETTE JEANES
RGN, MSc, Dip N, Dip IC
Director o f Infection Prevention and Control
Consultant Nurse, Department o f Infection Control
University College London Hospitals NHS Foundation Trust
Forewords by
P R O F E S S O R BA R R Y C O O K SO N
Honorary Professor
Epidemiology & Population Health Faculty
London School o f Hygiene and Tropical Medicine
P R O F E S S O R B E N E D E T T A A LLEG R A N Z I
Lead, Clean Care is Safer Care and Infection Control Programme
Service Delivery and Safety Department
World Health Organization
Geneva
A D J P R O F E S S O R M A RILYN C R U IC K SH A N K
Director, National Healthcare Associated Infection Program
Australian Commission on Safety and Quality in Health Care
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© 2016 Paul Elliott, Julie Storr and Annette Jeanes

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Contents
Foreword by Barry Cookson v

Foreword by Benedetta Allegranzi vii
Foreword by Marilyn Cruickshank ix
Preface xi
About the editors xiii
List of contributors xv
Acknowledgements xvii
Part I: Perspectives of infectionpreventionand control 1

1 Motivation and leadership in infectionprevention andcontrol 3
Annette Jeanes
2 Just infection prevention and control 15

Julie Storr
3 Leadership, quality, efficiency and productivity in infection control 29

Tara Donnelly
4 Infection prevention and control in the operating department: a
student's perspective 43
Taraneh Azizi
5 The lament 51
Harley Farmer
Part II: Perceptions of infectionprevention andcontrol 61

6 Stereotyping 63
Paul Elliott
7 Out-of-hospital infection prevention and control: a paramedic

perspective - could we do better? 79
Paul Vigar
8 Antibiotics: help or hindrance? 93

Sarah Pye and Clare Hancock
iv CONTENTS
9 The impact of Clostridium difficile infection on patients and their

families 111
Graziella Kontkowski
10 The challenge we all face together 117

Derek Butler
Part III: Possibilities for infection prevention and control 123

11 No stone left unturned: the relevance of the neurosciences to
infection prevention and control 125
Julie Storr
12 Infection prevention and control education and training: research

findings and an electronic learning experience for undergraduate
students 135
Debra Teasdale and Paul Elliott
13 Increasing the value and influence of infection prevention and control

specialists 155
Annette Jeanes
14 The use of marketing in infection prevention and control 167

Annette Jeanes
15 Patient and healthcare worker empowerment 175

Maryanne McGuckin
16 The role of healthcare culture in patient safety 189

Dave Grewcock, Aidan Halligan and Yogi Amin
17 Is outcome surveillance of healthcare-associatedinfections really

necessary? 197
Nizam Damani
Conclusion 207
Index 209
Foreword by Barry Cookson
Healthcare-associated infection and the related issues of antimicrobial resistance

were considered for many years to be Cinderellas of medicine and public health.
When I was first employed by the Public Health Laboratory Service in 1990 they did
not even appear in that organisation’s first business plan. Both are now recognised
as major global threats to patient safety and national economies.
An interesting question to ask of any healthcare worker is which books changed
their lives. For me it was Balint’s The Doctor, His Patient and the Illness1and for some
of my nursing colleagues, it was Walsh and Ford’s Nursing Rituals, Research and
Rational Actions.2 Both are, of course, many years out of date, but still worth read
ing today, emphasising as they do the sociological aspects of the art of medicine.
This book, I would predict, will serve in a similar role to countless infection
prevention and control practitioners. The editors, three experienced healthcare
educators, have led by example in writing, and gathering together, a very talented
and expert multi-disciplinary group of fellow authors to produce a provocative
and highly stimulating book. Indeed, it should be essential reading for infection
control-related courses, and the exercises that are included will serve well for prac
titioners’ continuing professional development for years to come. The references
are well-chosen, many of which would otherwise be hard to find. Readers will best
benefit if they have a good background knowledge of the evidence base for infection
prevention and control and related issues of antimicrobial stewardship.
If used in these ways, the book will make a major contribution in helping to
develop infection prevention and control specialists with the competencies to work
within a multi-disciplinary orchestra of healthcare workers capable of preventing
and controlling the multi-faceted problems posed by healthcare-associated infec
tion and antimicrobial resistance. This book also points out that this orchestra must
be aware that their audience: the patients, their families and representatives, have a
key role to play in informing how best to deliver healthcare and infection prevention
and control services. We will then be equipped to address proactively and reactively
as required, the ‘highly complex combination of physical, psychological and social
processes’ described in this admirable book.
v
vi FOREWORD BY BARRY COOKSON
Professor Barry Cookson

Honorary Professor
Epidemiology & Population Health Faculty
London School of Hygiene and Tropical Medicine
July 2 0 1 5
REFERENCES
1 Balint M. The Doctor, His Patient and the Illness. 2nd ed. London: Pitman; 1964. Millennium
Edition. Edinburgh: Churchill Livingstone; 2000.
2 Walsh M, Ford P. Nursing Rituals, Research and Rational Actions. Oxford: Heinemann
Nursing; 1989.
Foreword by Benedetta Allegranzi
Infection prevention and control (IPC) is vital in saving lives. As the lead for the IPC
Programme Clean Care is Safer Care at WHO, I am committed to supporting those
working every day to play a critical role in patient and health worker safety through
IPC improvements. The evidence tells us that multifaceted approaches will prevent
the avoidable infections that occur across the world every year. But from under
standing determinants and risk factors to measuring outcomes, IPC is a complex
science and gaps remain in the evidence base, particularly through good-quality
research. While we need to accelerate the research that will allow more lives to be
saved in every country, this should not paralyse us in considering and challenging
current realities. In part, this book starts a journey of thinking differently about IPC
and offers both stimulation and some innovative solutions going forward.
Leadership, culture, marketing, matters of justice, neuroscience and patient and
family perspectives are not traditionally the predominant themes that stand out
in a book on IPC. Indeed the conventional focus of the specialty has been heavily
weighted towards what can be considered technical, scientific matters - struc
tural, organisational and policy-related aspects of healthcare-associated infection,
grounded in microbiology. This book complements the science, it brings humanity
to IPC, intended to make us think, pause for a second, step outside the technical
and consider the social value of what we do every day. It is refreshing to see a shift
in focus.
Therefore, while acknowledging that in order to provide the highest quality of
prevention and care to patients it is important to base approaches and interventions
in the hardest science available, in parallel we must continue to consider the holistic
aspects of IPC, open our mind to new perspectives - challenge the status quo and
increasingly give a stronger voice to those who receive healthcare, including those
who suffer harm. This book is bold in attempting just that.
What I particularly like about this book is that it perfectly illustrates the diversity
of IPC. A number of the authors have worked with me personally at the interna
tional level and are acknowledged experts in the field. Through this book, all of
them bring experiences and reflections that could be described as a breath of fresh
Vii
viii FOREWORD BY BENEDETTA ALLEGRANZI
air. We hear from student nurses and lecturers, hospital managers and leaders, a
paramedic, academics and patients and their families.
This book should be welcomed and applauded for trying to shake up our think
ing and make us question how we think and what we normally do. I sincerely hope
it inspires some of you to think differently and of course act differently in the quest
to save people from the devastation of healthcare infection.
Professor Benedetta Allegranzi

Lead, Clean Care is Safer Care and Infection Control Programme
Service Delivery and Safety Department
World Health Organization
Geneva
July 2 0 1 5
Foreword by Marilyn Cruickshank
Patients expect safe, high-quality healthcare and their expectations are generally
fulfilled. However, far too many patients acquire an infection during their encounter
with the health system.
Growing public awareness through the media and public reporting of infection
rates have led to more urgent action on specific risks by policy makers seeking
answers to previously rising infection rates. The growth of multi-resistant organisms
within the health systems makes the need for action more urgent as the miracle of
antibiotics as a panacea becomes less reliable. Resistance may occur within months
of the release of a new antimicrobial, and resistance is outstripping drug discovery
and the development of new antimicrobials. The world is now facing the very real
possibility of a return to non-treatable infections, severe limitations on medical
procedure and escalating healthcare costs. Complex medicine such as organ trans
plantation, neonatal survival, intensive care and complex surgery may no longer
be viable rather than everyday occurrences should antimicrobial resistance gain a
hold in our health systems.
There are many strategies available for health systems to reduce infections
involving systematic, national responses to infection control, hand hygiene and
antibiotic stewardship. Bringing together policy makers and clinicians has been
found to contribute to successful outcomes in the implementation of change man
agement programs in reducing infection.
Improvement in technology provides tools for those charged with preventing
infections to look beyond some of the tried and true methods of infection preven
tion. Building design can enhance good practice by providing single rooms and
bathrooms for hospitalised patients; minimising patient transfers especially in
multi-patient wards can also have an impact on infection spread; sufficient nursing
staff numbers can also contribute to infection prevention.
Leadership at all levels of the health system, from national to hospital and within
the infection prevention team, must be one of the single most powerful mechanisms
to achieving change within the healthcare system. The opening chapters of this
publication provide the infection control practitioner with an insight into effecting
iX
x FOREWORD BY MARILYN CRUICKSHANK
change in their environment through good management practices and appreciating

the value of true leadership qualities. Without effective management and leadership
there can be no improvement.
Challenges to improvement are many, and not least is our inability to provide
randomised controlled evidence for all our practice. Using a common sense
approach which according to one of my close colleagues is not so common can also
be fraught with difficulty.
The prevention and control of healthcare associated infections is an essential ele
ment of patient safety and is the responsibility of all who provide care for patients,
not just the infection control team. Infections are no longer considered an accept
able complication but rather an adverse event. Although not all may be preventable,
it is possible to significantly reduce the rates preventing pain and suffering in
patients as well as freeing up valuable bed days and clinician time.
It is heartening and joyous to read through this publication, not focused on the
technical aspects of infection prevention, but focused on other just as pertinent
skills that will result in doing great work for patients.
Adj Professor Marilyn Cruickshank RN, PhD, FACN

Director, National Healthcare Associated Infection Program
Australian Commission on Safety and Quality in Health Care
Sydney, NSW
July 2 0 1 5
Preface
The adoption of appropriate infection prevention and control practices remains a

significant problem within not only medicine, health and social care but also within
our wider society at a global level, despite there being a significant and growing
evidence base indicating the impact of the right practices on patient outcomes.
Yet, despite this, compliance with safe infection prevention and control policy,
education and published information remains less than satisfactory and much to
the potential detriment of ourselves, our colleagues and the general population.
Further, much of the published literature, although acting as a consistent reminder
to us all, in many ways simply regurgitates the same information on a consistent
basis, which really does not serve to move things forward in a positive way.
With these points in mind, this book sets out to offer some new perceptions
and different perspectives related to infection prevention and control that may not
have previously been considered and, in some cases, may seem left of centre. This
is a very deliberate attempt to challenge us all to consider the status quo and to
stimulate fresh ideas about where the specialty goes next. In reading through each
of the chapters you will see that they are very individualistic and offer some unique,
challenging and in some cases moving perspectives with regard to how each of the
chapter authors perceives infection prevention and control, and from backgrounds
you might not necessarily expect.
Further, as you read through the various chapters you will see that not all are
referenced or, for that matter, particularly academic in nature. With regard to this,
we, the editors, felt that where perceptions and perspectives were concerned it is
not always necessary to be overly academic, because, where some of the chapters are
concerned, it has more to do with the humanity of what contributors have written.
In reading through each of the chapters it is hoped that this book will provide you
with the opportunity to reflect upon each contributor’s perception and/or perspec
tive, and we would ask that you will take each chapter on its own merits and allow
the limits of your thinking to be challenged.
Xi
xii PREFACE
LEARNING OUTCOMES
In reading through the chapters of this book you will have the opportunity to:
• reflect upon a number of differing approaches to infection prevention and
control
• consider what the future of the specialty might hold for specialists, educational
ists, practitioners and the public
• reflect upon your own attitudes and beliefs in relation to infection prevention
and control
• reflect on the potential to use skills developed in infection prevention and con
trol within other areas of professional practice
• recognise the constant changes in healthcare delivery that require continuous
ongoing development for not just infection prevention and control practition
ers, but all those involved in the provision of healthcare, irrespective of their
appointment or role.
• facilitate and empower yourself to challenge the status quo, push the limits of
infection prevention and control thinking and to reflect upon conventional
wisdom.
Paul Elliott, Julie Storr, Annette Jeanes

July 2 0 1 5
NOTE FROM THE EDITORS

With regard to each of the chapters in this book, should you wish to offer comment
on the content then it is requested that you contact the individual contributor(s)
directly.
Further, within each of the chapters the contributors’ thoughts are theirs and do
not necessarily reflect those of the editors or other contributors.
About the editors
Paul Elliott commenced his initial nurse education in 1971 at Royal Air Force
Hospital Ely. Following this, the first half of Paul’s professional career was spent
serving in the Royal Air Force, undertaking a variety of roles within acute, commu
nity settings, aeromedical evacuation and field deployments. Following retirement
from the Royal Air Force in 1985, Paul spent a number of years within the National
Health Service and in 1991 he moved into higher education, which is where his
career has continued to develop. Paul’s primary research interests centre on the
psychological aspects of infection prevention and control, and he has a range of
publications and conference papers within this area. With regard to his current
appointment, Paul is a Senior Lecturer in Adult Nursing and Infection Control
within the School of Nursing at Canterbury Christ Church University in Kent.
Julie Storr graduated as a nurse and health visitor from the University of Manchester
in 1990. Julie worked as a clinical nurse before specialising in infection prevention
and control at Scunthorpe and Goole Hospitals NHS Trust and then the Oxford
Radcliffe Hospital NHS Trust. In 2002 she was invited to join the National Patient
Safety Agency as Assistant Director of Infection Prevention and directed the award
winning cleanyourhands™campaign. Based on this work, in 2005 she was asked
to take a lead role with the World Health Organization (WHO) on its First Global
Patient Safety Challenge, pilot testing the WHO Guidelines on Hand Hygiene in
Health Care in South East Asia and Latin America. Since 2009 she has worked
for WHO’s African Partnerships for Patient Safety programme and more recently
within its Service Delivery and Safety Team as part of the Ebola response and
recovery effort in West Africa. Julie is a trained clinical hypnotherapist. She is on
the steering group of the charity HIFA (Health Information for All) and is studying
for a doctorate in public health (healthcare leadership and management) at Johns
Hopkins Bloomberg School of Public Health, in Baltimore, Maryland. She is an
external examiner at University College Cork. She sits on the editorial advisory
board of the Journal o f Infection Prevention and is currently a director of S3 Global.
Xiii
xiv ABOUT THE EDITORS
Annette Jeanes is currently the Director of Infection Prevention and Control

and Consultant Nurse Infection Control at University College London Hospitals.
She has worked at several London hospitals in intensive care, infectious diseases,
medicine and surgery. She has acted as an external advisor to a number of national
groups and forums. Her current research focus is improving hand hygiene compli
ance monitoring and performance. Other areas of interest include infection control
in sport, cleaning in healthcare, reducing infection in surgical wounds, and the
value of motivation and leadership in healthcare.
List of contributors
Yogi Amin Tara Donnelly

BSc, MB, ChB, FRCA Director - Quality, Efficiency and
Consultant in Neuro-Anaesthesia Productivity Programme, University
and Neuro-Intensive Care, National College London Hospitals NHS
Hospital for Neurology and Foundation Trust
Neurosurgery, University College
London Hospitals NHS Foundation Harley Farmer
Trust PhD, BVSc(Hons), BVBiol(Path),
Honorary Senior Lecturer, The UCL MRCVS
Institute of Neurology, University Virologist and Chief Executive Officer,
College London NewGenn Limited
Taraneh Azizi Dave Grewcock

BSc (Hons), Operating Department Head of Education Research and
Practice, RODP (HCPC) Development, University College
Student SIG Lead, Association for London Hospitals NHS Foundation
Perioperative Practice Trust
Royal United Hospitals Bath NHS Trust
Aidan Halligan
Derek Butler MB, BCh, BAO, BA, MA, MD
Chairman, MRSA Action UK Director of Education, University
Professional Engineer Nuclear Industry College London Hospitals NHS
Engineer, Westinghouse Electric Foundation Trust
Company Chief of Safety, Brighton and Sussex
University Hospitals NHS Trust
Nizam Damani
MBBS, MSc, PRCPath, FRCP1, CIC, Clare Hancock
DipHIC MPharm, MRPS
Associate Medical Director: Infection Clinical Pharmacist, The Royal Surrey
Prevention and Control, Craigavon County Hospital NHS Foundation
Area Hospital, Northern Ireland Trust
xv
xvi LIST OF CONTRIBUTORS
Graziella Kontkowski Debra Teasdale

Clostridium Difficile Support Group, MSc, PGCLT, BSc, RN
London Dean of the Faculty of Health and
[email protected] Wellbeing, Canterbury Christ Church
University, Kent
Maryanne McGuckin
FSHEA Paul Vigar
President, McGuckin Methods BSc (Hons), PGCLT (HE), MC Para,
International (A Patient Safety FHEA
Organization) Senior Lecturer, Paramedic Science,
Lead author of Patient Empowerment Canterbury Christ Church University,
section of WHO Guidelines on Hand Kent
Hygiene in Healthcare (2009) Patient Paramedic Practitioner, South East Coast
Safety Ambulance Service NHS Foundation
Former faculty member, University of Trust
Pennsylvania
Sarah Pye
RGN, DN, BSc (Hons), MA,
PGCLT(HE), MRCN
Senior Lecturer Practice Learning,
School of Nursing, Canterbury Christ
Church University, Kent
Acknowledgements
We would like to acknowledge and offer our thanks to:

• each of the contributors, for their chapters and for their understanding regarding
the length of time it has taken to complete this book
• Katrina Hulme-Cross, Louise Crowe, Gillian Nineham and Jamie Etherington
for their support and understanding with regard to the development of this
book.
XVii
For everyone, everywhere, who has been affected by
an infection that should never have happened
PART I
Perspectives of infection
prevention and control
C H A P TE R 1
Motivation and leadership in

infection prevention and control
Annette Jeanes
In infection prevention and control, practitioners are frequently expected to lead,

initiate or facilitate improvements or changes. The motivation and leadership of
people is often challenging, particularly when associated with improving practice.
This is even more complicated when you need to influence managers and leaders.
The purpose of this chapter is to explain some of the theories and concepts associ
ated with motivation and leadership and to suggest how these may be used within
this specialty.
THEORIES OF MOTIVATION
Kreitner1defined motivation as ‘the psychological process that gives behaviour pur
pose and direction’, while Bedeian2 suggested it is ‘the will to achieve. In this chapter
the term motivation is used to describe the force that makes individuals do what
they do, or perhaps what makes some staff wash their hands while others do not!
In ancient history, workers, slaves and servants were simply expected to obey and
do the work. Their motivation was based on a need to eat and survive. Motivation
was therefore relatively simple. In the current day some managers still believe that
it is simple and that they know what motivates their staff, but this is a complex and
developing field. Motivational theories vary and there is little consensus.
One traditional view of motivation is that people require tight control in the
workplace and respond to reward and punishment. This is often referred to as
the ‘carrot and stick’ method of motivation. Reinforcement theory3 is based on
3
4 INFECTION PREVENTION AND CONTROL
rewarding good behaviour and not rewarding behaviour that is not wanted. This
method has frequently been used to train animals and has also been successful with
humans; however, it is predictable and may in time dwindle in efficacy. It is the
basis for awards- or prize-based systems and is used in performance management.
Frederick Winslow Taylor was an early pioneer in ‘scientific management’; he
believed people were motivated by pay and worked more efficiently if work was
divided into a series of tasks.4 Staff could be allocated a simple, specific task and be
paid according to productivity. This approach was adopted widely in manufactur
ing industries - including Ford, where assembly lines led to greater efficiencies,
although boredom with repetitive tasks caused job dissatisfaction.5 In addition,
although workers were paid more if they worked faster, this could lead to lay-offs,
as fewer staff were required and there was a lack of overtime, which was a disincen
tive. This prompted conflict between managers and workers, and actions such as
‘working to rule’ developed in response.
Elton Mayo conducted what are now known as the ‘Hawthorne studies’.6 These
studies demonstrated that employee behaviour is linked to attitudes and that
rewards are not just monetary. It was concluded from this work that just being part
of a study or being observed and monitored changed behaviour and could improve
or change performance. The ‘Hawthorne effect’ is often used to explain the improve
ments in infection control performance noted while observation is taking place. A
good example is the improvements identified in hand hygiene compliance while
observational monitoring takes place.7
McGregor8believed that work was a natural requirement and that matching the
developmental needs of individuals to organisational goals leads to optimal moti
vation and performance. In his ‘x’ and ‘y’ theory of management styles he argued
that the ‘x’ type management style, which is autocratic and controlling, leads to
poor results, while the ‘y’ type management style, which is participative, allows staff
self-control and self-regulation, which in turn allows staff to develop and contribute
more. Standardised and consistent infection control practice may be difficult to
maintain and monitor in a self-regulated team if the team decides to do something
different from everyone else; this may be challenging for infection control staff.
Herzberg9 concluded that there are two elements to motivation. The first com
prises ‘hygiene’ factors, which include environment, supervision, relationships with
others and pay. These factors can demotivate if they are inadequate. The second ele
ment is related to job satisfaction and is termed ‘motivational’ factors - these include
recognition and achievement. This has been compared to Maslow’s hierarchy of
needs theory,10which places the basic physiological needs of food and shelter at the
base of the hierarchy, followed by safety, social, ego and self-actualisation at the top.
MOTIVATION AND LEADERSHIP IN INFECTION PREVENTION AND CONTROL 5
The ‘motivational’ factors can be misinterpreted as a rehash of the ‘carrot and

stick’ approach but it is more complex, as individual motivation varies. If you need
to ensure people do what you want, it is important to understand what motivates
them to do a job and consistently do it well. Herzberg9 argued that motivation
accrued from monetary reward and was also associated with the recognition of
value and achievement in the job. It can cause dissatisfaction if the pay is felt to be
too little for the effort, but work has a purpose beyond earning money. Work can
provide stimulation, responsibility, purpose and a structure to day-to-day life. It can
provide a social network, and individuals become part of a group, which provides
social and psychological support.
Vroom11 suggested that individuals are motivated by outcomes. These were
termed ‘valence’, ‘expectancy’ and ‘instrumentality’; they drive effort, performance
and reward, and they are shaped by individual beliefs and preferences. A healthcare
worker could theoretically clean hands well and consistently because he or she
believes it is an important part of infection prevention and that it contributes toward
patient welfare (valence). The healthcare worker could put in extra time and effort
because this would improve the standard of infection prevention achieved, which
would be noted (expectancy) and which may lead to improved patient outcome and
the associated kudos, recognition or promotion (instrumentality).
OTHER FACTORS THAT INFLUENCE MOTIVATION

Workplaces and work groups also have a role in motivation, as they provide a com
munication network and a cohesiveness that links the group. The core values are
generally shared by peers and dissent is discouraged, as dissent undermines the
dynamics of the group and the status quo. Peer pressure is an important motivating
factor in changing behaviours and embedding changes. Generally, people respond
to peer pressure and aim to be accepted by their peers. Groups may be unaware
that they hold negative values and perceptions, and this may influence their abil
ity to assimilate or evaluate change or initiatives objectively.12 Alternatively, peer
pressure can be a strong force in accepting changes or raising standards. There are
many examples of peer pressure improving infection control compliance, including
hand hygiene.13
Perceptions are also important and affect motivation, development and oppor
tunities. The concept of the self-fulfilling prophesy or Pygmalion effect14 is that if
opportunities are given and people are treated appropriately, they have the potential
to achieve a lot, but that subconscious cues and expectations influence the overall
performance obtained. Therefore, an optimistic and positive approach to change
in the right circumstances may have a positive motivational effect. There is also a
danger that focusing energy on non-compliant, poorly performing staff may demo
tivate the compliant staff, who may feel overlooked in the presence of the prevalent
negative expectation; this may be the case in many areas of infection control prac
tice, including waste disposal, isolation practices, screening, sampling and cleaning.
Job satisfaction is an important indicator of how individuals feel about their job.
If this can be improved it may lead to increased motivation and even productivity,
although the correlation between job satisfaction and productivity is tenuous.15Job
satisfaction may affect sickness and absence rates, contribute to staff turnover and
affect behaviours of individuals within the organisation; however, it is affected by
individual dispositions, characteristics and experiences.
To retain valued employees, some employers are now using approaches such as
job sculpting.16 This designs the job to meet the needs of the worker, using the prin
ciples of optimising production developed by Taylor.4 Empowerment, autonomy,
job enrichment, fulfilment and flexibility are all linked to increasing motivation.
Developing and supporting an infection control link staff programme, for example,
may lead to increased job satisfaction and motivation, as these staff are supported
to develop a knowledge and skill set that may have a positive benefit.
Effective managers and leaders understand the value of motivation and use it
judiciously. It is also important in infection prevention and control to understand
the role of leadership and managers in change management.
LEADERSHIP AND MANAGEMENT

Leadership plays an important role in change management and service improve
ment. Leadership influences change and often manipulates and manages change.17
There are many change management theories, but the classic original change model
was developed by Lewin et al.18 This three-stage model - unfreezing, changing and
then refreezing- essentially prepared the worker for change (unfreeze), made the
change (change) and then ensured the change became permanent (refreeze).
Another model commonly used is Kotter’s198-step change model (see Figure 1.1),
which begins with what has been described as a ‘burning platform’. This sort of
approach is used frequently in infection prevention and control strategies - for
example, prevention of needlestick injuries, and reduction of the use of antibiotics.
The problem with models such as Kotter’s is that they are leadership driven and
can be coercive. This may affect job satisfaction and motivation, which may also
lead to resistance to change. Consequently, the approach to leadership or style of
leadership is an important factor in change management. It can be influenced by a
number of factors, including experience, values, beliefs, preferences, ability, culture

and norms, the environments and the situation.
FIGURE 1.1 Kotter’s 8-step change model19
LEADERSHIP STYLES
The classic leadership styles described by Lewin18 are autocratic, democratic and
laissez-faire or delegative. Each style has its own positive and negative aspects. There
are also various types of leader:
• charismatic
• participative
• situational
• transactional
• transformational
• the quiet leader
• servant/authentic.
The style of leadership relates to the degree of managerial control. The less control
the leader or manager exerts, the more control the worker or follower has, and the
converse (see Figure 1.2).
Leadership Styles
Management has most Employees have the
of the knowledge & needed knowledge &
skills skills
Management
control
Employee
control
Autocratic Paternalistic Participative Delegative Free reign

style style style style style
FIGURE 1.2 Leadership styles
A number of styles of leadership or management have been shown to produce poor

outcomes, although they continue to occur:
• toxic leadership or management20
• post hoc management - a generally autocratic style, often only providing man
agement after the event or in a crisis
• micromanagement - very detailed and close management and control
• seagull management - flies in, makes a lot of noise, craps on everything and then
flies off again, leaving a big mess behind
• kipper management - a two-faced manager with different approaches for dif
ferent situations
• the glory hog or user - takes the credit but does not do the work.
Many infection control practitioners will have encountered at least one of these
examples.
The perpetuation of poor managers created by large organisations and by busi
ness schools has led to criticism. Sumantra Ghoshal stated: Asshole management
is not inevitable'21 He observed:
It is interesting that a confluence of very diverse endeavours - that of

economists to make the practice of management amoral, that of strategy
and organisation theorists to make it scientific, and that of journalists
and consultants to make it heroic - have collectively reinforced the rise
of asshole management.21
Ghoshal argued that management should be a ‘force for good’ but that in the estab
lished and what he termed ‘old style management’ it was ‘solutions first, people
second’, which led to an emphasis on the management of people to change.21
Axelrod22 proposed that an alternative to leader-driven change is collaborative
leadership. Key elements of collaborative leadership are engagement, relationships
and democracy. It is based on the principles of honesty, transparency and trust.
The Enron and WorldCom scandals prompted a desire for leaders who could
be trusted, and this led to the concept and publication of Authentic Leadership by
Bill George.23 The notion of ‘authenticity’ was already well established in counsel
ling, psychotherapy and coaching. It is defined as being true to character, true to
oneself; not living through a false image or false emotions that hide the real you,
being genuine not a copy or clone.
Authentic leaders purport to know and live their values; they win people’s trust
by being who they are, not pretending to be someone else or living up to the expec
tations of others. Character development, inner leadership or self-mastery is crucial
to becoming an authentic leader.
Elements of authentic leadership:
• being true to yourself in the way you work - no facade
• being motivated by a larger purpose (not by your ego)
• being prepared to make decisions that feel right and that fit your values - not
decisions that are merely politically astute or designed to make you popular
• concentrating on achieving long-term sustainable results.24
Popular use of the term ‘authentic leader’ and modifications has blurred the defini
tion, the main overlap being with ‘servant leadership’.25 The concept of ‘a leader who
serves’ is well established, with one of the earliest references to servant leadership
being Jesus Christ. Essentially, the concept is of a self-sacrificing leadership that
prioritises the interests of the organisation and the well-being of workers.
There are number of problems with this type of leader in practice, such as ‘How
long will such a leader or hero last? How can you be sure that their motives and
values are genuine? How do they accurately determine the best interests of organi
sation and workers? Isn’t compromise a more sustainable solution?’
Organisational constraints and imperatives may not easily support authentic

or servant leadership. Instead, the industrialisation of healthcare has promoted
speed and efficiency, increasing standardisation of tasks and the use of technology.
Control and consistency are important in this environment. It has been argued
that this has led the rise of a managerial class that oversees a deskilled workforce in
which division of labour is more common.26 Examples in healthcare include nurses
who have to be trained to give a flu vaccine because their jobs do not involve giving
injections, staff who cannot use a manual blood pressure machine or thermom
eter, or staff who need a computer to calculate doses of drugs or provide a plan
of care.
MANAGEMENT VERSUS LEADERSHIP

Kotter27 argued that the function of management is homeostasis and to keep the
system functioning constantly. Part of this process is control, and another part is
having a target or objective. Management systems are often designed to consistently
deliver a target, to monitor the system and act when the target is at risk; an example
is the monitoring and managing of budgets and finances.
The control and planning required by managers may be problematic in infection
control, as new microorganisms and outbreaks of infections are often unpredict
able and infections prevented are not noticed. In addition, the work required by
infection control staff is dependent on those who deliver the care or service. To
deliver improvements in practice, management and control of behaviours is usually
essential at the point of delivery, but the managerial pressure to perform or meet
targets is often focused on the infection control practitioners.
Managers may offer rewards for improved performance but require control
and constancy. Kotter argues that leadership is different, as it uses motivational or
inspirational processes to energise by ‘satisfying basic human needs: achievement,
belonging, recognition, self-esteem, a sense of control over one’s life, and living
up to one’s ideals’.27 He also argues that motivating people for a short time is easy,
particularly in a crisis, but that motivating them long term takes planning and
commitment.
Leadership and management are linked but they are not the same thing. Bennis28
composed a list of the differences:
• The manager administers; the leader innovates.
• The manager is a copy; the leader is an original.
• The manager maintains; the leader develops.
• The manager focuses on systems and structure; the leader focuses on people.
• The manager relies on control; the leader inspires trust.

• The manager has a short-range view; the leader has a long-range perspective.
• The manager asks how and when; the leader asks what and why.
• The manager has his or her eye always on the bottom line; the leader’s eye is on
the horizon.
• The manager imitates; the leader originates.
• The manager accepts the status quo; the leader challenges it.
• The manager is the classic good soldier; the leader is his or her own person.
• The manager does things right; the leader does the right thing.
Although twenty-first-century healthcare has its emphasis on efficiency, healthcare

workers are not just part of a machine. The value of people is frequently associ
ated with the knowledge and experience they bring to the job. To get the best from
people they need to be nurtured.
Peter Drucker29 wrote of the rise of the knowledge worker and how the require
ment was now less to manage people. ‘The task is to lead people. And the goal is to
make productive the specific strengths and knowledge of every individual’30 One
of the ways this has been done is by empowerment.
EMPOWERMENT
Empowered staff are able to make decisions, are given responsibility and can decide
how to undertake the work they do. This increases motivation, engagement and job
satisfaction. The quality of the service delivered may improve, as the staff are more
likely to accept ownership and responsibility for outcomes.
This does not occur in a vacuum and requires an organisational culture, leader
ship and management support system to facilitate and support empowered workers.
To succeed it also requires a skilled and knowledgeable workforce with a clear
understanding of the organisation’s objectives and values.
In some organisations this has been taken further, with self-managed teams
shown to be more effective than traditionally managed teams.31 These teams make
decisions and adopt approaches that fit their circumstances and which work.
Unfortunately, in the current era of bundles of evidence-based practice and
numerous imposed guidelines, it has become increasingly unlikely that infection
control practitioners will be encouraged to take approaches that are not in line with
standard practice. The imposition of innovations and interventions that have been
found useful in other organisations and situation is likely to continue, even though
they may not work elsewhere.
However, there are opportunities to adapt rather than blindly adopt imposed
initiatives. Empowering staff to make local adaptations and variations is likely to
be more effective than imposing and dictating. The role of infection prevention and
control practitioners is to ensure the staff have the education training and support
to make the adaptations with confidence and to allow them to own the initiative
and, it is to be hoped, the associated kudos.
CONCLUSION
This chapter has provided some explanation and detail of the theories and issues
of motivation and leadership. Understanding motivation is important in effectively
leading and managing or working with leaders and managers. It can improve the
effectiveness of infection prevention and control practitioners and the sustainability
of initiatives.
It is essential that you communicate effectively, simply and clearly. What is
your goal? What is the plan? Who do you need to influence? This may mean that
you have to adapt your style and methods according to the audience, situation or
opportunity. It is also important to ensure that you adapt your approach based on
your experience and by listening or learning from others.
Teamwork, encouraging others and empowering others are also crucial factors.
Infection prevention and control is largely about getting others to do things the right
way. This relies on them being motivated and engaged to do it consistently while
you are not there. This may be hard to achieve, as what motivates and engages staff
may vary from one organisation, team or individual to another.
Finally, integrity, reliability, stability, honesty and humility as a leader, manager,
team member or individual are important. Courage is crucial, as the potential dif
ficulties encountered in this specialty cannot be understated. In particular when you
have to speak out in identifying poor practice or care, communicate with difficult
managers or admit to an error. The way you behave and respond affects those you
interact with, and subsequently the safety and satisfaction of patients.
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4. Taylor FW. Principles o f Scientific Management. New York, NY: Harper & Brothers; 1911.
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Books; 1994.
6. Mayo GE. The Human Problems o f an Industrial Civilization. Reprint ed. London: Routledge;
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7. Eckmanns T, Bessert J, Behnke M, et al. Compliance with antiseptic hand rub use in intensive
care units: the Hawthorne effect. Infect Control Hosp Epidemiol. 2006; 27(9): 931-4.
8. McGregor D. The Human Side o f Enterprise. New York, NY: McGraw-Hill; 1960.
9. Herzberg FI. One more time: how do you motivate employees? Harv Bus Rev. 1987; 65(5):
109-20.
10. Maslow AH. A theory of human motivation. Psychol Rev. 1943; 50(4): 370-96.
11. V room VH . Work and Motivation. New York, NY: John Wiley & Sons; 1964.
12. Estlund C. Working Together: how workplace bonds strengthen a diverse democracy . New
York, NY: Oxford University Press; 2003.
13. Haessler S, Bhagavan A, Kleppel R, et al. Getting doctors to clean their hands: lead the fol
lowers. BMJ Qual Saf. 2012; 21(6): 499-502.
14. Rosenthal R, Jacobson L. Pygmalion in the Classroom: teacher expectation and pupils’ intel
lectual development. New York, NY: Rinehart & Winston; 1968.
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77(5): 144-52.
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social climates. J Soc Psychol. 1939; 10: 271-301.
19. Kotter JP. Leading Change. Boston, MA: Harvard Business School Press; 1996.
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21. Birkinshaw J, Piramal G. Sumantra Ghoshal on Management: a force fo r good. King’s Lynn,
UK: Prentice Hall; 2005.
22. Axelrod R. The Evolution o f Cooperation. Revised ed. New York, NY: Perseus Books; 2006.
23. George W. Authentic Leadership: rediscovering the secrets to creating lasting value. San
Francisco, CA: Jossey-Bass; 2003.
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Hum Relat. 1994; 47(1): 13-43.
C H A P TE R 2
Just infection prevention

and control
Julie Storr
Inform ation giving and anxiety reduction should be fundam ental

parts o f nursing.1
INTRODUCTION
Over 20 years ago, a conversation was stimulated on the challenges of moving away
from outdated nursing procedures that are based on myths and consist of ritualistic
behaviour and which are carried out by healthcare practitioners (nurses) without
thinking and insight.1 This chapter resumes the conversation in the present day,
through an infection prevention and control lens. It explores what, if any, are the
present-day myths and rituals in modern healthcare that are carried out in the
name of infection prevention and control, alongside practices that have become
accepted as the norm. Most important, it considers the unintended consequences
that such myths and misconceptions can have, particularly in terms of injustice,
inequity, ethics and psychological harm. It calls for action now where warranted
to stop injustice, to refocus on activities that are safe, evidence informed, patient
focused and, ultimately, sensible. It subsequently highlights the need to build capac
ity and capability across healthcare such that insight into the consequences of what
is carried out in the name of infection control is readdressed, posing the question:
‘What can we do better to ensure justice for infection prevention in the name of
patient safety?’ This chapter culminates in a number of proposed actions, including
a healthcare worker training revolution, research on the impact of redundant or
15
unnecessary practices on the psychological health of patients, a ‘consumer or future

patient’ awareness-raising campaign - driven by policy and supported by informed
media - and infection prevention and control strategies that are focused on halting
microbial transmission and subsequent harm from a holistic, rights-based perspec
tive that takes account of dignity, ethics, humanity and justice.
Hospital workers exercise care through a network of practices and fundamental
beliefs that are largely taken for granted. This author emphasises the ‘embodied
know-how that goes into a surgeon’s operations, or into the touch of the doctor or
nurse when examining a patient’ - care described as grounded in skilful micro
practices that healthcare workers have absorbed and carry out without freshly
thinking them through on each occasion. It is only when aspects of practice become
problematic that they are raised for debate and can be changed.2
For a long time infection prevention and control has been focused on the impact
of microbes on the health and well-being of patients, and on how practices control
the spread of these microbes. Is it now perhaps the moment to consider the patient-
related impact of some of the micro- and macro-practices that are in place in the
name of halting transmission; some of the ‘problems’ associated with these; and to
call time on those that at least might be unnecessary and at worst might actually
be harmful.
( 'N
BOX 2.1 A personal reflection
My first recollection of infection control, as it was then described, was during

the last century - the 1980s to be precise, and my first ward placement as a
student nurse. I recall being told in no uncertain terms and most seriously by
a healthcare assistant that on no account must I use talcum powder when
assisting a patient with activities of daily living, because of the infection hazard
it presented. Whether this was rooted in scientific evidence I never got to know,
because I accepted it on its face value as a fact.
V______________________________ ________________________________ J
The account described in Box 2.1 is reflective of a pattern that has permeated the
rest of my career, initially in nursing and more recently healthcare.
Similar ‘advice’ continues to be heard to this day, ranging from a dentist who
explained that the regulators instructed him to take a poster off the ceiling (it was
intended to be a distraction to the anxious dental patient) because it presented an
infection risk, to a nurse who explained medicine carts were no longer used for the
same reason. Ties, watches, sleeves, flowers, Christmas decorations, bed-sitters - all
JUST INFECTION PREVENTION AND CONTROL 17
frowned on in the name of infection prevention. Some of the frowning might well
be justifiable, and while talcum powder and Christmas decorations might not have
a significant effect on recovery or the psychological status of a patient, some of the
practices we do (some for no sound reason) in the name of infection prevention
and control can and do have consequences, which range from low-level annoyance
through to heightened anxiety levels of patients and their families. The negative
consequences, not of microbes but of the prevention and control mechanisms we
employ, have surprisingly generated little debate in the academic literature. This
chapter is intended to stimulate a new debate.
While much of infection prevention is evidence informed (or is increasingly so),
this chapter is predicated on the acceptance that some of the things we do under
the guise of preventing infection are based in mythology, some ritualistic and some
plain nonsense. Everything addressed in the next few pages can be challenged, dis
puted and argued against, and, as a progressive infection preventionist, I welcome
such discourse. This chapter is intended to push the healthcare community to revisit
what we do in the name of stopping infection from occurring and/or spreading.
Exploring the extent of this problem, if it exists, and its impact on patients will form
an important contribution to a patient-focused approach to infection prevention
and the pursuit of care and treatment that is patient-centred as well as concerned
with the important matter of risk reduction. Healthcare teams that interact with
patients 24 hours a day must be empowered to critique, understand and apply good
science as well as to know when to consign myths and injustices to Room 101.
This chapter will explore:
• unintended consequences of (unnecessary) patient isolation - actions that
ignore cognitive well-being and contribute to both under- and over-compliance
of necessary infection control practices such as the right times for hand hygiene
• implementation of policies and practices that have no grounding in infection
prevention evidence or logic (i.e. related to uniforms, buckles, beds, ties, patient
chairs, toys, visitors, and so on)
• the impact of misunderstanding the dynamics of microbial spread at the patient
bedside and therefore foregoing some important patient interactions, such as a
comforting touch
• losing sight of the human being, the person beneath the patient, including risk
communication and its impact on anxiety levels.
Martin Luther King Jr has been credited with the statement: ‘O f all the forms of
inequality, injustice in health care is the most shocking and inhumane.3,4* A number
of infection prevention and control practices grounded in myth have the potential
to result in and perpetuate injustice in modern healthcare, an issue that must be
addressed for patient well-being. Examples are not too hard to find. In the English
National Health Service at the time of writing there continue to exist hospitals that
ban visitors during outbreaks of norovirus, using the infection prevention and
control argument in its defence; this is, in fact, counter to national guidance that,
while discouraging social visitors, cites ‘operational expedience’ rather than infec
tion control as its rationale. Yet other National Health Service organisations are
considering the use of Skype and FaceTime as a means of communication between
patients and visitors when visiting is restricted because of infection risks.
r ~\
BOX 2.2 Some questions
Before reading further, consider the following: How much investment, time and
lobbying has gone into strengthening surveillance - really high-quality surveil
lance that has been proven to contribute to reduction in healthcare-associated
infection? How much investment is put into building high-quality, competent
practitioners who are skilled in epidemiology? How much pressure is there for
hospitals to undertake surveillance across the range of common healthcare-
associated infections? How much surveillance is mandatory? Contrast this with
the amount of effort and zeal that many in healthcare, including at the policy level,
put into ‘bare below the elbows’ , auditing of commodes, and deep cleaning?
What drove the latter focus on politically motivated edicts and what prevents
the former investment on interventions that are evidence-i nformed? Is this, in
the end, an injustice?
V______________________________________________________________ J
SETTING THE SCENE
There seems to be something very strange going on. Is it all in the interests
of being seen to be doing something very noticeable about the worrying
levels of hospital based infections, however ineffective and otherwise
disruptive.5
The Washington State Commission on African American Affairs reports that Martin Luther King Jr made this
statement on 25 March 1966, at the Second National Convention of the Medical Committee for Human Rights.
You don’t have to look too hard in the published and grey literature to find a plethora
of examples of the zealous application of practices in the name of infection preven
tion and control. What emerges from many of these examples is a trade-off between
the need to prevent harm (usually, but not always, to patients or other patients in the
vicinity) and the need to maximise the health and well-being of individual patients,
including physical and psychosocial well-being.
A number of these issues are described perfectly in a blog post exploring whether
well-minded infection control procedures are in fact subverted.6 Within the blog it
is suggested that many infection control procedures, with their origins in the main
tenance of patient safety, have become routinised into our mindset and detached
from their original purpose. The banning of flowers, which thankfully no longer
seems all-pervasive from an infection control perspective, is used to illustrate the
point. There is no evidence that flowers pose a risk of infection; however, as the
author states, the maintenance, arrangement and emptying of vases may be seen as a
burden to already busy staff, and the risk of spillage of water an unwanted side issue.
Rather than using these justifications, the infection control agenda added a sense
of legitimacy and a kickback to justify the exclusion of flowers from general wards.
Similar illustrations are used that include toys and magazines in communal areas
and restrictions on the number of visitors. In some instances infection control has
taken on a social role and become a means of control, or even a pointless exercise,
rather than an evidence-based practice.
Iona Heath,5 quoted at the start of this section, summarised some of the issues
in an article. She described the prohibition in modern healthcare of sitting on a
patient’s bed, in the name of infection control. The article presents a compelling
account of the benefits, as she perceives it, to patients when doctors are permitted
to sit on a bed during an encounter. Heath5 describes such interactions as precious
and, alarmingly, suggests that this ban on bed-sitters seems to be imposed even
when patients are dying. She suggests that infection control specialists enforcing
such approaches lack humanity and common sense, and she cites the national
evidence-based guidelines on infection prevention and control as being devoid of
any mention of bed-sitting (or flowers - an issue previously addressed by Heath5
in the BMJ). Her default assumption is that there is no evidence for such a rule.
Heath5 concludes by returning us to the issue of humanity and calls for bed-sitting
(and flowers) to be freely permitted unless there is robust evidence to deter these
‘elements of home’ from penetrating hospitals and improving patient well-being.
Patients consistently estimate that they have been given more time when
the doctor sits down rather than stands.5
It seems that considering infection through the narrow chink of a microscope lens
could contribute to some of the challenges described here. These brief examples
suggest a problem illustrative of misguided thinking on what’s right and wrong,
influenced by a lack of insight, misapplication of knowledge or, indeed, absence of
sound knowledge, and a silent infection prevention and control community that
needs to shout much louder if it is to be part of the solution and not a contributor
to the problem. The media undoubtedly play a role, as evidenced in a review of the
drivers and influencers of the media coverage of meticillin-resistant Staphylococcus
aureus (MRSA) in the early to mid 2000s.7 The authors concluded that the media
played a powerful role in driving policy away from scientific evidence and toward
popular, ‘common-sense’ solutions, and in addition the authors touched on the
weaknesses in the scientific community, including professional bodies, in their
inability to penetrate the media machine with counterarguments.
So far, this chapter has provided two anecdotal examples to illustrate that there
may be a problem. Does the scientific literature shed any more light on the subject?
HUMANITY, ETHICS, RIGHTS AND CONSEQUENCES

This section focuses on a snapshot of the literature that highlights the potential
injustices; it does not aim to present a full literature review balancing these points
with the benefits of infection prevention and control measures, as these are freely
available in many other documents. The key point being posed is that these meas
ures are being applied separately from other patient care needs.
Considering justice in infection control from an ethical standpoint draws out
the important point that most infection prevention professionals enter the specialty
from a clinical medicine background - one where the welfare of individual patients
trumps broader social concerns - and this can result in infection control measures
infringing on individual rights and liberties.8 Examples cited include surveillance,
isolation precautions and antimicrobial prudence. In terms of the impact of infec
tion prevention practices, patient isolation has received the greatest attention.
Isolation undoubtedly serves a purpose in helping to control the spread of some
microorganisms. However, there is some documented work that reports the isola
tion of patients and subsequent ‘barrier’ precautions can lead to fewer bedside visits
by doctors and nurses and thereby resultant negative psychological impact on the
patient, as well as poorer perceived satisfaction with treatment.9
A recent systematic review aimed to determine whether contact isolation leads to
psychological or physical problems for patients.10 The authors looked at 16 studies
on the impact of isolation on the mental well-being of patients, patient satisfaction,
patient safety or time spent by healthcare workers in direct patient care using vali
dated tools scoring for levels of anxiety and depression. Their findings conclude that
isolation has a negative impact on the mental well-being and behaviour of patients,
including higher scores for depression, anxiety and anger among isolated patients.
The literature revealed that healthcare workers spent less time with patients in isola
tion and that patient satisfaction was adversely affected, particularly influenced by
the extent to which patients were kept informed of their healthcare. Patient safety
was also negatively affected, although this has been contended in other studies, and
the review found an eightfold increase in adverse events. The authors suggest that
patient education may be an important step to mitigate the adverse psychological
effects of isolation. However, the review did not consider patient information within
the context of an empowered, well-educated and well-informed health workforce.
More recently, as part of a doctoral thesis, Parker11 synthesised eight qualitative
research studies focused on patients’ experiences of healthcare-associated infec
tions. The findings follow a similar pattern to that already outlined - experience was
largely negative, psychological needs were often overlooked and fear, worry, stress
and guilt were common features of the patient’s experience. The patient experience
was exacerbated by poor information-giving by staff, based on preconceptions and
assumptions. Parker11 describes the negative experience as resulting in a ‘double
iatrogenic effect’ on the patient. The issue of poor information-giving predicated
on limitations in staff knowledge and competence in the field is not explored in
any detail.
It seems logical from this brief review of the literature that isolation is applied
only when absolutely necessary for patient safety and that healthcare workers are
aware of its potentially negative side effects.
What emerges from much of the literature is the need for a philosophical and
ethical debate focused on the complexity that is infection prevention and control,
and its practices that are ubiquitous and often never challenged. Many of the aca
demic papers cited here focus on issues of justice, individual human rights, freedom
of movement, the greater good of society and citizenship. Bryan and colleagues,8
in particular, suggest that national guidelines and regulations sometimes fail to
offer tidy solutions to infection prevention and control problems. Therefore, what
is needed is a decision-making process that includes a careful review of the facts,
values and external factors (such as guidelines) and an awareness of relevant ethi
cal frameworks.
Healthcare-associated infection has also been considered from a patient rights
perspective, addressing respect for human dignity, and this adds an interesting
dimension to the debate.12 M illar12 describes the universality of human rights,
particularly for citizens unable to advocate for themselves, and considers the isola
tion of patients as a potential breach of the right to dignity and respect. Millar12
further discusses control strategies for MRSA and suggests that such measures oper
ate at the interface between public health and the promotion of public good, and
the care of individual patients - something that creates a tension within healthcare.
Millar12 proposes that historically there has been an acceptance by patients of the
many actions that are taken to prevent and control healthcare-associated infection;
however, by considering issues of patient rights, it becomes a matter of importance
to be able to justify the measures taken.
If patient rights are to be over-ridden, patients and the public might rea
sonably expect there to be transparent and explicit reasons, preferably
supported not only by professional and expert opinion of the evidence
but also consensus agreement with patients and the public.12
More recently, a World Health Organization Europe document13 considered the

important aspect of patient rights in relation to patient safety. Its chief focus is on
the right to safe healthcare and it explores patient empowerment as one compo
nent of this, in relation to a number of safety-related areas including hand hygiene
improvement. It does not concern itself with rights in relation to the unintended
consequences of patient safety interventions.
In terms of a possible resolution of the conflicts identified in this chapter, Stelfox
and colleagues9 call for multicomponent interventions that are implemented in the
name of patient safety, and this applies to many of the infection prevention practices
described so far - particularly isolation - to have their individual parts examined to
determine whether all elements are essential. They suggest that it might be possible
to ‘disentangle’ which isolation policy components are most important for infection
control and which may be most harmful to the isolated patient. They further call for
individualisation, citing that patients who experience the most negative effects of
isolation may not be those who present the greatest risk of microbial transmission.
These authors discuss the interdependence of individual patient characteristics,
clinician factors, environmental constraints and organisational culture as key
influencers of patient safety.
MRSA was described in a recent paper as ‘the infectious stigma of our time’,14the
paper challenging the reader to consider some of the things undertaken in the name
of infection prevention guidelines. Here are some examples of practices uncovered
during a reflective analysis of MRSA guideline application in Norway:
• older patients with dementia isolated for long periods
• patients denied access to a GP practice and had their consultation in a car park
• new employees made to stand naked and be examined for skin lesions.
The authors understandably ask the question, ‘Oh God, what are we doing?’ They
consider the dichotomy of guideline implementation and an appreciation of the
ethical dilemmas this can raise.
We isolate people as if they have highly contagious TB [tuberculosis], but

they may be as ‘healthy’ as persons with HIV [human immunodeficiency
virus].14
These authors go on to suggest that MRSA, in particular, is unique in that it can

result in the isolation of carriers who do not have clinical disease. This isolation
can result in feelings of anxiety and powerlessness, and this is further compounded
because often the time period for isolation is not well defined. The use of personal
protective equipment, in some instances, by visitors can result in fewer visits by
loved ones and in social deprivation. The authors conclude by calling for more
emphasis on ethics within guidelines such as those designed to limit transmission
of MRSA; at the very least they should contain an explicit ethical argument. The
authors further suggest that we have failed to learn the lessons from the era of HIV,
when in an attempt to prevent stigmatisation, universal precautions were intro
duced. The authors call for healthcare workers not to rely on passive conveyance
of the measures suggested in guidelines, but rather to reflect on possible actions,
particularly the ethical considerations and implications of the guidelines on patients
and relatives.14
It seems that, increasingly, the research community is beginning to challenge
some of the historic approaches to infection prevention and control. Spence and
colleagues15 describe how they have ceased to apply contact precautions within
their 285-bed hospital in the United States for patients asymptomatically colonised
with MRSA, with no noticeable impact on transmission. However, as with many
hospitals in the United States, all patients in this 285-bed hospital have their own
room; this is not the case at present in the United Kingdom.
Recently, there have also been some fresh voices and opinions heard on this
topic, highlighted through the power that is social media, with eminent infectious
disease physicians and epidemiologists in the United States using their blog post*
to share thoughts on topics such as ‘Why I Hate Contact Precautions’ and ‘Let Me
* haicontroversies.blogspot.com
r ;
BOX 2.3 Reflective exercise - the case fo r o r against
A
Consider the following scenarios.
• Visitors of a patient isolated because of a resistant organism are instructed
to wear gloves and a plastic apron on entry to the room and for the duration
of their visit
• A postpartum woman being treated for a breast abscess due to MRSA is
told she is not allowed to visit her infant in the busy neonatal intensive care
unit in which MRSA has not yet emerged as a significant problem (adapted
from Bryan et al.8)
• A sign outside the entrance to a ward instructing visitors not to take flowers
onto the ward
• A recommendation is made in a report of ‘failing hospitals’ for the health
service to consider introducing Skype and FaceTime for patients in isolation,
to minimise visitors
• A nurse in a nursing uniform, with a coat, the uniform looks clean and smart,
enters a supermarket; the manager of the shop emails the manager of the
local hospital to complain, citing risk of infection as a concern
• A report from a regulatory body that has undertaken a review of what are
considered ‘failing hospitals’ criticises the infection prevention and control
team because of a number of noticeable breaches of best practice, including
one example of nurses wearing buckles
• An elevator in a large teaching hospital instructs all visitors to clean their hands
as they enter a ward
For each scenario, try to answer the following three questions:

1. What is the key risk and who is it a risk to?
2. How strong, if at all, do you think the evidence behind the infection prevention
and control measures is?
3. What might be the unintended consequences of the measures, and to
whom?
If the measures are justified, in your opinion, how might the unintended conse
quences be lessened?
V__________________________________________________________ J
Hate on Contact Precautions Some More’. These challenging discussions must be

welcomed and the role of social media explored further as a catalyst for change.
The reflective exercises in Box 2.3 invite the reader to consider his or her own con
troversies and present a number of probing questions.
WHAT WE CAN DO MOVING FORWARD

This chapter has focused on aspects of infection prevention and control that may
have unintended consequences and which could be described as perpetuating
injustice for patients. A key focus has been on the impact of isolation on a patient’s
cognitive well-being, but there are other examples of practices implemented in the
name of infection prevention, practices where the consequences have so far evaded
academic scrutiny and have largely bypassed any sort of challenge or healthy debate.
These are summarised in the following list - this list is certainly not exhaustive, but
it aims to prompt action now where warranted to help stop injustice, and to refo
cus on activities that are safe, evidence informed, patient focused and, ultimately,
sensible.
• Patient isolation only when absolutely necessary for patient safety, taking heed of
the existing research (i.e. what we already know) about the psychological impact
of isolation and contact precautions
• Compassion-informed risk communication when addressing infection/coloni-
sation in patients, making the best use of all available skills and resources
• The development of a competent infection prevention-informed workforce and
a gigantic leap forward in capacity building at the undergraduate and postgradu
ate level, driven by competent specialist practitioners
• Informed leadership, policymakers and regulators across every level of health
care who promote the right culture for infection prevention
• An informed media ready to listen to a strong, credible and convincing scientific
community
• The use of digital social media to promote the right messages
• Revisiting of the learning from HIV and universal precautions and consideration
of the ethical argument for all infection prevention interventions
• Refocusing on evidence base and surveillance, and the impact of recommenda
tions and data on behaviour
• Empowering patients and consumers - patient education and information on
the rationale for everything undertaken in the name of infection prevention
and control
And there are other aspects that should at least be considered now:
• research that looks beyond the impact of the germs, exploring the impact of
redundant or unnecessary practices on the psychological health of patients
• a revolution in healthcare worker training, and bold moves to change how we
approach this, with the goal of true capacity building and true behaviour change
• revised infection prevention and control strategies that are focused on halting
microbial transmission and subsequent harm from a holistic, rights-based per
spective that takes account of dignity, ethics, humanity and justice.
CONCLUSION
The topics that have been touched on in this chapter show that a number of practices
appear to have lost sight of the person beneath the patient, and some of them have
undoubtedly lost sight of the dynamics of spread of microbes at the bedside that
can lead to patient harm. Based on what we now know in the twenty-first century,
this chapter calls for all those working in healthcare to refocus on what infection
prevention and control stands for, perhaps to redefine the specialty, and certainly to
ensure that the practices carried out in its name never lose sight of the patient and
his or her family. This requires strong, informed leadership to generate the right
cultural milieu and a cadre of bold, progressive and pragmatic healthcare personnel
to drive a new agenda.
Bryan and colleagues8 introduce the notion of practical wisdom and love as
key virtues for competence and caring, and that all healthcare workers, including
infection preventionists and hospital epidemiologists, need practical wisdom to
guide them in decision making in the face of uncertainty, to seek a balance between
individual rights and the common good; temperance to seek restraint in the use of
healthcare resources; and courage to engage busy and politically powerful physicians
and administrators in dialogue. In conclusion, this chapter calls for an immediate
cessation of the perpetuation of any injustice that is introduced or promoted in the
name of infection prevention and control.
Additionally, infection prevention practitioners need to lead by standing up and
denouncing anything that contributes minimally to patient safety and emerge as
the credible, respected champions of logic, patient-centred care and safety. In the
achievement of an exemplar culture of infection prevention and control, there is a
need to win the hearts and minds of clinicians and managers. Much progress has
been made but the need remains to strive for the right balance between risk, human
rights and human wrongs. This is a challenge to all involved in healthcare and will
involve a multifaceted approach. Infection preventionists should be blazing the
trail, but it is the doctor, the nurse, the student, the porter, the domestic assistant
and all those who exercise care through what Farrands2 described as the network of
practices and fundamental beliefs that are largely taken for granted. These are the
workers who touch the lives of patients every day. Each interaction should be safe
and sound, just and sensible, and not influenced in any way by myths and rituals
that have the potential to cause harm.
REFERENCES
1. Walsh M, Ford P. Nursing Rituals, Research and Rational Actions. Oxford: Heinemann; 1989.
2. Farrands R. Hospitals: human bodies? RSA Journal. Summer 2013; 159(5554): 22 -3 .
3. Moore A. Tracking Down Martin Luther King, Jr.’s Words on Health Care. HuffingtonPost.
com; 2013 Jan 18, updated 2013 Mar 20. Available at: www.huffingtonpost.com/amanda-
moore/martin-luther-king-health-care_b_2506393.html (accessed 15 December 2014).
4. Washington State Commission on African American Affairs. Health Disparities: health
gap reflects history o f racism and mistrust. Olympia, WA: Washington State Commission
on A frican A m erican A ffairs; n.d. Available at: w w w .caa.w a.gov/priorities/health/
HealthDisparities.shtml (accessed 15 December 2014).
5. Heath I. Do not sit on the bed. BMJ. 2010; 340: c1478.
6. Lilford R. Richard Lilfords Friday Blog: can well-minded infection control procedures be
subverted? 2012 Dec 7. Available at: richardlilfordsfridayblog.wordpress.com/2012/12/07/
can-well-minded-infection-control-procedures-be-subverted/ (accessed 9 March 2013).
7. Boyce T, Murray E, Holmes A. W hat are the drivers of the UK media coverage of meticillin-
resistant Staphylococcus aureus, the inter-relationships and relative influences? J Hosp Infect.
2009; 73(4): 400-7.
8. Bryan CS, Call TJ, Elliott KC. The ethics of infection control: philosophical frameworks.
Infect Control Hosp Epidemiol. 2007; 28(9): 1077-84.
9. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control.
JAMA. 2003; 290(14): 1899-905.
10. Abad C, Fearday A, Safdar N. Adverse effects of isolation in hospitalised patients: a system
atic review. J Hosp Infect. 2010; 76(2): 97-102.
11. Parker N. The Psychological Impact o f Nosocomial Infection: a phenomenological investiga
tion o f patients’ experiences o f Clostridium difficile [dissertation]. Leicester: University of
Leicester; 2011.
12. Millar M. Patient rights and healthcare-associated infection. J Hosp Infect. 2011; 79(2):
99-102.
13. World Health Organization (W HO). Exploring Patient Participation in Reducing Health
Care-Related Safety Risks. Copenhagen: W HO Regional Office for Europe; 2013.
14. Braut GS, Holt J. Meticillin-resistant Staphylococcus aureus infection - the infectious stigma
of our time? J Hosp Infect. 2011; 77(2): 148-52.
15. Spence M R, D am m el T, C ourser S. C o n tact precautions for m eth icillin -resistan t
Staphylococcus aureus colonization: costly and unnecessary. Am J Infect Control. 2012;
40(6): 535-8.
C H A P TE R 3
Leadership, quality, efficiency and

productivity in infection control
Tara Donnelly
STONE SOUP
There is a tale told in many traditions of a wandering peasant woman who arrives in
a village to find a community struck by deep poverty and famine. She arrives in the
village square, takes a smooth stone from her apron pocket and claims it has magical
properties such that she is able to make delicious soup from it. A crowd develops
and the villagers look on with scepticism, as she asks for the largest cauldron they
have to be filled with water and placed on a fire. Nonetheless, they bring it to her.
She drops in the stone and then tastes the soup, declaring it good, but that it would
taste even better with the addition of a potato or two. A villager, with the prospect
of just a few plain potatoes for his dinner, obliges, the potatoes are chopped and
thrown in the pot. Tasting again she said it needs just a hint of onion, an onion
appears and is added to the bubbling cauldron. Some carrots, herbs, a little ham, and
pepper come forth from the villagers and finally the peasant woman declares that it
is sublime. There is more than enough for everyone and the soup is shared out. The
villagers agree that the ‘stone soup’ is the most delicious they have ever eaten; all take
their fill and for the first time in months hunger is defeated. The peasant woman
carefully extracts the magical stone and is given a comfortable room for the night
by the grateful villagers, before making her way to the next village in the morning.
29
APPLICATION TO HEALTHCARE
The stone itself possess no magic of course; although it does produce a ‘magical’
result. The story is an allegory about the power of belief and the inherent ability
of a community or team to be able to achieve those things that were previously
deemed impossible. The magic was there all along - the community had the ele
ments it needed but it took powerful leadership and a central vision to enable them
to work collectively. On their own a few potatoes or a sorry carrot won’t make much
of a dent in hunger but shared as part of a recipe they can make much more of a
difference.
The story of stone soup strikes me as very relevant for the National Health Service
(NHS) and other healthcare systems. Incredible improvements in service can be
achieved when staff work collectively for the benefit of their patients. Sometimes
at the start of the improvement journey, the task can feel hopeless and impossible;
the ambition can even seem ridiculous. The role of the leader can be described as
creating a vision of the future that is attractive, and demonstrating confidence and
determination that this vision is possible, such that others will share this belief.
HOPE
The power of belief in inspiring change is a theme of Helen Bevan’s when she writes:
Hope is the antidote to fear. There is a growing body of evidence about

the impact of hopeful actions that every NHS leader should take notice
of, particularly in these tough times ... The driving force of hope is belief.
As NHS leaders, we have to believe that changes can be made and that
we can make them. It is only through our own hopeful thinking (and
its demonstration) that we create the capacity to generate and enhance
hopeful thinking and action in those we lead.1
However, hospitals - my own area of experience for the past 20 years - are strikingly
complex places, and at times a phenomenally ambitious goal is needed to simplify
what staff are striving for and make success possible. Toward the end of his career,
the esteemed management guru Peter Drucker,2 who had worked across most
aspects of the private sector, decided to turn his attention to the US health service
and emerged somewhat bewildered, declaring: ‘Even small healthcare institutions
are complex, barely manageable places ... large healthcare institutions may be the
most complex organizations in human history’.2
Because of this complexity, achieving change in hospitals can sometimes feel
LEADERSHIP, QUALITY, EFFICIENCY AND PRODUCTIVITY IN INFECTION CONTROL 31
impossible. The message from the stone soup fable is that with a strong enough
vision, inspiring belief, the community - in our case staff - can be mobilised to find
solutions through working collectively.
SETTING THE AMBITION

As the director of operations in a busy teaching district hospital, the Whittington,
in north London, I found setting the ambition to be tremendously important. The
NHS can be a real political football, such that the landscape, rules, incentives and
systems change with alarming regularity. While it is important for board members
to keep up to speed with these changes, it is perhaps just as important to protect
staff from them at times, to avoid distracting people with too many unrelated objec
tives, and to maintain focus on the key big things that make a difference to patients.
Often the vision that you ask staff to espouse needs to be relatively long-term, and
en route there can be many barriers to achievement, but holding one’s nerve and
keeping the faith remains very important, as does allowing the team sufficient space
and autonomy to achieve the vision their way.
The Whittington’s maternity service has a well-deserved excellent reputation and
an emphasis on normal birth. We were looking to expand our service and create a
birth centre dedicated to midwifery-led care; we decided to be ambitious about this
and aim to create the best birth centre in the country. One of the interesting effects
of ambitious goals is that they can inspire others and attract them to the work more
effectively than modest goals. At an early point we approached Janet Balaskas, the
woman who began the ‘active birth’ movement, whose centre for yoga and birth
preparation was by chance just around the corner from the hospital. Janet is an
expert, nay guru, on normal birth, and was delighted to be involved in the work
to design the best birth centre we possibly could, with features that help support
the hormonal response in labour, and a birth pool in every room. Just as in the
stone soup allegory, we had within our community the answers to the questions
we sought; by starting with an ambitious vision, we gained interest from those best
placed to help.
In terms of convincing people to believe that an audacious goal is possible, the
view from the top is key, as this sets direction. It is critical that the senior team and,
ideally, the trust board believe in what you seek to achieve, and the more ambitious
the goal is, the more important it is to have top-team support.
In 20 1 1 -1 2 the maximum threshold for meticillin-resistant Staphylococcus
aureus bacteraemia at University College London Hospitals NHS Foundation Trust
was five. There was considerable scepticism about the achievability of this, and
before the start of the year it was highlighted to monitor as a significant risk. The
chief nurse, Katherine Fenton, outlined to the executive board that scepticism could
be dangerous and could lead to self-fulfilling prophecies. She stated that her belief
was that the senior team needed to get behind this and the first step was believ
ing that it was possible and not allowing people to state the impossibility of it but,
rather, to use that energy to work on solutions. This we agreed to do and the trust
achieved only five bacteraemia that year. ‘Hope is an overt choice that we make as
leaders,1 as Bevan says.
‘THE CURRENCY OF LEADERSHIP IS ATTENTION’

Dr Jim Reinertsen, a compelling public speaker, is also a former hospital chief execu
tive officer (CEO) and now a leader at the Institute of Healthcare Improvement in
Cambridge, Massachusetts Boston, the pre-eminent global improvement centre for
healthcare. He uses a phrase that, for me, sums it up beautifully: ‘the currency of
leadership is attention’.3 If you care about something, and want others to do so too,
and you happen to be in the fortunate position of being a leader, then all you must
do is pay attention to that thing and others will watch and do so too. That is your
‘currency’ as a leader. But sometimes, you will need to pay it an awful lot of attention.
Leaders vary hugely, of course, in their makeup; however, evidence demonstrates
that many leaders in the NHS and beyond tend to be at the end of the psychological
spectrum that is more active and dynamic - they like to get things done and move
onto the next thing. In the language of Belbin: a shaper, rather than a completer
finisher.4 However, sometimes you need to pay an issue a great deal of attention and
keep on doing so, even when you might have preferred to move onto the next thing.
There is another saying: that you need to communicate a message eight times using
eight different media before all staff will have heard it. Essentially, even when you
and those around you are entirely bored of reiterating the message, it may still not
be out there among front-line teams.
CRACKING ‘BARE BELOW THE ELBOW’

If you have ever spent any time on a ward in an NHS hospital, you will have seen
groups of young men and women who look identical to new graduates of any pro
fession. Carrying piles of paper and files, smartly turned out, not yet world weary,
they could, with a different background, be trainee accountants or lawyers. Only the
bleep or a stethoscope reveals them as belonging to one of the clinical professions.
Nurses, by contrast, are clearly denoted as such. The seniority nuances within the
colours of the uniforms may pass the casual observer by, but in their short-sleeved
practical dress or tunic with trousers, and pinned-on watch, it is almost always clear
which ones are members of the nursing profession.
At the London hospital where I was chief executive, my director of infection
control, May, and I were concerned about infection rates of Clostridium difficile
in particular; we wanted to make changes that were really significant - if possible,
game-changing. One day, at my regular monthly one-to-one with her, we were
debating how to crack ‘bare below the elbow. That is, how to ensure that on enter
ing any clinical area all staff removed coats and jackets, hung them up securely,
removed watches and any wrist jewellery, and rolled up their sleeves above the
elbow in order that they could decontaminate their hands and arms to a sufficient
standard of cleanliness.
She suggested to me that we consider providing uniforms for medical staff to
ensure we were able to comply with best infection control practice. She and the
director of human resources had recently held a session with a group of doctors in
training. Medical students undertaking their programme of professional education
had asked how they could reduce what they carry onto wards and into departments,
and how they could ensure at all times that hand hygiene could be carried out fully.
The discussion moved onto secure areas for jackets, coats, handbags, wallets and
valuables; this was clearly a real problem for these doctors. The question, ‘what
would it take to resolve this?’ was asked, and I was told that as part of this discussion
the suggestion of a uniform emerged from the doctors themselves. They put it that
if there were good facilities for showering, changing and storage of property, they
would be happy to use these and to change into short-sleeved scrubs or whatever
before entering clinical areas.
I thought this was a superb idea; however, there were clearly many dimensions
to it. What was gold dust in terms of change management was the fact that the idea
had come from the doctors themselves.
However, I didn’t think that ‘scrubs’ would cut it. ‘Scrubs’ are those loose cotton
pyjama-like outfits that are designed for use in hot operating theatres, usually pale
green or pale blue. Popular with staff, as they are very comfortable and easy to move
in, they are also baggy, with a deeply slashed neckline and made of a washed-out
cotton, and I felt that they were not sufficiently presentable or professional. We were
looking for something that was a closer equivalent to a suit suitable for medical
professionals.
May had looked into this and found another option, newly announced by the
manufacturer. This was a short-sleeved tunic top and slimline trousers, available
in a dark navy with silver pinstripe, with a large pocket at the front for bleeps, and
the word DOCTOR embroidered on the chest. The pinstripe contained real silver
and the manufacturer was promoting the fact that silver is naturally antimicrobial.
For us this wasn’t the point, but here we had an extremely professional-looking
proposal. May got hold of some trial uniforms and tested them with the doctors,
who liked them.
With the medical director on board, we decided to mandate uniforms for doctors
in training from the next intake, and while there were issues - from sizing to order
ing to storage in between, I well remember the day when I walked onto a ward and
finally saw every single doctor in these fantastic new uniforms. They looked crisp,
professional, assured and modern. What was fascinating was how much patients
and their relatives liked the uniforms. Above all, they could clearly identify when
they had encountered a doctor.
STRATEGIC VERSUS OPERATIONAL FOCUS

Within the literature on leadership, there is much emphasis on the importance of
senior leaders, and particularly chief executives, maintaining a strategic focus. The
recommendation is often to be ruthless with one’s time and to spend it on the key
big issues facing the organisation, delegating everything else to members of the
team, and certainly not spending time on the minutiae.
It is, of course, critical to keep focus on the wider strategic issues, such as where
the organisation is heading, key relationships and how staff and patients in the
hospital are feeling. Too often the operational cry of a busy, pressurised healthcare
organisation can leave its leaders providing none of this focus.
Stephen Ramsden obe, an inspirational healthcare leader and early patient safety
activist, describes how, when leading a hospital as a CEO, he gradually delegated
the operational running of the trust to his executive team. Instead of chairing the
weekly operational meeting, he would use the time to get out into the hospital.
‘What is the role of a chief executive?’ I constantly ask myself this and I
firmly believe the NHS has got it wrong. Too much emphasis is placed on
operational performance, constantly reinforced by the wider NHS perfor
mance management culture. The interpretation of personal accountability
often seems to translate into the chief executive signing letters of com
plaint, and hospital infection data returns, and tracking out-of-network
intensive unit transfers.
The symbolism has fostered the wrong emphasis on the chief execu
tive role. Many of us have neglected the really important objective of
transforming our organisations, setting ambitious improvement goals

(way beyond national targets), being visible to our staff and developing
talent in our organisations.
I have begun to change my role dramatically. On the premise that to
achieve transformational change you must first change yourself, I have
transferred the reporting line for clinical directors from myself to the
medical director, and stopped attending weekly executive team meetings.
The changes allow me to spend 30 minutes a day on walkabout. It is the
first time in my 16-year chief executive career that I have found a visibility
formula that works for me. It has put me back in touch. I feel better, staff
feel better and, hopefully, we will change some of the cultural barriers that
are so frustrating for all ... I can now spend more time on reducing our
hospital standardised mortality rate and patient safety. Nothing should
be more important to chief executives than saving lives and showing their
staff they care about this .
Many chief executives are probably already doing all this. But some
may still be stuck in an operational role that they feel is warranted by their
financial problems. The role of the chief needs to be re-examined. We can
be so much more effective than we have been allowed to be.5
Stephen used his time to build and maintain strong relationships with his clinical
teams, and he witnessed first-hand how patient safety was being considered and
how staff and patients were feeling. He was also role-modelling to his leadership
team the importance of visibility and in Lean Management terminology, ‘going to
the gemba’ - going to the workplace and seeing for yourself how the service is work
ing. What Stephen tried is admirable and takes real bravery. I believe that if more
chief executives were able to lead in this way, we would have a stronger and more
effective NHS. As he says, ‘If the chief executive is not leading transformational
change there is a good chance no one is’.5
This is important, as the hospital leadership climate links to the quality of patient
care. This has been evidenced by a number of studies including a 2011 report by
Michael West6 and colleagues cited by the NHS Leadership Academy:
Drawing on data from the annual NHS Staff Survey and other sources, the
report ‘shows how good management of NHS staff leads to higher qual
ity of care, more satisfied patients and lower patient mortality’ (2011: 2).
By giving staff clear direction, good support and treating them fairly and
supportively, leaders create cultures of engagement, where dedicated NHS

staff in turn can give of their best in caring for patients. The analysis of
the data shows this can be achieved by focusing on the quality of patient
care; ensuring that all staff and their teams have clear objectives; support
ing staff via enlightened Human Resource Management practices such
as effective appraisal and high quality training; creating positive work
climates; building trust and ensuring team working is effective.
The authors say that these elements together can lead to high quality patient care
and effective financial performance. Employee engagement is shown to be especially
important. This in turn is seen as fostered by effective leadership and management.
A number of correlations were revealed with staff engagement ‘having significant
associations with patient satisfaction, patient mortality, infection rates, Annual
Health Check scores, as well as staff absenteeism and turnover. The more engaged
staff members are, the better the outcomes for patients and the organisation
generally’.
ROLE OF THE SPONSOR: ENSURING DELIVERY

However, having said that, it is important to note that sometimes the minutiae
really matter. Within every key campaign will be an element of detail, which, if
disregarded, could stall the whole change. When senior leaders sponsor work, they
need to find this problem and solve it, regardless of the level of detail involved.
There were numerous examples of this within the uniform campaign; obtaining
lockers, building shower and changing facilities, sorting out padlocks, for instance.
However, the one that really stays with me is that it was only as we took delivery
of uniforms, just before go-live, that it became apparent that the trousers arrived
un-hemmed.
There was a school of thought that the uniforms could be given out like this, with
doctors in training responsible for hemming the trousers. My view was that this
was impractical, and if we were serious about giving this the best chance of success
we needed to make it error-proof - that is, as straightforward as possible for our
doctors to comply with the new system.
The manager of the education centre had been put in charge of the project, which
was a good move, as she had the right approach, being bright and motivated to suc
ceed, and she was also in a useful position in the organisation, as building strong
relationships with doctors in training was part of her role.
The consultant medical staff at that trust were in the habit of taking lunch
together in the education centre, and I used to join them, typically twice a week,
to catch up informally. It was a great way of getting into conversation with a good
range of consultants, to understand the mood of the organisation, and it was almost
always very entertaining.
As the project took off, I would call in to the manager during these visits, to check
on progress and see if all was going well. At one of these sessions she suggested that
a member of her team who had dressmaking skills could do fittings with each of the
doctors and then hem the trousers correctly over a number of evenings; this way
we could quickly get the issue sorted. I endorsed this and made arrangements for
the individual to be paid overtime for her needlework. Now the leadership gurus
would no doubt be tutting at me wildly by this point, for getting so involved in the
operational detail rather than maintaining a strategic focus, but I see this issue as
critical and in so many projects a great idea fails to launch ‘for want of a nail’.
W ithout this type of consideration, delivery of the goal would have been
affected. Attention to details as microscopic as these is required to ensure a suc
cessful campaign, and, as Reinertsen points out, this attention is the very currency
of leadership.
A Department of Health visit that took place after the introduction of uniforms
for medical staff stated that we were the best hospital that they had visited across
the NHS in terms of our compliance with ‘bare below the elbow’
COURAGE AND COMMITMENT

Leaders also need to demonstrate personal courage and commitment if we are to
constantly innovate in our approach to these key safety issues. Another area that
needs to be addressed when tacking C. difficile is the use of antimicrobials. Reducing
the availability of broad-spectrum antibiotics is now a clearly understood and evi
denced part of the reduction of rates of C. difficile. However, in 2007 it was a rather
different story. As part of our work, we invited in the Department of Health expert
Professor Brian Duerden to review all aspects of our infection control work and to
help us draw up our microbial policy. He did so and we implemented it.
However, there was considerable resistance and opposition, which claimed that
we had gone too far in our antimicrobial policy - further, it was argued, than any
other trust in the NHS was going at that time - that patients would be at risk as
we miss infections, that length of stay would undoubtedly increase, particularly in
our extremely efficient acute medicine unit, which would create serious flow issues
within the hospital. All this from well-respected consultants, including those expert
in clinical pharmacology, which made for some difficult medical committees.
Some of the opposition seemed to be about more than the issue at hand; perhaps
the change was more profound than we had appreciated. Atul Gawande, is a surgeon
and Harvard academic who has written very compellingly on the negative impact of
medical hierarchy on surgical safety, in his excellent books Better and The Checklist
Manifesto. In a BBC interview on the impact of the surgical checklist, he says: ‘There’s
tremendous hierarchy in an operating room, and when people get a chance to say
their name out loud, it actually changes the likelihood that they will speak up later
when they have a problem or have any doubts’,7 and the surgical safety checklist
has been described as a tool to help flatten hierarchy and thereby increase safety.
I don’t think it is unreasonable to suppose that hierarchies exist across medicine,
albeit in the minds of some rather than in reality, and I believe that what may have
been at the bottom of the fierceness of the opposition was that ‘backroom’ clinicians
such as microbiologists were restricting the clinical autonomy of ‘field’ doctors.
People could no longer prescribe as they had done, and the truth was that we didn’t
fully know what the implications of this would be.
Before one medical committee I suggested to May, who is petite, that as I hap
pened to have a custom-made size 8 flak jacket in my loft (belonging to a dear friend
who was then a war correspondent), I should bring it in for her to wear at the next
meeting as a visual prop. We toughed this out together, the medical director met
with those who behaved inappropriately, but even so it was very demanding to lead
for infection control at this time.
The policy was agreed and implemented and we monitored performance closely,
bringing it back to key meetings such as the board of directors, hospital manage
ment board and the medical committee.
COMMUNICATING THE CHANGE

The Institute for Healthcare Improvement run a fantastic conference on executive
leadership and safety, reputed to be the best globally. I was fortunate enough to be
sponsored to attend by the NHS Institute for Innovation and Improvement when
working with them on developing the Productive Operating Theatre. Within this
programme the role of executive leadership is identified as being to provide direc
tion and to build in a way that will make the past become unacceptable and the
future appear more attractive. In doing this, particularly explaining why the status
quo won’t do and why alternatives are desirable, as well as necessary, communica
tions play a major role.
At the trust where I was working, the communications function had been
outsourced. The aim had been to raise the profile of communications including
external coverage, and a firm had been selected that had good political insight,
which was seen as a distinct advantage. These aims are, of course, laudable and
the outsourced provider did a good job in these areas. However, my very strong
feeling was that the trust needed to focus much more strongly on its internal com
munications and that it was always going to be very difficult for an outside agency
based in central London, where clients were almost exclusively private sector, to
achieve the intimacy required to pull off great internal communications in a trust
near Twickenham.
So on my recommendation the board took the decision to end the contract and
rebuild the in-house team. Considerable revamping then took place of the trust’s
newspaper, the website and other media, and we were one of the first hospitals to
use film as a medium for patients to learn more about our facilities.
We made these changes to our communications setup because we felt that to
build our reputation further we needed to start with the messages to our own staff.
While the changes weren’t directly linked to the infection control work, having a
switched on, responsive and energetic in-house communications team was key to
launching effective infection control campaigns.
THE IMPACT
And the rates? They plummeted. C. difficile is a truly horrible disease. It is extremely
painful, it is debilitating, it takes away dignity and, indeed, it can take away life. If
you contract C. difficile or - more provocatively but not unfairly so - if we give you
it, your chances of dying are increased. The mortality rate looks from studies to be
6% -30% .8
The differences in our rates between the first quarter of 2007 to the second was
a drop of 40%. Had the first-quarter rate continued, we would have been looking
at 316 cases that year; instead, we had 178, and in the following year this was down
to 123. Rates per 100 000 bed days reduced from 140.4 to 94.8.9 There was plenty
more to do to get them down further - every case is one too many - but it seemed
that control had been gained and those very high historic rates have never been
returned to.
The data demonstrate a reduction in the rate of C. difficile at the hospital after
implementing this wide range of measures. It is hard to attribute benefits to par
ticular schemes but clearly the overall impact was positive. The improvement has
continued for subsequent quarters and not returned to the pre-2008 levels. It should
be noted that when looking at the performance data in retrospect, the first quarter
of 2007 was a particularly high period for C. difficile for the trust (regardless of
location of origin being community or hospital-acquired), with a number of prior

quarters and years being considerably lower.
APPROACHES TO MEETING THE QUALITY AND EFFICIENCY

CHALLENGE
Surviving the most significant and sustained period of financial constraint in NHS
history while retaining the quality has been called ‘the biggest challenge facing the
NHS’ by its then chief executive, Sir David Nicholson, in 2009.10 This was reiter
ated in 2014 by his replacement as incoming CEO of NHS England, Simon Stevens,
when he said:
we meet ... at a defining moment in the history of our National Health

Service. A time when the standards of care for the vast majority of our
communities continues to be extremely high . but also a time of the
most intense public focus ever on the quality and safety and dignity of
our care . Coinciding with the most sustained budget crunch since the
Second World War. Now in Year Five of essentially flat health funding.11
University College London NHS Foundation Trust (UCLH) is a large central

London trust made up of seven hospitals. It is a busy trust, providing a range of local
and more specialist services and undertaking a large research portfolio. UCLH is
also part of UCL Partners, the world’s largest academic health science system. An
early foundation trust, UCLH did very well out of the years of growth, successfully
growing its national and local services in line with the investment in health services
that was made by the Blair and Brown administrations.
With the global economic recession, increases to NHS budgets ceased, and this
combined with rising demand led to significant challenges. UCLH began its work
on meeting the quality and efficiency challenge in January 2010. As lead director, I
established a small programme office and launched the trust’s approach to Quality,
Efficiency and Productivity (QEP).
The aim was to make sustained financial savings, while maintaining the hard-
won quality gains for which we were known - such as being rated among the best
hospitals in London for patient experience and having one of the best survival rates
in the country.
The UCLH QEP programme established a number of principles.
• Involvement o f Everyone: part of core work, led by operational leaders, all staff
involved, strong communications element
• M ake Life Simple: using Lean as our method, simplifying processes wherever
possible
• Keep Patients Safe: the mantra that safer care is cheaper; minimise harm, includ
ing falls, infections, pressure ulcers
• Use the Evidence: be better at learning from elsewhere, events and visits
programme
• Spend Money Wisely: ensure that every purchasing decision is as good as it can be.
Using information for improvement was seen as central from the start and the key
performance metrics, which include quality, efficiency and productivity measures,
are all presented as statistical process control charts. Because statistical process
control charts demonstrate real shifts rather than normal variation, they are well
suited for documenting changes linked to improvement work.
UCLH has a highly devolved, clinically led structure and the QEP programme
is based on this. The vast majority of schemes are implemented at a local level and
overseen by the relevant medical director and clinical board. The programme office
focuses on supporting change in trust-wide schemes and also coordinates reporting
on progress. In its first 4 years, the programme has achieved recurrent efficiency
savings of over £140 million, with quality markers continuing to improve.
Returning to the analogy that opened this chapter, the QEP programme has had
plenty of ‘stone soup’ moments. A reduction in spend on agency staff of 75% has
been achieved through a vision of working entirely without agency staff, using our
own staff or those on our staff bank, who know the trust well. The first department
to achieve this was the busy maternity service, who got to zero agency midwives,
a real triumph in a service where continuity is so important but frequently eludes
us. It is heartening to see that the power of belief, underpinned by excellent process
change, and clinicians and managers working together for patients, can deliver a
level of change that could perhaps be described as miraculous.
REFERENCES
1. Bevan H. Who’s afraid of the big bad wolf? Health Serv J. 2011; 121(6239): 14-15.
2. Drucker P. Managing in the Next Society. New York: Truman Talley Books; 2002.
3. Reinertson JL, Pugh M, Bisognano M. Seven Leadership Leverage Points fo r Organization-
level improvement in health care. Cambridge, MA: Institute for Healthcare Improvement;
2005.
4. Belbin M (1981). M anagem ent Teams: why they succeed or fa il. H einem ann ISBN
0-470-27172-8.
5. Ramsden S. On being a good chief executive. Health Serv J. 2007; 117(6073): 34.
6. West M, Dawson J, Admasachew L, et al. NHS Staff Management and Health Service Quality:
results from the NHS Staff Survey and related data. London: Department of Health; 2011.
Available at: www.gov.uk/government/publications/nhs-staff-management-and-health-
service-quality (accessed 23 June 2015).
7. Lee D. Dr Atul Gawandes Checklist fo r Saving Lives. BBC World Service; 2010 Feb 5.
8. Hota S, Achonu C, Crowcroft N, et al. Determining mortality rates attributable to Clostridium
difficile infection. EmergInfect Dis J. 2012; 18(2): 305-7.
9. Clostridium difficile: updated guidance on diagnosis and reporting. D epartm ent of
Health. www.gov.uk/government/publications/updated-guidance-on-the-diagnosis-and-
reporting-of- clo stridium- difficile
10. Nicholson D. The Year: NHS Chief Executive’s annual report 2008/09. London: Department of
Health; 2009. www.gov.uk/government/publications/department-of-health-departmental-
report-2009 (accessed 24 June 2015).
11. Stevens S. Thinking like a patient, acting like a taxpayer - from NHS challenges to new
solutions? Speech at NHS Confederation Annual Conference, 2014 June 4. Liverpool www.
england.nhs.uk/2014/06/04/simon-stevens-speech-confed/
C H A P TE R 4
Infection prevention and control

in the operating department: a
student’s perspective
Taraneh Azizi
Operating Department Practitioners (ODPs) and theatre personnel have direct

involvement in infection control issues,1 as it is a part of their everyday working
practice. Student ODPs are constantly reminded of the importance of infection
control during their pre-registration training.2 There is distinct and continued
dedication within this area in the academic institutions that provide the relevant
healthcare programmes. Infection prevention and control plays a large part in the
ODP programme but applies to all staff members who work in theatres, which is not
limited to ODPs but also comprises registered and non-registered staff. Surgical site
infections are one of the many types of healthcare-associated infections (HCAIs)
that patients are at risk of contracting following a visit to the operating department,
as patients are at higher risk and are more vulnerable than usual because of the
nature of such invasive procedures being carried out.3
( ^
Write down a list of five activities in your clinical practice that are relevant to
infection prevention and control, and give an example in each activity of what
would be considered suboptimal practice.
J
43
Healthcare students based in the operating department are given a broad exposure
to the implications of substandard infection control. Examples include provision
of statistics relating to HCAIs, the aetiology of infections, the different types of
infection, and preventive methods used in the healthcare environment. The theatre
environment has more considerations than simply undertaking hand hygiene; there
are many wider issues associated with infection control in the operating depart
ment, including surgical hand asepsis, prepping and draping, gowning and gloving,
and instrument decontamination.4
As part of the professional education and clinical training given, student ODPs
are made fully aware of the importance of infection control and surrounding issues.
These include fundamental issues such as personal hygiene, and suitable attire being
worn in and around the theatre environment. In all clinical areas, there should at
least be personal protective equipment (PPE) available such as eye protection and
disposable gloves and aprons at a minimum.5 However, there are also more complex
issues, such as what is considered sterile and unsterile, and within the sterile area
what is considered to be ‘clean’ and ‘dirty’. These are included in a variety of modules
within healthcare programmes to reiterate the application of infection control and
represent them in different areas within their work setting. Therefore, students can
identify the application of infection prevention and control within a variety of areas
aimed at demonstrating best practice that is evidence based.6
Students are given the most current and up-to-date research supported through
healthcare journals and other academic reading material. Infection control is a
pertinent issue in the operating department, as there are severe implications when
infection prevention methods are not followed or best practice is not demonstrated.
Patients who are exposed to a surgical environment are at risk of infection from
the surgery alone, irrespective of the complexity of surgery being undertaken. Part
of the ‘chain of infection’ means that infection can be introduced through various
routes in this environment: invasive monitoring, non-sterile contact, poor ven
tilation and instrument contamination.7 Where potential routes of infection are
controlled and prevented, the highest possible standard of care can be delivered
and patients experience safer surgery.8 Students receive training at taught sessions
at their academic institutions, but they also receive training on placements from
existing staff within theatres.9
Typical daily infection control considerations for the ODP would begin before
the practitioner even enters the department. The practitioner must ensure that
he or she has demonstrated high standards of personal hygiene and washed his
or her hands before entering the theatre suite. Suitable theatre blues and theatre
shoes provided by the department must be worn, and these are not removed from
INFECTION PREVENTION AND CONTROL IN THE OPERATING DEPARTMENT 45
the department.10 In addition, theatre attire is washed at certain temperatures by

linen services for the hospital. All jewellery must be removed, with the exception
of simple stud earrings or a plain wedding band. Hair must be tied up and covered
with a disposable theatre hat, provided by the department. The theatre practitioner
can then enter the operating suite and begin the working day.11
Daily tasks include scrubbing up for surgical procedures, whereby surgical hand
asepsis is carried out before every operation by all staff in the sterile area immedi
ately around the operation site. The first scrub of the day is performed with a nail
brush. Scrubbing up needs to be with a suitable scrub solution and following the
appropriate standards for surgical scrub technique.12 The practitioner will then
gown and glove and approach his or her instrument set, which contains sterile
surgical instrumentation and supplementary swabs, sharps and other countable
items. Some patients may need shaving immediately prior to surgery and selection
of a suitable prep solution for the skin will be required. The theatre practitioner will
assist the surgeon by passing instruments within the sterile area and ensuring the
sterility of the equipment being used during surgery and accounting for all instru
ments, sharps and items used during each operation.13
At the end of the procedure, all items and instruments are accounted for and
all gowns, gloves and waste from the operation goes into the appropriate clinical
waste bag and is removed from the theatre into the ‘dirty’ or sluice corridor.14 The
theatre practitioner then has to clean the theatre before the next patient arrives and,
after all cleaning is completed, hand washing is exercised by all theatre staff before
contact with the next patient. This is repeated depending on the number of cases
in each theatre, but theatres may need time to ‘stand’ or equipment may need to be
removed from the theatre before certain known infected cases.
Each task actually has vast implications for infection control and should be
considered in what is best practice. For example, a part of everyday theatre practice
is scrubbing for surgery. It is not as simple as routine hand washing. Hands must
be kept higher than elbows at all times to ensure that ‘dirty’ solution or water runs
down the arms and not onto ‘clean’ hands. Rinsing must take place in this same
position for the same reasons. The six-step scrub procedure must be followed to
ensure that all areas of the hands are washed with scrub solution. Even drying of
the hands must be done in a certain way; using the opposite hand to dry the other
hand, starting from the hand and working down to the elbow and vice versa on the
other hand with a separate sterile paper towel. Theatre practitioners must always be
aware of where they are and what they are doing, to ensure they are demonstrating
best practice in relation to infection prevention and control. As a student, this is
a lot of information to take on board in the theatre environment. All of a sudden,
there are things you cannot touch or be near because you are considered ‘unsterile’.
This is quite different from any other healthcare environment.
There are a lot of considerations for the theatre practitioner when working in an
operating department. The manner in which sterile supplementaries are opened,
the way that practitioners gown and glove up prior to surgery and many other daily
theatre activities must be carefully considered, to ensure that infection prevention
and control standards are appropriately met.5 This is crucial because surgical site
infections are one of the biggest groups of infections acquired in the healthcare
environment.
Infection control and prevention is a remarkable area in healthcare. Numerous
colleagues and staff members are able to identify times where they have witnessed
poor practice in relation to infection control, and unfortunately these matters
often go unchallenged. Students and newly qualified staff are generally not in a
position to challenge practice that comes from staff more senior to them. Students,
in particular, are faced with the continual challenge of engaging in poor practice
because mentors request that the practice of their students should echo their own.
Students can perceive negative attitudes toward infection prevention and control
from qualified practitioners, and this can impede student learning. This should be
the opportunity to eliminate poor infection control from the operating department
and set the standard for a better future. Mentors should work toward overcoming
barriers to good infection prevention practice.15
From personal experience, I found during my programme of professional edu
cation that students were arriving at and undertaking clinical placements with a
different level of knowledge than some of their mentors. In fact, and as controversial
as it may sound, the knowledge and practice of some students is far superior to that
of their seniors.16 Thus it is important to recognise that learning is and always will
be a two way process where students and their mentors can learn from each other.
For example, personal experience yielded a situation where a theatre practitioner
attempted to demonstrate surgical hand asepsis through scrubbing prior to surgery.
The practitioner was considered a senior member of staff because of the longev
ity of the practitioner’s service, and resulting experience in a variety of areas. The
scrub-up process that the theatre practitioner demonstrated as current practice
(and practice therefore that the theatre practitioner is teaching to students) had
since been superseded by newer and more current techniques. The demonstration
included a scrub time of 5-10 minutes with a surgical scrub solution in at least three
different scrubs. The first scrub was up to and including the elbows, the second
scrub was just below the elbows and the third scrub included the hands and wrists
only. Current guidelines11 state that two scrubs of 2 minutes’ minimum time with
an appropriate antiseptic solution is a suitable scrub procedure prior to surgery.

Although it is not poor practice to scrub for longer than this, new evidence has
suggested that there is no added benefit by scrubbing for longer than 2 minutes.17
The extent to which some registered staff are unaware of current standards
or guidelines regarding infection control is concerning for the students who are
mentored by them. This also has implications for patients where they witness staff
perhaps not carrying out hand washing where they feel the staff should. Patients
reflect positively towards healthcare professionals who are visibly seen to take pre
cautions on hand washing during their care. The practitioner who demonstrated
the dated practice as described earlier is not alone. Infection control awareness
extends to a range of practitioners who work within the operating department. For
example, surgeons have been seen to use alcohol scrub as their first scrub of the
day, and hands are often seen to not be kept higher than the elbows as part of their
scrub technique.18 Similarly, anaesthetists have been seen to not scrub or gown up
prior to a spinal anaesthetic; scrubbing up for a spinal anaesthetic is a crucial part
of best practice during this type of anaesthetic because of the invasive nature of the
procedure. Healthcare assistants have also been seen to not wear hats in the neces
sary clinical areas; the list goes on.
There is a strong element of ritualistic behaviour in localised environments.
Despite ongoing work and more current research around evidenced-based practice
relating to more up-to-date clinical practices, elements of nursing remain tradi
tional. Clinical judgement is being undermined, while routines and rituals seem to
be guiding care pathways. This in effect limits the possibility of positive change.19
Although the issues here are quite complex and change is progressive, the sense of
security that rituals provide overrides practice in clinical areas because of the sense
of security that rituals and traditions provide to nursing staff.
r ;
Consider a student practitioner of a different discipline within health and social
^
care. Give an example of an additional issue regarding infection prevention and
control that you think affects the student in his or her particular specialty.
V__________________________________________________________ J
From a student perspective, it is disappointing to have experiences in clinical
practice that are so different to what is being taught at university. The conflicting
teachings are inconsistent with one another, and it can be confusing and challenging
for students to accept what, in fact, is best practice. Students need more consist
ency and clarity with infection control. All staff who work in theatres need a much
stricter and better-defined record of continuing professional development that will

document competency and knowledge relating to infection control in their work
environment on a regular basis. The e-learning systems that are currently available
are not an effective method of recording regular updates.20
In an alternative placement, personal experience has identified other infection
prevention and control issues that are equally important, outside of the operating
department. In a ward setting across an emergency care centre and a clinical deci
sion unit, the practice of practitioners is much more open and practice feels, to an
extent, under continual scrutiny. This appears in the form of relatives, colleagues
and infection control link nurses. Personally, it was evident that this feeling of being
watched made the practitioner more aware of their practice and particularly at times
when the practitioner was in the presence of others.
In the ward environment, the student practitioner is introduced to an environ
ment that is very different to the familiarity of an operating theatre. The concern
of strict surgical asepsis and sterility is diminished, and replaced by the seemingly
basic tasks of everyday ward nursing. This includes changing bed linen, assistance
with personal care and use of commodes. As a student, the change in environment
was incredibly challenging from an infection prevention and control perspective.
There was an incident where an infection prevention and control link nurse
performed a routine inspection on the ward that resulted in the student practi
tioner being identified as demonstrating incorrect infection control practice. The
task being performed was a bed linen change, a task that distressed a patient due
to pain on movement. Therefore, the bed linen had to be changed with the patient
still on the bed, and this was achieved by the patient rolling from side to side while
the linen was changed by two attending practitioners: the student and a healthcare
assistant. The patient was calling out in pain during the process, and so the bed was
changed quickly to avoid further distress to the patient. When the bed was changed
and cleaned down with sanitising wipes, the student practitioner then took the
linen from the patient’s bedside over to the nearest red laundry sack. The infection
control link nurse witnessed this action and pulled the student to one side, explain
ing that this was not the correct way to have performed that particular task. It was
explained to the student practitioner that to avoid spreading potential infection,
any used bed linen is considered as soiled, and therefore a suitable laundry sack
should be moved to the patient’s bedside, rather than transferring dirty linen across
the ward to the laundry sack.
It was not that the student practitioner was not aware of how to perform this task
to the accepted standard; rather, the priority for the student at that time had been
to minimise the distress to the patient, and infection prevention and control was
potentially compromised by this action. This is an example of how a fundamental

task performed on a daily basis can have implications for infection prevention and
control. In this instance, the student practitioner had followed what other qualified
staff on the ward had been doing, and this shows how important the student/mentor
learning relationship can be in influencing infection prevention and control in the
future. It can be confusing for students who are trying to balance what they have
been taught at university with what they are told to do in practice; often there is a
conflict between the two, which should not be occurring in modern-day practice.
Infection control is a practical part of everyday practice that is clearly not being
adhered to and prevention is a core element of patient safety. Monitoring of continu
ing professional development is essential in providing safer healthcare practices.21
( ^
Your mentor demonstrates to you how to perform hand hygiene and then asks
you to copy the practice. The hand hygiene that your mentor demonstrates is not
what you believe to be in line with local policy and the evidence-based practice
you have been taught on your course. What do you do?
V______________________________________________________________ )
SUMMARY
Student healthcare practitioners should be taught the most current and highest
standards of infection control practice, relating to evidence-based practice sup
ported by a number of academic resources. This requirement is often inconsistent
with the experiences of students on clinical placement, and this has the potential
to affect the future practice of these students as registered healthcare practition
ers. Ultimately, this affects patient care, treatment and outcome. Students can be
exposed to poor practice on a regular basis and so need more support from senior
staff, especially when presented with conflicting practices from mentors. Teaching
staff thus need to ensure that they are current and up to date with evidence-based
practice and guidelines that are in line with the academic content from the student’s
university or college. Hospital trusts need to review infection control training and
competency of their staff to ensure that patient safety is not compromised.
( A
Taraneh Azizi has now been qualified for 2 years and is working as a registered
ODP in the main theatre department at the Royal United Hospital in Bath.
V___________________________________________________________ )
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1. Williams M. Infection control and prevention in perioperative practice. J Perioper Pract.
2008; 18(7): 274-8.
2. Harvey P. Role of the mentor in the theatre setting. J Perioper Pract. 2012; 22(7): 232-6.
3. Wilson R. Minimising the spread of infection in the operating department. J Perioper Pract.
2012; 22(6): 185-8.
4. Wilson J, Loveday H, Hoffman P, et al. Uniform: an evidence review of the microbiological
significance of uniforms and uniform policy in the prevention and control of healthcare-
associated infections. Report to Department of Health (England). JH ospInfect. 2007; 66(4):
301-7.
5. Pratt R, Pellowe C, Wilson J. National evidence based guidelines for preventing healthcare
associated infections in NHS hospitals in England. J Hosp Infect. 2007; 65(Suppl. 1): S1-64.
6. Gopee N. Mentoring and Supervision in Healthcare. London: Sage; 2008.
7. D am ani N. M anual o f Infection Control Procedures. 2nd ed. Cambridge: Cambridge
University Press; 2003.
8. Al-Benna S. Infection control in operating theatres. J Perioper Pract. 2012; 22(10): 318-22.
9. Richmond S. Minimising the risk of infection in the operating department: a review for
practice. J Perioper Pract. 2009; 19(4): 142-6.
10. Sivanandan I, Bowker K, Bannister G, et al. Reducing the risk of surgical site infection.
J Perioper Pract. 2011; 21(2): 69-72.
11. Association for Perioperative Practice (AfPP) Standards and Recommendations fo r Practice.
Harrogate: AfPP; 2011.
12. Dougherty L, Lister S, editors. The Royal Marsden Hospital Manual o f Clinical Nursing
Procedures. Oxford: Wiley-Blackwell; 2011.
13. Wicker P, O’Neill J, editors. Caring fo r the Perioperative Patient. 2nd ed. Oxford: Wiley-
Blackwell; 2010.
14. Department of Health. Health Technical Memorandum 07-01: safe management o f healthcare
waste. London: Department of Health; 2006.
15. Ward D. Attitudes towards infection prevention and control. BMJ Qual Saf. 2012; 21(4):
301-6.
16. Azizi T. Young person advisor to the AfPP board. AfPP Newsletter. September 2012.
17. Weaving P, Cox F, Milton S. Infection prevention and control in the operating theatre: reduc
ing the risk of surgical site infections (SSIs). J Perioper Pract. 2008; 18(5): 199-204.
18. Pirie S. Hand washing and surgical hand asepsis. J Perioper Pract. 2010; 20(5): 169-72.
19. Zeitz K, McCutcheon H. Traditions, rituals and standards, in a realm of evidence based
nursing care. Contemp Nurse. 2005; 18(3): 30 0 -8 . Available at: www.contemporarynurse.
com /archives/vol/18/issue/3/article/2101/tradition-rituals-and-standards-in-a-realm -of
(accessed 13 September 2013).
20. Drayton S. The Advantages and Disadvantages o f eLearning [blog]. BusinessZone; 13
August 2013. Available at: www.businesszone.co.uk/blogs/scott-drayton/optimus-sourcing/
advantages-and-disadvantages-elearning (accessed 23 September 2013).21
21. Association for Perioperative Practice (AfPP). Foundations in Practice. Harrogate: AfPP;
2010.
C H A P TE R 5
The lament
Harley Farmer
The nightingale’s beautiful song is sung because life isn’t going to plan for the bird,
despite its best efforts. The song we cherish is a voice of anguish, a lament. It’s a
message to others of its kind, yet singing at night exposes the nightingale to attack
by predators. The message is fine but when it helps predators, the outcome can be
problematic. Healthcare professionals, including infection control professionals
(ICPs), use peer-reviewed journals to convey their desire to improve outcomes for
patients. The message is fine but when it helps antagonistic lawyers, the outcome
can be problematic. Is there a useful analogy between the nightingale’s song and
the healthcare-associated infection (HCAI) profession’s literature when both gen
erate exposure to threat? I believe so. The nightingale is not going to change, so it
will remain exposed. Change is something the HCAI profession has to use with
due caution, as change can bring new dangers. In this chapter, I will suggest failure
to change presents a greater danger than change. For years ICPs and others have
developed new approaches and products to break HCAI cycles. Regrettably, the
‘system’ prevents us from fully achieving the aims. Despite our best efforts, many
people still die from HCAIs, leaving ICPs with a need to explain why. My novel The
R eaper’s Rainbow1takes an understanding of HCAI cycles to the public. Questions
woven into the plot bring readers to the realisation that they can play their part in
protecting themselves from infections. For a long time they’ve been told to ‘wash
your hands’ but few do it. The novel delivers a new perspective, allowing them to
realise the advantages of change. I favour asking questions, as questions deliver
answers. Without the right questions, the right answers remain hidden. Sometimes
the right questions can be challenging, and those in this chapter are offered to ICPs
in that light.
51
It can help to view intractable problems such as HCAIs from a different per
spective. Using simple psychology tools such as reframing and strategic visioning,
I ask people to visualise HCAIs as being very rare. Rather than hoping the deaths
could be reduced by even 50%, which would still leave thousands of deaths every
year, what if we started at zero and concentrated our efforts on the few that would
inevitably happen? The commonest question this induces is: how? It’s a good ques
tion that reliably exposes boundaries and limiting beliefs. I ask you to rearrange
the letters in how to make who. Throughout this chapter, whenever you want to ask
how? try, instead, asking who? How tends to highlight barriers, while who usually
increases resources.
REFLECTION EXERCISE 1
Give yourself a moment to consider those times when you knew what could
be done to improve patient safety but you found you had too few resources to
take the positive action. How different would things be now if you’d had those
resources then?
Considerable progress is being made in infection prevention with the introduction

of internationally accepted best practices. There are too many to mention here, so by
way of example I will place emphasis on the use of hand rubs. ICPs justifiably point
to successes such as meticillin-resistant Staphylococcus aureus (MRSA) infections
now being less prevalent in Britain than infections due to meticillin-susceptible
S. aureus (MSSA). Congratulations are due, when viewing from the technical per
spective of ICPs. Now consider how it looks from the viewpoint of a family bereaved
by an MSSA infection. Changing R to S and congratulating ourselves matters little
to them: their loved one is dead. Do we attempt to point out how much better it is
that their loved one died from an antibiotic-susceptible bacterium because we’ve
achieved pleasing success against the antibiotic-resistant equivalent? No. We quietly
lament in the knowledge that MSSA is a natural part of normal skin flora and pre
dates the introduction of antibiotics. It has always been a potential pathogen, even
though the introduction of antibiotics brought MRSA into greater prominence. Did
patients who have died from HCAIs enter the hospital with the expectation of only
being protected against MRSA? No, they rightly expected to be protected against
infection from all pathogens.
THE LAMENT 53
DEBATES
There are three simultaneous but distinct debates occurring. ICPs can feel buoyant
in the technical debate. However, we are judged in the outcom e debate when people
continue to die from infections. It’s easier for the public to remember the person
who went into hospital for a toe operation and died from infection than it is for
them to remember our lengthy proclamations on best practices. In the outcome
debate, you may well hear the question, ‘How bad are these best practices?’ The
enormous cost of HCAIs mean the fin an cial debate is also disconcerting. Those
three debates - technical, outcome and financial - are ongoing.
[ F:inancic >' ]
. .
FIGURE 5.1 Three simultaneous but distinct debates
When most emphasis is placed on the technical debate, less attention is given to
the outcome and financial debates. In actively partaking in all three debates, I’ve
heard some interesting questions and have raised more of my own, including those
presented here. The answers to those questions suggest a lot more can be done to
avoid HCAIs. The references cited in this chapter justify that statement. There are
complicating factors such as poor adherence to practices and anionic cleansing
products chemically inactivating cationic antimicrobial products. If those known
weaknesses are inherent in our best practices, can those practices really be deemed
entirely fit for purpose? The many peer-reviewed articles highlighting areas where
improvements can be made suggest not. Was a family bereaved by an avoidable
HCAI best served by current best practices? No.
Take some time to examine the ingredients in the cleansing and antimicrobial
products used in your facility. Pay particular attention to whether anionic (nega
tively charged) and cationic (positively charged) ingredients are ever likely to be
used on the same surface, providing the chance to inactivate each other.
Most HCAI discussions focus on the technical debate. That would seem reasonable,
as it’s essential to know whether a product kills pathogens. In the outcom e debate,
people assume the products can kill microbes and ask why those microbes are still
killing people? In the technical debate the focus is on microbes dying; in the outcome
debate it’s on people dying.
CONFLICT
Wouldn’t you agree those two debates appear to be opposites and it would be helpful
to reduce the conflict? If so, an obvious question is how? That has always revealed
barriers. Try who? Are there people wanting to help, who haven’t been engaged yet?
Yes, millions of them. They’re the public, especially those who’ve become patients.
It’s the patients who develop the infections, perhaps introducing a perspective that
patients are the problem. Would it be useful to turn that problem into the solution?
Do patients have spare time, do they bring a collective wealth of experience and
do they have a personal interest in avoiding lethal infections? Yes; and they don’t
require payment! Half the people in most hospitals are patients - a massive, largely
untapped, human resource.
Another large group in hospitals is healthcare workers. They must be paid, mak
ing them an expensive resource. Does it make sense to look after them as best we
can? Yes, but does that happen with current best practices? Let’s explore one exam
ple. Imagine if alcohol hand rubs had never been introduced. What would happen
if, in these times of valid health and safety considerations, someone suggested the
hands of staff should be doused in a flammable solvent numerous times every day?
Laws would prevent any employer introducing such hazardous technology. Yet that
is one of the actions that best practices advocate. If it’s so wrong, why is it done?
A technical answer is that alcohol on hands kills superficial transient bacteria.
One counterargument from the outcom e debate is to ask whether alcohol hand
rubs were a major part of the infection prevention strategy throughout the global
MRSA epidemic? Could it be that alcohol hand rubs are not stopping lethal bacterial
THE LAMENT 55
infections? Are numerous lethal bacterial infections happening while alcohol hand
rubs are readily available? Arguably, yes is the answer to all three questions. Nobody
knows how many patients have been saved by alcohol hand rubs, but evidence from
hospitals around the world shows how many patients died from bacterial infections
while alcohol hand rubs were at their bedsides. Obviously, alcohol hand rubs are
only one component of an overall infection prevention strategy, but if one compo
nent that is given such prominence can be challenged so easily, the whole system
becomes open to challenge.
Evidence-based research is the basis of best practices, yet any HCAI death sug
gests evidence of failure to protect that specific patient. ICPs who advocate alcohol
hand rubs can counter by saying that the problem lies with staff not using the rubs.
That’s a valid technical riposte, so let’s investigate this poor compliance. Chronic
hand eczema (product-related dermatitis on the hands) is well known among
healthcare workers.2 Is it reasonable to expect a person with hand dermatitis to
apply a flammable solvent to their damaged hands? No. Is there evidence-based
research of poor user compliance rates of alcohol hand rub usage? Yes.3 Yet, we fail
to care for those damaged hands when we give alcohol hand rubs great priority in
best practices to prevent HCAIs. On this basis, is the term ‘best practices’ looking
more like the ‘best o f current practices’?
What is the incidence of chronic hand eczema (product-related dermatitis on

the hands) among the healthcare workers in your facility? Is special provision
allowed for them to use effective non-alcohol hand rubs that are deemed to
be non-hazardous by your occupational health team? If so, why can’t the non
hazardous rub be used by everyone in the facility?
THE ATTACKERS
Now for the really challenging questions ... the attacker will be a lawyer whose
questions may be biased toward unreasonable answers because the lawyer is more
interested in a specific legal outcome than any technical niceties. Is all this evidence-
based research freely available to lawyers acting against hospitals in cases of lethal
HCAIs? Is it reasonable to assume a lawyer could convince a jury that all this evi
dence was known by the ICP who advocated the use of alcohol hand rubs in the
hospital where the HCAI victim died? Could it be argued that the ICP knew there
was poor user compliance of the alcohol hand rub and that might have played a
part in the failure to save this victim’s life? Despite that, did the hospital’s ICP still
advocated its use? Yes, answers to questions like that favour attack. Some of those
questions are undoubtedly unfair from the ICP’s technical perspective, but the
lawyer’s aim is to influence the jury of a poor outcome from the deceased patient’s
perspective. This will not be a balanced debate; fairness should not be anticipated.
The nightingale’s lament exposes the bird to attack by predators. Researchers and
those working for healthcare providers assiduously present their evidence-based
research to the world, embellished with their anguish. Their data, their lament,
shows that many patients continue to die from HCAIs. Lawyers are poised to attack
and anyone who relies on a ‘best practice’ defence exposes themselves.
Evidence-based research in peer-reviewed journals in the medical, health and
social care literature is the basis on which best practices are based. That provides
comfort and support from the technical viewpoint. It shows we know our current
limitations. Now let me demonstrate how easily that same literature can assist
aggressive lawyers. During a 3-hour search in the Journal o f Hospital Infection, I
found the following facts and statements:
• Hand hygiene compliance remains poor3
• 54% followed infection control measures only when they perceived an infection
threat to themselves4
• HCAIs are seen as major safety issues at a global level by the World Health
Organization5
• It is unlawful for a public body to act incompatibly with a person’s rights6
• Providers and commissioners of English NHS care are now under a legal obliga
tion to have regard to the NHS Constitution, which establishes a patient’s rights6
• Compliance with good practices is generally poor7
• Staff generally cleaned their hands after clinical examination, presumably
because protection of self seems to be the obvious trigger for performing hand
hygiene, and not protection of patient.8
These are extracts from just one of the many well-respected journals, the very
material on which current best practices are based. Could a lawyer argue that cur
rent best practices are actually the best o f fa iled practices? Around the world, tens
of thousands of patients die from HCAIs every year. Might this be why the legal
aspects6 also appear in medical literature? The legal challenge was a major element
of the textbook that preceded Elliott’s work,9 So I believe it is well established.
THE LAMENT 57
Take a while to determine how often in the previous year those who manage
your facilities needed to give due consideration to legal challenges related to
poor patient outcomes. Are you able to take action to reduce the incidence of
poor outcomes?
So far in this chapter, of the many components of an overall HCAI prevention

strategy, only alcohol hand rubs have been discussed. It’s fairly easy to see how a
lawyer can use the evidence-based research to lead a jury into taking a perspective
contrary to that of researchers, health providers and their staff. The latter gener
ated and implemented the data as a means of showing what they believed needed
to be improved. If it can be shown they continued to advocate the use of alcohol
hand rubs in the face of all this evidence of failure, the jury could be easy to influ
ence. Remember, the excellent points used in the technical debate might have little
relevance to jurors who learned much of what they know about infections from
the media. The press sensationalises the poor outcom e from hospital infections,
so that’s where an attacking lawyer could begin. The legal arena is not one where
the best technical debate wins; it’s one where a group of lay jurors could be asked
to decide what led to the very poor outcome in one specific lethal HCAI case. ICPs
have helped compile the published data as they seek to steadily improve outcomes.
While the latter is happening, the very same data prove current outcomes are poor
and that can only happen if best practices are failing patients who become infected.
Returning to the example of a lethal MSSA infection, the jury could well accept
a technical statement that alcohol hand rubs kill MSSA. However, this hypothet
ical court action is only happening because a patient died from MSSA infection. If
the alcohol was not to blame, who or what was? A lawyer could make a case that
healthcare providers, their management and ICPs head that list.
Give yourself a little space to compare your perspectives with those of your
patients and their families. Might you feel their expectations are unrealistic in
these times of modern intrusive healthcare? If so, how would you attempt to
enhance their appreciation of your realities?
The threat to ICPs is the very evidence-based research they help to compile and
publish. That’s unfair from the technical angle but perfectly justifiable in both the
outcom e and financial debates. It’s all a matter of perspective.
CHANGE IS SAFER
If researchers, healthcare providers and ICPs continue with current best practices
and continue to achieve the same results, they could be targeted with their own
data in this manner. For too long, ICPs have concentrated on the technical debate
and have achieved results that many people, including themselves, consider to be
inadequate. That’s why they strive to improve patient safety. Rather than abandon
ing the technical debate, they’ll benefit from encompassing the outcome debate to
find a completely different way of addressing the problem. As an example, refram
ing the patients from being part of the problem to being part of the solution will
improve the chances of success. That simple step will reveal ways of positively using
all their valuable evidence-based research to protect patients. The first step is that
easy. Encompassing the financial debate in the same manner makes it even easier,
as that adds much needed financial resources.
When ICPs change their perspective and begin to visualise HCAIs as very rare
events, they’ll find matters evolve quickly. When that happens, this chapter will
have achieved the objective of breaking the HCAI cycles. Patients will have helped
when they were incorporated into the who, but most of the credit will rightly go
to ICPs whose new perspective allowed the patients to better defend themselves.
If little changes, most of the blame will continue to be directed at the same pro
fession, and rightly so. Social media is now firmly established. Failure to change in
the face of poor outcomes is now more hazardous than change. If you feel embat
tled, staying where you are while publicly lamenting the poor patient outcomes is
the most dangerous option. Since your adversary knows of alternatives that can be
argued to be safer for patients and better for staff, you can be asked to explain why
you didn’t utilise those choices that were clearly available. Citing World Health
Organization paperwork and peer-reviewed articles containing evidence-based
research will be a weak defence. Remember, if the answers were there, you would
be using them and this hypothetical court case would not exist.
Consider another question. If you were forced, in court and under oath, to say
whether all the answers needed to end HCAIs were in the medical literature, what
would you say? This question is a nasty trap. If you say that the answers are there,
you can be asked why you had not utilised them to protect the patient who died. If
you say that they are not there, you can be asked to explain why you advised your
THE LAMENT 59
hospital to use practices that your profession’s own evidence has shown were failing
many thousands of patients every year.
Now for the good news! Moving on from this trap, and many others like it,
requires little effort. The three debates have been presented as separate conflicting
entities and the lawyers capitalise on that conflict. When you completely encom
pass all the debates and overlap them, you’ll find enormous resources. Remember
that nobody wants the infections, including the lawyers who know how easily they
could become patients. They would prefer you to break the HCAI cycles before they
encounter them in person.
Technical
Outcome
Financial
FIGURE 5.2 One single but larger debate in which all the resources are available
Once you genuinely begin to envisage HCAIs being very rare events, you’ll have
virtually everyone on your side. If you’re not genuine and hope to play the public
for fools, consider how many people will not be on your side. The public now know
the choice is between very few infections or thousands of needless HCAI deaths.
SIMPLE ACTIONS
What can be done now to make a real difference?
• Actively challenge paradigms. As an example, is alcohol actually the best choice
for hand rubs?
• Test whether your products and practices are fit for purpose. Considering
alcohol again, is your primary purpose to follow best practices or to safeguard
patients?
• Act on the real problem. Gram-negative bacteria have always been the biggest
killers, yet hasn’t more effort gone into MRSA because of press coverage?
• Appreciate that reducing infections in the current manner takes time. Consider
how long it took to halve the incidence of MRSA infections in Britain. The sec
ond is always harder and is likely to take longer. What will you say to a newly
bereaved family during that time? Be patient?
• Advance beyond the constraints of best practice and technical thinking by also
encompassing outcom e ideas. You will be joining an already active resource of
like-minded people known as patients.
• Seek safety in numbers by working with patients and the public. Until then you’ll
remain the minority, exposed to easy attack.
• Appreciate that healthcare workers’ hands are the principal carrier of transient
pathogens, so to concentrate on them is to put less emphasis on the source, the
patients. Once patients become part of your solution, you’re finally addressing
the source.
• Consider answers outside peer-reviewed literature. You know the answers you
need are not all there, or you would be using them. Nor will they be there until
people like you ask the appropriate questions. Those questions are frequently
asked in the outcom e debate, accompanied by helpful answers you can easily
implement.
The answers you seek are available because the relevant questions have already been
asked. Your life would be so much easier if you had those answers among your
resources, don’t you agree? Virtually everyone wants to be on your side. Wouldn’t
allowing them to help reduce your anguish and end the lament?
REFERENCES
1. Farmer H. The Reapers Rainbow. Cambridge: NewGenn; 2009.
2. Lampel HP, Patel N, Boyse K, et al. Prevalence of hand dermatitis in inpatient nurses at a
United States hospital. Dermatitis. 2007; 18(3): 140-2.
3. Smith SJ, Young V, Robertson C, et al. Where do hands go? An audit of sequential hand-
touch events on a hospital ward. J Hosp Infect. 2012; 80(3): 206-11.
4. Farrugia C, Borg MA. Delivering the infection control message: a communication challenge.
J Hosp Infect. 2012; 80(3): 224-8.
5. Cookson B, Mackenzie D, Coutinho AP, et al. Consensus standards and performance indica
tors for prevention and control of healthcare-associated infection in Europe. J Hosp Infect.
2011; 79(3): 260-4.
6. Millar M. Patient rights and healthcare-associated infection. J Hosp Infect. 2011; 79(2):
99-102.
7. Pittet D, Panesar SS, Wilson K, et al. Involving the patient to ask about hospital hand hygiene:
a National Patient Safety Agency feasibility study. J Hosp Infect. 2011; 77(4): 299-303.
8. Dancer J. Infection control ‘undercover’: a patient perspective. J Hosp Infect. 2012; 80(3):
189-91.
9. Elliott P, editor. Infection Control: a psychological approach to changing practice. Oxford:
Radcliffe; 2009.
PART II
Perceptions of infection
C H A P TE R 6
Stereotyping
Paul Elliott
In presenting this chapter my aim is to get you thinking about stereotypes, which
will always inevitably be linked to the prejudices and attitudes each of us holds, and
of course there consequences to ourselves and others.1 I will aim to do this both
within a general context and specifically with regard to Infection Prevention and
Control (IP&C). It is my further intention that this chapter will not be excessively
academic in nature but, rather, thought provoking.
( ^
LIST 6.1 Everyday stereotypical situations
Consider the following examples.
• You are in a supermarket waiting in line to check your goods out but the per
son in front of you is moving slowly and not packing their goods as quickly
as you would wish or as quickly as you would expect them to do. Do you
become frustrated at this? If this has been the case consider what thoughts
you may have had about this individual. What perhaps have you muttered
about them under your breath or to someone who may be with you in the
queue?
• Have you ever seen another individual behave in a certain way that, to you,
made no sense or may even have seemed completely bizarre? If this has been
the case, what determinations did you make about this person?
• Have you ever been driving a motor vehicle and another individual has done
something to distract you or has caused you to feel, shall we say, somewhat
upset? What was your reaction?
J
63
So, to start with I would like to ask you to think about and make a list of stereotypes
you hold. Should you start by questioning whether or not you have any, you are
frankly fooling yourself! Everyone has and applies stereotypes in their day-to-day
life as a way of helping them to make sense of the world within which they interact
(List 6.1).
Whatever your reaction to the examples in List 6.1, they will have been drawn
from stereotypes and are likely to have been insulting and/or derogatory (List 6.2).
( 'N
LIST 6.2 Stereotypical reactions
• Supermarket:
— For goodness sake get a move on! Silly old fool!
— People who pack that slowly should be in care!
• Bizarre behaviour:
— What an idiot!
— Are they thick or something!
• Motor vehicle:
— Perhaps in this situation you composed a string of short singular words or
made reference to certain aspects of the individual’s anatomy!
— Perhaps in this situation you chose to elicit certain hand gestures that may
involve a number of fingers!
V______________________________________________________________ J
In considering this, a question I would pose is: how do you define, for example, the
terms fool, thick or, for that matter, making reference to the individual’s anatomy in
a derogatory way? With regard to each of these I would suggest they are connota
tions related to the notion of an individual’s intelligence.2
At this point I would like to ask you to write down, without referring to any
literature or seeking another’s opinion, your definition of intelligence. Having done
this please take some time to reflect upon whether you perceive intelligence to be a
single characteristic or a range of multiple characteristics and then read on.
In reality intelligence is not something that can or should ever be defined in a
singular way,3 as is the case with that contained within List 6.2. Even intelligence
quotient tests, which are taken by some as objective measures of an individual’s
intelligence, should only at best ever be perceived as a subjective guide, as there
remains much debate regarding what such tests actually measure and whether or
not they truly measure human intelligence at all.4
Arguably intelligence can be perceived as many different things in relation to the
STEREOTYPING 65
f \
LIST 6.3 Variables that serve to facilitate stereotyping
1. We tend to accept and rationalise6 in a cognitively economic way7 what is
set before us in a subjective as opposed to an objective way. Where the
concepts of subjectivity and objectivity are concerned I would suggest to you
that humans are incapable of being objective about anything. Why? Because
an individual’s perception of the behaviours of others is and will always be
drawn from their own past experiences, which may differ from the experi
ences of the individual they are applying a stereotype to.
2. Each individual’s perception or definition of what constitutes intelligent behav
iour can be as broad as it may be long. For example, with regard to the speed
at which one individual is able to pack their goods in a supermarket queue
is not indicative of the speed at which another could or is able do so. Nor is
the ability to pack goods in any way a good measure of intelligence. Yet, this
is a classic situation where individuals will be likely to apply their concept of
intelligence or lack of it to others through the stereotypes they invoke.
3. The beliefs an individual holds about what should or should not constitute
normal behaviour is likely to facilitate the application of stereotypes. However,
these can be highly subjective, in that where the concept of normality is
concerned there is no universal definition. Yet, in observing the behaviour
of others one of the ways in which we make sense of such is by drawing
upon our beliefs. For example, behaviour taken within a health or social care
context can lead health and social care professionals to make decisions
based upon what they observe others doing, which in turn tends to lead to
the formulation of a belief about a given individual. However, such beliefs are
likely to be intuitively based (Figure 6.1) and also drawn from stereotypes
that the health or social care professional holds. However, such beliefs are
arguably a consequence of our prior learning, which can, for example, be
family, culturally, peer group or professionally based. The other point I would
make about beliefs and their ability to facilitate the application of stereotypes
is that human observation of any kind is highly suspect. A classic example of
this is related to what is known as eyewitness testimony.8 For example, if you
and a colleague were to observe the exact same event together at exactly
the same moment in time, how likely would it be that you would both relate
what you saw in exactly the same way with the same degree of accuracy?
The chances of this happening would be questionable.8Thus the application
of stereotypes through what we observe are generally unreliable in making
judgements about others. A very good way of thinking about this is through
an adaptation of the Cognitive Continuum 9 (Figure 6.1), where beliefs and

stereotypes would be intuitive (Level 6). Any judgements or decisions that are
formulated on intuition alone are neither valid nor reliable, and where infection
prevention and control is concerned would be inherently unsafe.
V___________________________ ______________________________ J
knowledge and/or skills an individual possesses.5 Further, it could be argued that

types of intelligence are infinite with each individual’s range of intelligences being
multiple and unique to them.5 Where intelligence and an individual’s behaviour
are concerned, that individual’s behaviour is arguably never random but is always
the result of a given stimulus resulting from a physiological, psychological or social
experience. In the case of the examples set out within List 6.1, those individuals
would have behaved in the way they did for a reason. However, just because others
cannot determine that reason or it is not immediately apparent, the application of
stereotypes, which may serve to ridicule or be prejudicial of a person’s intelligence,
are not warranted. As such, instead of stereotyping individuals, what we ought to
do is look beyond the obvious and pose the question, why? The problem is of course
that human nature is such that with regard to looking beyond the obvious there are
three variables that could serve to restrict this (see List 6.3).
Published material stereotypes
Clinical evidence stereotypes
Reflection stereotypes
Equipment stereotypes
Peer group stereotypes
Intuitive stereotypes
FIGURE 6.1 The Stereotype Continuum9

STEREOTYPING 67
In essence, where stereotypes are concerned one individual’s intelligence is argu

ably another’s stupidity, with the stupidity element generally being related to the
individual expressing a stereotype.
CLARIFICATION OF LEVELS WITHIN FIGURE 6.1
Level 1
To accept without question what is published as correct and/or will make an
effective contribution to the practice of IP&C is to adopt a stereotypical per
spective. For example, to assume that a journal where something is published
is indicative of an article’s quality and its potential for facilitating safe practice is
arguably not only a stereotypical perspective but also indicative of intuitive level
thinking and decision making. It is the content and applicability to the provision
of good, safe, health and social care intervention that matters and not where it
has been published, or for that matter who wrote it. From a safe practice per
spective, I would argue that if a publication has no application to the real world
of IP&C it is of questionable value.
Level 2
To accept without question that because a clinical procedure has always worked
in the past it will continue to work and be safe constitutes a stereotypical perspec
tive. With regard to IP&C, the chain of infection has been colloquially accepted
as a valid and reliable measure for assessing the risks of cross- infection. Yet, I
would argue that such acceptance is inherently flawed, because there appear to
be no empirically based findings to support either the development of this chain
or to what degree it contributes to any reductions in cross-infection. Further, this
chain only tells one-third of the story where the assessing of cross-infection risks
are concerned. Thus the continued acceptance of the chain of infection in its
current format does in itself constitute a stereotype, because it fails to recognise
the psychological and social factors that constitute the other two-thirds of the
story and which will also contribute to the potential for cross-infection to occur.5
The chain of infection

• Infectious agent
• Reservoirs
• Portals of entry
• Portals of exit
• Susceptible host
• Mode of transmission
Level 3
Reflection is by its nature a subjective process whether it be in action or on
action, and as such it is likely to be subject to stereotypical influences. If a
practitioner were to rely simply upon their reflective thoughts, judgements and
decisions, this would inevitably increase the risk of questionable IP&C practice.
NB: Reflection that is in action is where an individual is reflecting as event occurs
in real time. Reflection that is on action is where the individual is reflecting after
the event has occurred.
Level 4
Equipment is designed and produced by people who are both human and fallible
and can therefore have the potential to fail and/or provide unreliable protection
where infection prevention and control is concerned. For example, there is pub
lished literature to indicate that hand hygiene should be undertaken both before
and after the wearing of gloves10 because as a piece of equipment they may not
guarantee 100% protection. However, it is notable that Rock et al.11 appears
to suggest that hand hygiene before the application of gloves may not always
be necessary in some situations. However, a potential counterargument to this
could be that contamination is not unidirectional in its flow but multidirectional,
in that it can be passed both ways, between practitioner and other individuals
and vice versa. Choosing not to undertake hand hygiene before putting gloves
on would seem not to take account of any contamination already on the hands
of the practitioner. Although the evidence presented by Rock et al.11 is interest
ing, my concern would be that such a view could lead to intuitive-level decision
making (Figure 6.1) and complacency, which could in turn lead to an increased
risk of cross- infection. In essence it should never be assumed that a piece of
equipment will give 100% protection where the potential for cross-i nfection is
concerned.
Level 5
Infection prevention and control practitioners transmit large amounts of infor
mation, verbally, non-verbally or in writing between one another. Yet, what has
to be remembered is that when the transfer of such information takes place,
stereotypes are likely to come into play. When passing information on, the indi
vidual will transmit the information that they believe is relevant and what others
STEREOTYPING 69
ought to know. However, what the individual thinks others ought to know is not
necessarily what others really need to know. For example, cast your mind back
to an interaction where you were receiving information from a colleague about
a patient and initially it seemed that you had been provided with all relevant
information. However, when you encountered the patient it very quickly became
evident that you had in fact not been given all relevant information but that there
were gaps in what you had been told. Thus the individual giving you the informa
tion had stereotyped what they perceived was important and you ought to know
about the patient. Based upon the information you had been given, you would
have started to determine what you perceived your role to be with the patient
until you realised that you had not been given all the information. Subsequently
you then had to cognitively reappraise the situation to reduce the potential for
harm or cross- infection to occur.
Level 6
Intuition, or gut feeling as it is more often referred to, has the same subjective
stereotypical potential as reflection, except to a greater degree where the insti
gation of safe IP&C practice is concerned. In essence, intuition or gut feeling
could be described as, in the absence of objective evidence, making it up as
you go along! For example, although the feelings we have may be drawn from
past experience (our knowledge base) to apply such in isolation would serve to
constitute a stereotypical approach to IP&C practice based on the assumption
by an individual that their knowledge base is up to date, correct and safe which,
of course, is not always the case.
Summary
Each of Levels 1-6 (Figure 6.1) taken in isolation can only be perceived as serving
to facilitate unsafe IP&C practice. What every practitioner should do where IP&C
is concerned is to take each of the 6 levels, as the word continuum indicates.
Thus, practitioners should be combining and applying several levels at the same
time, while moving up and down all levels of the continuum on a continual basis,
if their practice is to be potentially safe.
V___________________________ ______________________________ J
Where individuals have applied stereotypes either intentionally or in the heat of
the moment they may, following such, experience feelings of stress, anxiety, anger,
embarrassment or fear of retribution and will thus attempt to justify such stereotypes
through dissonance-based rationalisations.5,12 For example, if you were to witness
an incident or accident where an individual was clearly in need of your professional

intervention but you chose not to make such an intervention and to simply pass by
or ignore the situation, you might, if recognised, find yourself subject to investiga
tion from your professional or regulatory body as a result of an act of omission on
your part. In reflecting upon this in terms of Freud’s model of the human psyche
(Figure 6.2), your Id (your basic desires - what you wanted to do or did) would be
in conflict with your Superego (your moral conscience - knowing what you should
Conflict occurs
The Id The Superego
An individual’s basic desires An individual’s moral conscience
an individual’s stress the Ego

mediates between the Id and
the Superego
Outcomes
This mediation process can result in a number of potential outcomes:

Rationalised as opposed to rational excuses
Intuitive stereotypes
Unrealistic beliefs
Prejudicial attitudes
FIGURE 6.2 A model of the human psyche (adapted from Atkinson e t al., 2011)13
STEREOTYPING 71
have done) and would arguably be manifested as feelings of stress. Therefore, in

striving to alleviate any degree of stress you might experience, your Ego (the media
tor between your Id and Superego) would seek to resolve such conflict that exists,
through the establishment of excuses for failing to act within the confines of your
professional code of conduct and moral duty that to you might seem quite accept
able but to others could well be perceived as questionable (List 6.4).
( ^
LIST 6.4 Stereotypical excuses for failing to help out
• I didn’t stop because I might catch something!
• I couldn’t find anywhere to park!
• I expect the paramedics will arrive soon!
• It’s not part of my job description!
• I can’t be expected to do everything!
• Oh well, I’m sure they’re alright!
• I know I should’ve helped but anyway, I’m sure no one will have noticed or
recognised me!
• I know I should’ve helped but what could I have done? I had nothing with me!
• Who cares! Probably their own fault anyway!
• They’re probably just fooling about, it’s got to be a hoax!
V___________________________ _____________________________ )
At this point, consider if you have ever passed by an incident of any sort where
you knew full well you ought to have intervened but did not. How did you feel
afterward? What excuses did you come up with? How consistent were any excuses
you arrived at with your given code of professional conduct or, for that matter, the
expectations of society in general?
Inevitably the making of a derogatory statement, gesture or act of omission
must be perceived as unprofessional, overtly prejudicial and not consistent with the
public perception or the expectations of any professional organisation to which you
may be affiliated. Further, such cognitively economic7 determinations are in essence
heuristics (colloquially known as rules of thumb)14 emanating from, for the most
part, very limited information, and as such they will inevitably be underpinned by
stereotypical inferences (snap judgements about people, places or objects).
From my own experience of applying heuristics and stereotypical inferences
many years ago as a part of my professional role, I encountered an individual whom
I perceived as being clearly homeless (a stereotype in itself for which I was wholly
guilty). As the department within which I was working was quiet, and having given
the individual something to eat and a warm drink, we got chatting, during which
a number of stereotypes came to mind: smelly, dirty, possibly infectious and a bit
thick (I now look back on these determinations with much shame - they were not
only prejudicial but also reflective of what I perceived this individual’s intelligence
to be). However, as our conversation progressed I became aware that this individual
knew a great deal about healthcare and, in particular, medicine. It subsequently
transpired that this individual used to be on the British Medical Association’s
Register of Medical Doctors, which took me completely by surprise and I found
myself thinking, why would such a person let themself come to this? (The asking
of such a question was in itself representative of stereotypical thinking). However,
what this individual relayed to me was that they had simply reached the point
where they could no longer tolerate the stress and excessive working hours of their
role. They had therefore made a conscious decision to drop out, as this individual
described it. They went on to say that they now had no stress, had made many
friends within the homeless community and had a little money each week to help
them out. For me this was a defining moment, in that I have never thought about
homeless people in the same way since. This experience made me realise that the
stereotypes I held at that time were fundamentally prejudicial. However, that is not
to say I no longer hold stereotypes. Like everyone else, of course I do! However,
since this experience, what I have tried to do is to be less judgemental and to look
beyond the obvious. With regards to this particular situation what I did was to apply
subjective labels prior to ascertaining the facts of the situation which in reality is
what people tend to do as a way of making sense of a situation they do not fully
understand or are not fully conversant with.
Within the context of health and social care, the application of labels is some
thing that occurs at an institutional level. For example, let us consider the word
‘patient’. It is taken from the Latin patior,15 which means to bear and/or suffer. So
when we apply the label patient to those who seek our intervention, what are we
actually saying or implying? Are we saying that these people who place their trust
and lives in our hands are there to suffer, and having suffered, then have to bear the
consequences of our actions or omissions? Such a view taken within the context
of IP&C might be perceived as having some relevance. For example, the failure to
undertake appropriate standard precautions, which then leads to an individual con
tracting an infection that they did not have prior to seeking our intervention, clearly
means that they will suffer something that they did not have when they entered into
our care and which might have been prevented. A point in case being the failure
to undertake hand hygiene correctly or at all, when there is a wealth of evidence to
support this practice.16-19 Thus when an individual contracts a healthcare-associated
STEREOTYPING 73
infection through no fault of their own, it may be that the word patient as a stereo
type reflects its meaning in the truest sense of its original Latin meaning. Further,
the word patient is a clear stereotype that we use to deny people their individuality,
and yet we speak much about the importance of maintaining individuality under
the guise of person-centred care.20
So, in continuing to reflect upon stereotypes and their impact upon IP&C prac
tice and outcomes it is vital to remember that the stereotypes we hold and apply may
well serve to increase the risks of cross-infection, reduce adherence to IP&C policy
and procedure, such as standard precautions, and have a negative impact upon the
way individuals perceive IP&C5 as an overall measure for not only promoting health
and wellbeing but also maintaining the right to life of others.21
Arguably, the quality of our IP&C practice is influenced by the attitudes and
beliefs we hold or those enforced upon us by others, and the subsequent stereo
types we apply. For example, with regard to the way we practise IP&C, or not, as
the case may be, let us consider the notion of truth in relation to what each of us
believes constitutes safe and appropriate practice. However, in starting to consider
this concept perhaps we should ask the question, what is truth?22
At this point what I would ask you to do is write down on a piece of paper some
thing that you believe to be absolutely true. Having done that, ask yourself: How
do I know what I have written down is absolutely true? As an example, you might
have written down, I am a safe practitioner! But, what evidence can you provide to
objectively justify this? (List 6.5 for what you might say.)
( ^
LIST 6.5 You might say
• I always adopt appropriate standard precautions!
— But could you recite these if asked? My point being: if you cannot recite
them, how can you be sure you are really adopting what constitutes
standard precautions? Thus is it really true that you always adopt such?
• I have never cross-infected anyone!
— Are you sure? Just because you believe this does not make it true. It may
be that a link between what you did or did not do and an individual or
number of individuals who contracted an infection has never been estab
lished. You may just have been lucky enough not to have got caught or
identified as the culprit!
• I have always adopted appropriate hand hygiene!
— Are you sure? Do you know what appropriate hand hygiene is? If you think
it is hand washing then you are completely wrong! Why? Because washing
is only one of the six stages of the hand hygiene process.
— Stage 1 - recognising the need to adopt hand hygiene
— Stage 2 - wet the areas to be washed
— Stage 3 - apply the cleansing solution
— Stage 4 - wash the areas to be cleansed
— Stage 5 - rinse the areas washed thoroughly
— Stage 6 - completely and thoroughly dry the areas rinsed.5
• People thank me!
— How do you know they were being truthful? They may just be saying this
because they think they will get a better quality of care from you? The truth
of what they really believe may be quite different.
• M y colleagues tell me so!
— They may say this because they perceive you as being powerful or they
may be afraid of you. Or they may tell you this because it is the easiest
way out of what might be an embarrassing or confrontational situation.
• I have never made a mistake!
— Who says so? You, so what! You may just be being cognitively economic7
and suffering from dissonance effects.5,6 Thus your perception of what
constitutes a mistake may be affected as a result of a rationalised, as
opposed to rational, perspective.
• M y level o f seniority, appointment or experience simply precludes the pos
sibility o f my causing cross-infection, because I am an expert!
— Really! Such an attitude is more likely to result in cross-infection occurring
as a result of an egocentric and egotistical perception of one’s own impor
tance. In essence, no one is above causing cross- infection. We all have
the potential to do so. Such an attitude might be indicative of an individual
having been promoted to the level of their incompetence.
V____________________________ _____________________________________________________ J
With regard to the examples within List 6.5, these are beliefs that individuals might
hold and honestly believe to be true. However, let’s consider the following example
from List 6.5: ‘I have always adopted appropriate hand hygiene!’ A good number of
years ago I presented a paper at an international IP&C conference. Having intro
duced myself, I posed the following question to the audience:
In absolute honesty, as professionals, put your hand up if you have always

undertaken hand hygiene as well as you knew you should have done.
STEREOTYPING 75
The reaction was, to say the least, surprising, as not one person in the audience
raised their hand. At that point, a clear and audible rumble went across the room.
The implication being that in the past these individuals had constituted a clear
cross-infection risk through failing to undertake appropriate hand hygiene. Yet,
when individuals spoke to me following the presentation they all, without excep
tion, said that until that moment they believed they always had adopted appropriate
hand hygiene and were shocked to realise that their belief was not true. With
regard to such beliefs and the nature of truth, they are all likely to have been estab
lished through and/or influenced by stereotypes these individuals believed made
their IP&C behaviour safe and appropriate. So, believing our practice is safe and
appropriate does not necessarily make it factually true, and as such it constitutes
a misnomer between reality and our subject perception. Where such a misnomer
exists it will inevitably enhance the potential for stereotypes being applied and for
unsafe IP&C to occur.
Where IP&C is concerned, we as health and social care professionals need to be
continuously aware of the stereotypes we apply, the context in which we apply them
and be alert to the consequences that their application can have upon ourselves and
others. The essential point is that we all have beliefs, attitudes and prejudices that
are manifested in the form of stereotypes, and we apply these on a continual basis in
order to help us make sense of the world we live in. In many ways these stereotypes
are ego-related defence mechanisms that enable us to justify and make sense of the
people and objects we encounter and the environments in which we exist as a part
of our professional lives and our activities of living.23 Stereotypes are an integral
part of each of us as human beings and they allow us to draw conclusions that to
us on an individual basis make perfect sense but which may not necessarily make
sense to others. For the most part, the stereotypes we apply are purely intuitive in
nature (Figure 6.1) and inherently unreliable, and as such they can serve to facilitate
dangerous attitudes and beliefs within a biomedical context24 leading to physical,
psychological and/or social harm being caused to others.
So, in concluding it is my hope that having read through this chapter your
understanding and, perhaps more important, your awareness of stereotypes has
been enhanced. It is also my hope that in the future you will have a greater aware
ness of the way you apply them and that you perhaps think twice before you do so.
r ; A
Having concluded this chapter, I would like to say a few words in memory of
a friend and colleague, Professor Melanie Jasper, who is sadly no longer with
us. I knew Melanie for many years and had nothing but the highest respect and
regard for her. It is my opinion that Melanie was an international leader within the
profession of Nursing and that her passing is a great loss to not only the profes
sion of Nursing but healthcare overall. Melanie, you will be missed.
V__________________________________________________________ J
REFERENCES
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and discrimination. Science. 2011; 332(6026): 251-3.
2. Legg s, Hutter M. A Collection o f Definitions o f Intelligence. 2007. Technical Report. Available
at: http://arxiv.org/pdf/0706.3639.pdf (accessed 9 January 2015).
3. Gilman L. The theory of multiple intelligences. Human Intelligence: historical influences,
current controversies. Teaching Resources. 2001. Available at: www.indiana.edu/~intell/
mitheory.shtml (accessed 9 January 2015).
4. Richardson K. What IQ tests test. Theory Psychol. 2002; 12(3): 283-314.
5. Elliott P, editor. Infection Control: a psychosocial approach to changing practice. Abingdon:
Radcliffe; 2009. pp. 5 3 -7 , 235-6.
6. Elliott P. Recognising the psychosocial issues involved in hand hygiene. J R Soc Promo
Health. 2003; 123(2): 12-14, 88-94.
7. Roth I, Frisby J. Perception and Representation: a cognitive approach. Milton Keynes: Open
University; 1992. p. 22.
8. Tversky B, Fisher G. The Problem with Eyewitness Testimony. Stanford, CA: Stanford
Journal of Legal Studies; 1999. Available at: http://agora.stanford.edu/sjls/Issue%20One/
fisher&tversky.htm (accessed 9 January 2015).
9. Hamm RM. Clinical intuition and clinical analysis: expertise and the cognitive continuum.
In: Dowie J, Elstein A, editors. Professional Judgement: a reader in clinical decision making.
Cambridge: Cambridge University Press; 1996. pp. 78-105.
10. Glove Use fo r Healthcare Workers. Heidelberg, Victoria: Hand Hygiene Australia; 2014.
Available at: www.hha.org.au/About/GloveUsePolicy.aspx (accessed 9 January 2015).
11. Rock C, Harris A, Reich N, et al. Is hand hygiene before putting on nonsterile gloves in the
intensive care unit a waste of health care worker time? A randomized controlled trial. Am J
Infect Control. 2013; 41(11): 994-6.
12. Festinger L. Cognitive dissonance. Sci Am. 1962; 207(4): 93-102.
13. Atkinson S, Tomley S, Landau C, et al., editors. The Psychology Book. London: DK Penguin
Group; 2011. pp. 95 -7 .
14. Shah A, Oppenheimer D. Heuristics made easy: an effort-reduction framework. Psychol
Bull. 2008; 134(2): 207-22.
15. Neuberger J. Do we need a new word for patients? BMJ. 1999; 318(7200): 1756-8.
16. Rickard N. Hand hygiene: promoting compliance among nurses and health workers. Br J
Nurs. 2004; 13(7): 404-10.
STEREOTYPING 77
17. Randle J, Clarke J, Storr J. Hand hygiene compliance in healthcare workers. J Hosp Infect.
2006; 64(3): 205-9.
18. Al-Hussami M, Darawad M. Compliance of nursing students with infection prevention
precautions: effectiveness of a teaching programme. Am J Infect Control. 2013; 41(4): 332-6.
19. Ataei B, Zahraei S, Pezeshki Z, et al. Baseline evaluation of hand hygiene compliance in three
major hospitals, Isfahan, Iran. J Hosp Infect. 2013; 85(1): 69-72.
20. Kouble G, Bungay H. The Challenge o f Person-Centred Care: an interprofessional perspective.
Basingstoke: Palgrave Macmillan; 2009. pp. 29-50.
21. Wilkinson R, Caulfield H. The Human Rights Act: a practical guide fo r nurses. London:
Whurr; 2001. p. 25.
22. Davidson D. Truth. Int JPsychoanal. 2004; 85(Pt. 5): 1225-30.
23. Planning Care and Documentation. London: King’s College London; n.d. Available at: http://
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9 January 2015).
24. Ogden J. Health Psychology: a textbook. 5th ed. Maidenhead: McGraw-Hill/Open University
Press; 2012. pp. 4 -8 .
C H A P TE R 7
Out-of-hospital infection
prevention and control:
a paramedic perspective -
could we do better?
Paul Vigar
It is 3.30 a.m.; Julie is a paramedic treating a patient who has crashed his motorcycle
into some metal railings outside of a school and impaled his right leg on one of the
railings. It is cold and raining heavily.
The patient is in a great deal of pain and has been bleeding heavily. While fire
fighters prepare their equipment, Julie prepares to administer intravenous fluids
and analgesia to her patient. She is wearing her high-visibility jacket, waterproof
trousers, a helmet and a pair of nitrile gloves. She considers the potential for
infection in this incident and how she can minimise the risks, given her personal
protective equipment and environment. She can’t help thinking that this would be
much easier in hospital!
INTRODUCTION
Out-of-hospital clinical practice has an important role to play in reducing morbid
ity and mortality due to healthcare-associated infections, and every practitioner*
working in this setting has the potential to reduce the risk of infection by operating
* The term 'practitioner’ in this chapter refers to any clinician or healthcare professional and does not specifically
refer to a specialist practitioner role such as that of the 'paramedic practitioner’.
79
consistently within best practice guidelines.1A no-tolerance attitude to preventable

healthcare-associated infections is now prevalent in the National Health Service.2
Outside of hospital, however, more complex care is now being delivered2 and
this presents unique challenges for infection prevention and control; this has led
to new, innovative ways of working, contributing to safer practice and reduced
hospital stays for patients.
This chapter uses the paramedic role to explore the key issues of infection pre
vention and control in the out-of-hospital setting at a time when there has been a
significant shift in its status, but the principles can be applied to any practitioner
working in this environment, including doctors, nurses, physiotherapists, health
visitors, occupational therapists, social workers and healthcare support workers.
One of the cornerstones of out-of-hospital infection prevention and control in
the emergency setting is the treating of all body fluids as potentially infectious, as
the health status of most patients is unknown. It is vital that practitioners working
in the out-of-hospital environment have high regard for their own personal hygiene,
carefully manage interactions with patients and adequately maintain equipment
that may become contaminated with potentially infectious organisms, organic
matter or chemicals. Practitioners inevitably have more control over any given
situation, leaving their patients at a much greater risk of contracting an infection
than themselves, but recent guidance places some responsibility with patients too.2
Despite the high risk of exposure to infectious disease, in my experience,
knowledge of the aetiology and transmission of infectious disease has been poor
and vehicles have not been as clean as patients might expect. Factors such as the
appointment of specialist infection control leads, higher education, new equipment,
ambulance design and central depots for the cleaning and maintenance of vehicles
and equipment are going some way to address a poor record of out-of-hospital
infection prevention and control.
REFLECTION EXERCISE 7.1

There is a new pandemic flu virus that has reached the United Kingdom. You
are a practitioner who has been asked to assess a 53-year-old woman in her
home who has a fever and a cough.
• When do you start thinking about infection prevention and control?
• How might you adapt procedures used in hospital to the out-of-hospital
environment?
• How could you protect yourself from potentially becoming infected?
OUT-OF-HOSPITAL INFECTION PREVENTION AND CONTROL 81
RISK ASSESSMENT
Issues around the prevention and control of infection should be a part of any
dynamic risk assessment in the out-of-hospital setting and should begin with infor
mation that is received about the call, such as the presenting signs and symptoms
of the patient, information from family members or other healthcare professionals
and details of the environment. This information could trigger the need for personal
protective equipment (PPE) and will contribute to the management of the patient.
The Department of Health highlights three key high-risk areas for the transfer
of infection to patients in the pre-hospital setting: (1) direct contact with hands,
(2) invasive devices such as cannulas and (3) the emergency environment.1

You have been called to the scene of a road traffic collision involving two cars
and a lorry. There are four patients to manage: three of the patients are still in
their cars and one has been ejected from his vehicle and is lying in the road.
You have requested further resources but in the meantime you must triage the
patients and deliver any lifesaving treatment.
• What kind of PPE should you be wearing?
• How might PPE compromise your ability to adhere to infection prevention
and control guidelines?
• From an infection prevention and control perspective, what considerations
should be given to assessing four patients in close proximity?
PERSONAL HYGIENE
Healthy skin is an effective barrier to microorganisms, and so breaks in the skin
should be covered to minimise the risk of pathogenic organisms entering the body
via this route.
High standards of personal hygiene are expected by all healthcare professionals,
but given that hands are the most common way in which microorganisms might
be transported and subsequently cause infection, good hand hygiene* is the single
most important method for minimising the risk of infections.1 Studies have shown
that a nurse’s hands can be contaminated during even clean procedures such as
lifting patients and performing patient observations.3 Paramedics are constantly
in contact with their patient, the surrounding environment, the ambulance and
* Hand hygiene comprises both hand washing with water and a cleansing solution and the use of hand rubs.
equipment, yet access to hand hygiene facilities in the out-of-hospital environment

is challenging. However, the move over recent years from hand washing to hand
rub with alcohol-based preparations under certain conditions has revolutionised
hand hygiene practices.4
The World Health Organization describes the five moments of hand hygiene3 and
the National Patient Safety Agency has provided a number of resources focusing
on non-ward-based care (see Figures 7.1, 7.2 and 7.3).5
BEFORE AFTER
PATIENT PATIENT
CONTACT CONTACT
AFTER CONTACT
W TH PAT ENT
SURROUNDINGS
FIGURE 7.1 The five moments of hand hygiene (National Patient Safety Agency5)
Reproduced with the permission of the WHO from Five M om e n ts o f H a n d Hygiene.
O ^O C E
<r
BEFORE AFTER
PATIENT PATIENT
CONTACT CONTACT
AFTER CONTACT
WITH PATIENT
SURROUNDINGS

Have a think about the five moments of hand hygiene described by the World
Health Organization3 and illustrated in Figures 7.1,7.2 and 7.3. Consider some
of the practical challenges of working outside of the hospital environment.
r ;
BOX 7.1 Challenges of hand hygiene in the out-of-hospital setting
a
• The patient’s medical history or history of presenting complaint may be

unknown.
• You may have just got out of a vehicle: you may have been using communica
tion equipment; you may have been driving, putting you in contact with vehicle
controls; and you would have touched the outside of the vehicle.
• You may have to carry equipment to the patient.
• There may be a need for an immediate assessment or action in an emergency.
• The patient may require time-critical, invasive interventions.
• Access to hand-washing facilities may be limited, e.g. at the scene of a car
accident or an assault in the high street, or in a dirty environment.
• Hand-washing facilities may be inadequate, e.g. at a patient’s home.
V_____________________________ ___________________________ )
Hands that are visibly soiled must be washed with soap and water,3 which may not
be available in the out-of-hospital setting. Even if hand-washing facilities are avail
able, the quality will vary given that the maj ority of locations will be patients’ homes.
While it would be possible to install running water and sinks in an ambulance, the
availability of sinks is not considered a priority by the World Health Organization,3
especially when there are limited resources and many practitioners will not be
working in an ambulance. In the absence of soap and water, detergent wipes can
be used followed by alcohol gel once the hands are dry.1 However, there is little evi
dence on the clinical and cost-effectiveness of such alternatives.2 Detergent wipes
could be stored in response bags to further increase compliance at the patient’s side
when hands are soiled, and alcohol hand rubs are now widely available.
It is my experience that compliance with hand hygiene techniques outside of
hospital is poor but there is little credible research in this specific setting. It is likely
that reasons for poor compliance out of hospital will be the same as in hospital and
include poor access to hand hygiene supplies, skin irritation caused by the clean
ing agents, interference with the clinician-patient relationship, carelessness, poor
knowledge of the guidelines and a lack of time.36
While it is current practice to only wear gloves when there is a risk of coming
into contact with blood and other body fluids, it is my experience that some prac
titioners working out of hospital wear gloves while performing other tasks such
as opening doors and driving. Gloves do not offer complete protection and are no
substitute for good hand hygiene, and the prolonged use of gloves can itself result
in the transmission of infection.3
The World Health Organization explains that artificial acrylic fingernails are
associated with poor infection prevention despite the use of soap or alcohol gel.3
Such nails are often banned under uniform policies but the wearing of plain wed
ding rings is permitted, despite being associated with an increased frequency of
hand contamination.3
PERSONAL PROTECTIVE EQUIPMENT

Uniforms are not considered to be protective equipment7 and there is no conclusive
evidence that uniforms play a direct role in spreading infection, but they should
minimise risk to patients and be clean.8 Whether uniform is worn or not, out-of
hospital practitioners should have access to equipment that they can utilise in the
event of a potential exposure. The choice of equipment should be based on a risk
assessment7 to include the risk of transmitting microorganisms to the patient2 or
other healthcare workers.1
The Department of Health introduced a ‘bare below the elbows’ policy, which
aims to prevent the spread of infection from contaminated sleeves and to facilitate
better hand hygiene procedures,1 but there is a tension between staff comfort in
cold, wet environments, health and safety when wearing high-visibility clothing
and infection prevention and control. The National Institute for Health and Care
Excellence acknowledge that practitioners working outside may have to wear PPE
in line with health and safety legislation but that there should be provision for
adequate hand decontamination.2
PPE could include disposable sterile or non-sterile gloves, plastic aprons, sleeve
protectors (when wearing jackets), shoe protectors, paper suits, face masks and
safety eyewear. Some emergency workers are now even equipped with respirators
for use with patients suspected to be suffering with severe acute respiratory syn
drome or in the case of a pandemic flu outbreak.19 Table 7.1 illustrates when PPE
should be worn in the out-of-hospital environment.
TABLE 7.1 Personal protective equipment in the out-of-hospital setting*

Personal protective Reasons to be w orn
equipm ent
G loves R is k o f c o n ta c t w ith b lo o d o r b o d y flu id s
W h e n s h a rp o r c o n ta m in a te d ite m s a re b e in g h a n d le d
C o n ta c t w ith n o n -in ta c t s k in o r m u c o u s m e m b ra n e s
R is k o f c o n ta m in a tio n fro m b lo o d o r b o d y flu id s
P o te n tia l c o n ta m in a tio n fro m c le a n in g p ro c e d u re s
W h e n tra n s p o rtin g k n o w n in fe c tio u s p a tie n ts
S le e v e p ro te c to r P ro te c ts u n ifo rm fro m w ris t to e lb o w fro m b o d y flu id s a n d s k in
c e lls
S h o e p ro te c to rs A s fo r ite m s a lre a d y liste d , if a d d itio n a l p ro te c tio n is re q u ire d
P a p e r s u it A s fo r ite m s a lre a d y liste d , if a d d itio n a l p ro te c tio n is re q u ire d
Face m a s k R is k o f c o n ta c t w ith b lo o d o r b o d y flu id s fro m s la s h e s o r
re s p ira to ry d ro p le ts
R is k o f in h a lin g in fe c te d re s p ira to ry p a rtic le s
Eye p ro te c tio n R is k o f c o n ta c t w ith b lo o d o r b o d y flu id s fro m s p la s h e s o r
re s p ira to ry d ro p le ts
R e s p ira to r P ro te c tio n a g a in s t c e rta in re s p ira to ry d is e a s e (e.g. s e v e re a c u te
re s p ira to ry s y n d ro m e , p a n d e m ic flu )
* Based on information from the Department of Health1and Pellowe et al.9


You are a practitioner working on your own in a car and you have been called
to a 22-year-old male and a 19-year-old female who have fallen from an off
road motorcycle on a farm. The male patient has fractured his right femur, has
a large open wound to his upper right arm with substantial tissue loss, is in a
great deal of pain and is unable to move, while the female patient is complaining
of a shoulder injury.
• What procedures might you need to carry out that increase the risk of infec
tion for these patients?
• What challenges are there for infection prevention and control in this scenario?
• How can you best minimise the risk of infection when managing these
patients?
ASEPTIC TECHNIQUE
Asepsis is defined as the absence of pathogenic organisms, and aseptic technique
is a method used to prevent the contamination of the body through clinical pro
cedures.1 Aseptic technique plays a vital role in preventing the transmission of
infection but an adequate sterile field can rarely be achieved outside of hospital, and
so a non-touch technique is adopted to include good hand hygiene, the wearing of
sterile or non-sterile gloves where appropriate and not touching key parts of items
that will be in direct contact with the patient.
Gloves can tear easily, particularly at the scene of road traffic collisions where
there might be metal and glass hazards and the majority of products offer little
protection against sharps injuries. Where there is more than one casualty, gloves
should be changed between patients and before moving onto a new task,1but this
can be challenging, especially when combined with the use of alcohol hand gel in
an emergency situation where time-critical procedures may need to be performed
or where you need to assess more than one patient rapidly.
Intravenous cannulation has long been carried out in the out-of-hospital set
ting by paramedics and other healthcare professionals alike, but it poses a clear
infection risk; by definition there is an inherent risk of infection, as the needle
provides a direct route for microbes into the patient’s bloodstream.10 The intrave
nous cannula may be contaminated by the patient’s skin flora at the insertion site
or by the introduction of other organisms via the cannula hub or injection port.10
Where intravenous cannulas cannot be inserted aseptically, they are classified as
‘emergency inserted, resulting in a replacement cannula being used at the receiv

ing hospital.1
Other equipment such as skin preparation applicators containing chlorhexidine
gluconate and isopropyl alcohol, sterile cannulation packs and disposable tourni
quets are contributing to more effective infection prevention and control when
performing intravenous cannulation. Endotracheal intubation is being supported
by disposable laryngoscope handles and blades, which are in stark contrast to the
reusable equipment in bags available to paramedics in the past and often cleaned in
sinks at the hospital after use. Careful attention must be paid to ensuring kit bags
are not overstocked, which can cause damage to the packaging of single-use items
prior to use.

You are working alone in a car and have been asked to attend an elderly lady
who has had a fall and has sustained a deep laceration to her left forearm. You
decide that the best way to close this wound is using sutures. Your patient lives
alone and appears a little unkempt, her flat is dirty and untidy, and she has five
cats living with her who use a litter tray.
What can you do to minimise the risk of infection in your management of this
patient?
EQUIPMENT AND VEHICLES

Increasingly, equipment bags are made of fabrics with an antibacterial treatment
that are easy to wipe clean and patient assessment devices feature disposable parts
where there is contact with the patient.
The use of needles in the out-of-hospital setting can be risky, given the unpre
dictable nature of the environment, the potential for poor light, and so on. Given
that the majority of exposures are due to inappropriately discarded needles among
allied healthcare professionals,11needles that are automatically sheathed or retracted
are now in use around the United Kingdom. Sharps bins are generally available in
response bags, ambulances and response cars to enable easy access in all manner of
scenarios, with sizes varying depending on their location and intended use.
Blood and body fluids, which are considered hazardous, can now be cleaned up
with wipes or kits that are now readily available in most UK ambulance services,
and when used with the appropriate PPE these contribute to timely management
of body fluid spills with a view to reducing the risk of infection to clinical staff,
patients and bystanders in public areas, although there is a dearth of research in this
area. Ambulances and response cars are equipped with clinical waste bins for the
disposal of waste associated with clinical presentations and procedures but there is
not always access to non-clinical waste bins.
The cleanliness of premises and vehicles is an important component of the
provision of clean, safe care, and the National Health Service Constitution clearly
states that services will be provided in a clean and safe environment fit for purpose
based on national best practice.12 While there have been significant improvements
in the cleanliness of ambulances over recent years we must not become compla
cent. Frequent cleaning of vehicles and a weekly deep clean of an ambulance by
practitioners used to be commonplace, but the increasing year-on-year demand
on ambulance services13 has compromised this process. In my experience, interior
ambulance surfaces have been poorly maintained, with dirt and dust visible to the
naked eye in the past, stretchers are rarely wiped, and patient monitoring equipment
is not always regularly cleaned between patients to this day.
The availability of cleaning materials, especially surface wipes, together with
education has increased compliance with these tasks, but regular cleaning needs to
be balanced with the demand and pressure to attend increasing numbers of emer
gency calls. There are new innovative systems embedding themselves in the United
Kingdom now, such as Make Ready, where vehicles are regularly deep cleaned and
swabbed for the presence of microorganisms by specialist teams as part of a regular
maintenance, cleaning and equipment stocking schedule.14 In addition, ambulance
design is evolving with consideration given to facilitating effective hygiene and
infection control including rounded corners, covered joints, separation of clinical
and non-clinical waste, sealed drawers, easy-clean seats, removable seatbelts and
readily demountable equipment for cleaning.15
Most linen has the potential to harbour microorganisms and will be deposited at
hospitals for washing, having been segregated into general and contaminated linen
bags. Where patients are not being transported to hospital, having been assessed
and treated on an ambulance, linen is left on the ambulance until it can be safely
disposed of, which can be unsightly and may pose an infection risk to other patients
treated in the vehicle prior to safe disposal of the linen. This could easily be resolved
with a suitable storage area.
MOVING FORWARD
Everyone providing care in the community should be educated about the standard
principles of infection prevention and control and there should be sufficient sup
plies of equipment available.2
Traditionally, infection control training for ambulance staff was minimal, but
this limited training has given way to higher education with university paramedic
science courses obliged to equip students with the skills to establish and maintain
a safe practice environment that minimises the risk to service users and practition
ers,16 and to be aware of local infection control procedures.17
Human health-related behaviour is determined by our biology, environment,
religion and culture as well as our education,3 and so all of these factors need to be
understood and considered when taking action on improving infection prevention
and control behaviours and may be a useful focus for research.
While a zero tolerance approach may be difficult to achieve in the out-of-hospital
setting in real terms, to move forward we need effective infection prevention
and control measures, a strong commitment from clinical leaders and managers,
healthcare-associated infection to become an indicator of the quality and safety of
patient care and the provision of quality information to the public as well as clini
cal staff.6
There also needs to be a robust system of monitoring and audit to monitor
compliance and drive improvements, which could include financial remuneration
through the Commissioning for Quality and Innovation payment framework,
which rewards National Health Service organisations for meeting locally agreed
quality improvement and innovation goals. However, a recent review identified
disappointing results in terms of the impact of this framework on existing goals.18
SUMMARY
Reducing the number of healthcare-associated infections is crucial and out-of
hospital practitioners have an important role to play in achieving this goal. Despite
the challenges of the working environment and a poor record of managing infection
prevention and control outside of hospital, clinical practice is changing.
It is clear that a number of factors contribute to effective infection prevention
and control in the out-of-hospital setting discussed in this chapter and illustrated in
Figure 7.4; there is a paucity of research relating to many of the key topics raised, but
it is apparent that a multifactorial approach is needed to improve current practice
and clinical outcomes.
FIGURE 7.4 Key issues for out-of-hospital infection prevention and control
Better education and training, more stringent policies and procedures, effective
leadership, new systems of working and access to more appropriate equipment at
the right moments of patient care are all contributing to improved infection pre
vention and control, but there is still some way to go and any action needs to be
sustained if changes to clinical practice and behaviour are to be achieved.
Most important, there needs to be more research into issues of infection preven
tion and control in the out-of-hospital setting, and longer-serving members of staff
need to be able to access the same literature as new paramedics in higher education
and be motivated to do so. The National Institute for Health and Care Excellence
highlights research recommendations that include barriers to compliance, the
clinical and cost-effectiveness of using wipes and gels when clean running water is
unavailable, and the effectiveness of different substances used for skin decontami
nation prior to gaining vascular access.2
There needs to be much more emphasis on infection control when teaching

and assessing clinical skills; further consideration given to how current methods
of infection prevention and control can be modified, given that the role of the
ambulance service is changing to include the management of patients in their own
home; and sharing of good practice.
Finally, systems of monitoring and audit need to be implemented to monitor
compliance and identify deficiencies that can be acted on in this battle against
healthcare- associated infections.
REFERENCES
1. HCAI and Cleanliness Division, Department of Health. Ambulance Guidelines: reducing
infection through effective practice in the pre-hospital environment. London: Department
of Health; 2008. Available at: http://webarchive.nationalarchives.gov.uk/20130107105354/
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/
digitalass etZdh_087428.pdf (accessed 2 March 2015).
2. National Institute for Health and Care Excellence. Infection: prevention and control o f
healthcare-associated infection in primary and community care: NICE guideline 139. London:
NIHCE; 2012. www.nice.org.uk/guidance/cg139
3. World Health Organization (WHO). World Health Organization Guidelines on Hand Hygiene
in Health Care. Geneva: W HO; 2009. Available at: http://whqlibdoc.who.int/publications/
2009/9789241597906_eng.pdf (accessed 19 June 2012)
4. Boyce J, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of
the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/
APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report. 2002; 51:
1-50. Available at: www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (accessed 30 July 2012)
5. National Patient Safety Agency. Your Five Moments Explained: hospital non-ward based
care. 2011. Available at: www.npsa.nhs.uk/cleanyourhands/resource-area/nhs-resources/
education/training-five-moments/ (accessed: 30 July 2012)
6. C hief Medical Officer. Winning Ways: working together to reduce healthcare associated
infection in England. London: Department of Health; 2003. Available at: http://webarchive.
nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/
dh_digitalassets/@dh/@en/docum ents/digitalasset/dh_4064689.pdf (accessed: 2 March
2015)
7. Health and Safety Executive. Control o f Substances Hazardous to Health. 6th ed. Merseyside:
HSE Books; 2013.
8. Department of Health. Uniforms and Workwear: guidance on uniform and workwearpolicies
fo r NHS employers. London: Department of Health; 2010. Available at: http://webarchive.
nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/
dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_114754.pdf (accessed 2 March
2015)
9. Pellowe C, Loveday H, Pratt R, et al. Standard principles: personal protective equipment
and the safe use and disposal of sharps. Nursing Times. 2007 Nov 20. Available at: www.
nursingtimes.net/nursing-practice/specialisms/management/standard-principles-personal-
protective-equipment-and-the-safe-use-and-disposal-of-sharps/291502.article (accessed
2 March 2015).
10. Department of Health. High Impact Intervention no. 2. Peripheral intravenous cannula care
bundle: saving lives, reducing infection, delivering clean and safe care. London: Department
of Health; 2007. Available at: http://webarchive.nationalarchives.gov.uk/20120118164404/
hcai.dh.gov.uk/files/2011/03/2011-03-14-H H -Peripheral-intravenous-cannula-bundle-
FIN%E2%80%A6.pdf (accessed 5 January 2014).
11. Health Protection Agency. Eye o f the Needle: surveillance o f significant occupational
exposure to bloodborne viruses in healthcare workers. London: HPA; 2008. Available at:
http://webarchive.nationalarchives.gov.uk/20140714084352/http://www.hpa.org.uk/webc/
HPAwebFile/HPAweb_C/1227688128096 (accessed 2 March 2015).
12. National Health Service. NHS Constitution. London: NHS; 2012. Available at: www.nhs.
uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/nhs-constitution-
interactive-version-march-2012.pdf (accessed 30 July 2012).
13. Association of Ambulance Chief Executives. Taking Healthcare to the Patient 2: a review
o f 6 years’ progress and recommendations fo r the future. Association of Ambulance Chief
Executives; 2011.
14. South East Coast Ambulance Service NHS Foundation Trust. M ake Ready. South East
Coast Ambulance Service NHS Foundation Trust; 2013. Available at: www.secamb.nhs.uk/
about_us/our_developments/make_ready.aspx (accessed 20 December 2013).
15. The Helen Hamlyn Trust; National Patient Safety Agency. Design fo r Patient Safety: future
ambulances. London: The Helen Hamlyn Trust; National Patient Safety Agency; 2007.
Available at: w w w .nrls.npsa.nhs.uk/resources/type/guidance/?entryid45=59816& p=3
(accessed 17 October 2013).
16. Health Professions Council. Standards o f Proficiency:paramedics. London: Health Professions
Council; 2007. Available at: www.hpc-uk.org/assets/documents/1000051CStandards_of_
Proficiency_Paramedics.pdf (accessed 30 July 2012).
17. Quality Assurance Agency for Higher Education. Paramedic Science. Benchmark statement:
health care programmes. Gloucester: Quality Assurance Agency for Higher Education; 2004.
Available at: www.qaa.ac.uk/en/Publications/Documents/Subject-benchmark-statement-
Health-care-programmes---Paramedic-Science.pdf (accessed 24 July 2012).
18. MacDonald R, Zaidi S, Todd S, et al. Evaluation o f the Commissioning fo r Quality and
Innovation Framework: final report. 2013. Available at: http://hrep.lshtm.ac.uk/publications/
CQUIN_Evaluation_Final_Feb2013-1.pdf (accessed 2 March 2015).
C H A P TE R 8
Antibiotics: help or hindrance?
Sarah Pye and Clare Hancock
INTRODUCTION
Regardless of the numerous guidelines, extensive research, worldwide media
campaigns and public awareness-raising initiatives, antibiotic resistance remains
a threat to global public health.1 This chapter will consider the extent to which bac
teria are evading the antibiotic. How bacteria become resistant will be discussed,
along with the strategies that are being implemented to combat the rising number
of antibiotic-resistant infections.
REFLECTION EXERCISE
Consider why antibiotic resistance occurs. Reflect upon the consequences of
antibiotic resistance in healthcare and consider what actions can be taken to
reduce the problem. Compare your thoughts with what follows throughout the
chapter.
THE EXTENT OF THE PROBLEM

In 2011, over 40 million prescriptions for antibacterial drugs were dispensed in the
United Kingdom (UK).2 Alarming stories about antibiotics are a regular feature of
the mass media and recent newspaper headlines have highlighted the antimicrobial
93
resistance (AMR) crisis in healthcare.3,4 It has been estimated by the European

Commission5 that in the European Union:
• approximately 25 000 patients per year die from drug-resistant bacterial
infections
• approximately 4 million patients per year acquire a healthcare-associated
infection
• the costs associated with AMR exceed 1.5 billion Euros.
There have been repeated public health campaigns to increase awareness of the
risks associated with inappropriate antibiotic prescribing. For example, the annual
European Antibiotic Awareness Day coordinated by the European Centre for
Disease Prevention and Control aims to raise awareness about the threat to public
health of antibiotic resistance, and prudent antibiotic use.
Despite these efforts, recent research by the Health Protection Agency6 has
shown that over half of those visiting their doctor for a respiratory tract infection
expected a prescription for an antibiotic. A quarter of people surveyed thought that
antibiotics were effective treatment for most coughs and colds.
With rising rates of AMR, the rational and prudent prescribing of antibiot
ics presents a major challenge for healthcare providers. Consequently, the World
Health Organization (WHO) has called this ‘a developing global crisis in health
care’ requiring urgent action to address the problem.7
HOW AND WHY DOES ANTIMICROBIAL RESISTANCE DEVELOP?

AMR is not a new phenomenon8 - resistance was observed within years of anti
biotics being available for widespread use. For example, in 1963 ampicillin was
introduced as the first broad-spectrum penicillin. At launch it was active against
Escherichia coli but by l965 ampicillin-resistant E. coli had been discovered.9
AMR develops due to the occurrence of genetic mutations, which allow bacteria
to resist the action of an antimicrobial agent.10 Exposure to antibiotics creates an
evolutionary pressure that selects for bacteria with resistant traits: an example of
Charles Darwin’s ‘survival of the fittest’ evolutionary theory. Inappropriate prescrib
ing and poor adherence to treatment by patients both contribute to the development
of AMR.11
The use of certain antibacterial treatments can predispose patients to future
antimicrobial-resistant infections. For example, Clostridium difficile infection
often occurs after a patient has received antibiotic treatment.12 The risk of devel
oping C. difficile infection is greatest with ampicillin, amoxicillin, co-amoxiclav,
ANTIBIOTICS: HELP OR HINDRANCE? 95
second- and third-generation cephalosporins, clindamycin, and quinolones,

but most antibiotics have been associated with this side effect.12 Patients who
have recently received antibiotic treatment, particularly quinolone or macrolide
antibiotics, are thought to be at greater risk of developing a meticillin-resistant
Staphylococcus aureus (MRSA) infection compared to those who have received no
antibiotic treatment.13
TREATMENT OF ANTIMICROBIAL-RESISTANT INFECTIONS

The management of antimicrobial-resistant infections is a continually changing
landscape, with new challenges appearing on a regular basis.14 The management
of MRSA and C. difficile infections are well described, but healthcare profes
sionals need to be aware of changing resistance patterns. The emergence of new
multi-resistant infections, such extended-spectrum beta-lactamases (ESBLs) and
carbapenemase-producing Enterobacteriaceae, to antibiotics is cause for consid
erable concern, as difficult-to-treat infections have the potential to put significant
strain on the healthcare system.
Infections caused by bacteria-producing ESBLs are one example of a difficult-to-
treat infection that is on the increase. ESBLs are enzymes that enable the bacteria
to resist the action of commonly prescribed antibiotics, such as cephalosporins
and penicillins. ESBL infections were discovered in the 1980s and, until relatively
recently, were rarely encountered. Risk factors for developing an ESBL infection
include serious underlying disease, prolonged hospital stay, presence of invasive
medical devices and previous antibiotic usage.15 Treatment options are limited but
include nitrofurantoin, fosfomycin and carbapenems.
Carbapenem antibiotics, such as imipenem and meropenem, have a broad
spectrum of activity and are used for the treatment of severe hospital-associated
infections and polymicrobial infections.16 As such they are often used as last-line
treatments for resistant infections. Worryingly, carbapenem resistance has begun to
develop, resulting in bacteria that are resistant to all but a handful of antibiotics. A
growing number of bacteria from the Enterobacteriaceae species, such as E. coli and
Klebsiella, have been noted to produce carbapenemase enzymes.17 These enzymes
destroy carbapenem antibiotics, and therefore bacteria producing them can cause
multidrug-resistant infections.18 Resulting infections present a therapeutic chal
lenge, as there are limited treatment options, such as colistin and tigecycline.19
This is has been a growing problem in recent years. The United States, India and
parts of Europe are all reported to have high prevalence of healthcare-associated
carbapenemase- producing Enterobacteriaceae.20
FUTURE DEVELOPMENTS AND NEW ANTIMICROBIAL TREATMENTS

As bacteria have developed resistance to treatment with traditional antibiotics,
hope has turned to the development of new drugs to overcome the problem.21 The
complex process of taking new chemical entities from the laboratory bench to the
patient, and the significant associated development costs, mean that the supply of
new treatments by the pharmaceutical industry has not met the demand in recent
years.7
Both WHO22 and the European Commission23 have called for innovation in anti
biotic drug development to help tackle this crisis. WHO24 has recommended that
government incentives should be used to encourage the pharmaceutical industry
to invest in research and development for new antimicrobials. It has also suggested
that fast-track systems could be developed for medicines regulators to bring new
agents to the market.25
New antibacterial drugs have reached the market in recent years, but speed of
drug development has not matched the demand for new treatments.26 Some new
treatments have failed to live up to expectations. For example, tigecycline was
released in 2006 as a treatment for complicated skin and soft tissue, and intra
abdominal infections. In 2011, the Medicines and Healthcare Products Regulatory
Agency issued a warning that tigecycline should only be used when other antibiotics
are unsuitable, because of increased mortality rates observed in clinical trials.27 As
such, the treatment has a limited value and is not routinely used. The usefulness of
newly launched antimicrobial drugs, such as ceftaroline and fidaxomicin, remain
to be seen.
The development of AMR is inevitable and we can only act to slow its progress,
not eradicate it completely.28 Due to the rapid replication of bacteria and the associ
ated genetic mutations that lead to AMR, scientific research will always struggle to
keep pace. Drug development is unlikely to provide timely solutions, in sufficient
volume, to tackle the growing problem of antimicrobial-resistant infections.29
Therefore, it is essential that existing antimicrobials are used prudently, following
local guidance and sensitivity results where these are available, to slow progress of
AMR. The many factors that influence the prescribing of antibiotics and can lead
to antibiotic misuse shall now be considered.
WHAT DO WE MEAN BY ANTIBIOTIC MISUSE?
REFLECTION EXERCISE
Reflect on what is meant by antibiotic misuse. Compare your thoughts with the
discussion outlined in this section.
If prudent prescribing is required, are antibiotics currently prescribed irresponsibly

or misused? The link between antibiotic use and resistance is noted, and misuse
of antibiotics is indeed considered to be a causative factor in the rise of AMR.30
If bacteria continue to evade the antibiotic this is a problem that could in fact
get worse. WHO recognises this as a global threat and calls for ‘stronger action
worldwide to avert a situation that entails an ever increasing health and economic
burden’.31 Interventions have been aimed at reducing the risks associated with AMR,
including targeted education for the public, health workers and prescriber, and
awareness-raising campaigns. These activities span almost 2 decades of interven
tion, but they have done little, it seems, to reverse the tide. As the most commonly
prescribed drug, the way in which antibiotics are used is vital in the fight against
antibiotic resistant bacteria. A recent report, Antibiotic Resistance Threats in the
United States, 2013, from the Centers for Disease Control and Prevention (CDC),32
states that ‘up to 50% of all the antibiotics prescribed for people are not needed or
are not optimally effective as prescribed. From the vast array of published literature,
antibiotic misuse could be described as:
• unnecessary prescribing of antibiotics, overuse (e.g. for viral infections)
• use of broad-spectrum antibiotics, or narrow-spectrum antibiotics used
incorrectly
• misuse and inappropriate dosing, route of administration and/or treatment
duration
• prescribing in the absence of microbiological culture results.
There is evidence to support the view that there is a clear link between antibiotic
resistance and the use of antibiotics by patients and prescribers. This evidence is
global and spans over a decade.33-36 It is important that the role of prescribers and
the public in tackling this problem is considered. The reported issue of misuse
of antibiotics perhaps assumes there is a general belief that there is a problem.37
However, this may not be the case. There is evidence3839 to suggest that not all
clinicians or patients see antibiotic resistance as a reason for antibiotics not to be
prescribed; some clinicians even view the risk as ‘theoretical or minimal’ and some
state ‘the issue has been exaggerated. It seems interventions are required in the
education of both prescribers and the general public. Perhaps a starting point would
be to consider why prescriptions are issued in the first place. It could be argued that
a prescription is issued to achieve a therapeutic objective, either to:
• relieve a symptom
• reach curative outcome
• or prevent a condition occurring.
In the case of a prescription for an antibiotic, it is apparent that the prescriber

should be aiming to reach a curative outcome. This would assume an accurate diag
nosis is made, the bacterium causing the infection is known and there is evidence
to suggest an antibiotic will cure the infection.
However, there is evidence to suggest that prescribers are not influenced by
clinical factors alone when prescribing.40-45 While an abundance of evidence exists,
a systematic review by Lopez-Vazquez46 warns that some evidence has limited
significance due to limitations in methodology, although this review did recognise
complacency (patient expectation) and fear (complications) as related to inappro
priate prescribing.
WHAT INFLUENCES ANTIBIOTIC PRESCRIBING?
REFLECTION EXERCISE
Reflect upon what you feel may influence antibiotic prescribing and then com
pare your thoughts with the influences identified in this section.
There is an abundance of evidence to suggest that non-clinical factors are also

considered when making the decision to prescribe medication, including antibiot-
ics.47-54 These factors have been categorised into those relating to the patient and
those relating to the prescriber.
Prescriber-related factors include:
• personal characteristics
• knowledge
• features of clinical practice
• prescribing preferences
• local management policies

• patient expectation
• fear of uncertainty about diagnosis, complications, experience
• evidence and policy
• drug companies
• patient demand or satisfaction.
Patient-related factors include:

• socioeconomic status
• quality of life
• expectations and wishes
• lack of knowledge
• beliefs of health and illness
• previous treatment with antibiotics.
Macro and micro decisions relating to prescribing practice have been observed in
a small study examining variations in prescribing practice among general practi
tioners (GPs).55
Where non-clinical influences on prescribing have an effect on the number of
prescriptions for antibiotics, it seems that measures to reduce antibiotic prescrib
ing will need to respond to these factors in addressing the issues highlighted by the
World Health Organization56 and the International Forum on Antibiotic Resistance
colloquium.57 These factors, it would seem, require intervention at several levels.
For example, public education is required to raise awareness of the role of antibiot
ics in disease; prescribers need to be judicious in their decisions to prescribe an
antibiotic. These strategies aim to reduce the risks associated with misuse or overuse
of antibiotics.
The factors listed earlier could be considered in the context of the following:
• the prescriber-patient relationship
• uncertainty of diagnosis and progression of illness
• lack of knowledge and understanding of the role of antibiotics.
THE PRESCRIBER-PATIENT RELATIONSHIP

There is some evidence to suggest that patients are more likely to be given an
antibiotic if they ask for one, or when they exert pressure on the prescriber to
prescribe.58-60
REFLECTION EXERCISE
Reflect upon why patients may exert pressure on the prescriber to prescribe and
compare your thoughts with the suggested list outlined in this section.
• To prove they are ill

• To feel something is being done
• Because they have faith in medicines
• Rather not alter their lifestyle
• Because it has worked before
• To avoid cost of purchasing medicine
• Addiction
• As an alternative to other treatment
• ‘Just in case’
• Direct-to-consumer advertising (United States and New Zealand)61
Prescriber-patient relationship factors may be linked to the personal characteristics

of prescribers or fear of retribution if an antibiotic is not prescribed and the patient
becomes more unwell. A study considering the use of broad-spectrum antibiotics
found that GPs were likely to prescribe because of a desire to do the best for the
patient and society.62 Factors relating to the wider healthcare system could also be
contributing to the possible misuse of antibiotics. In Germany, cost considerations
may influence the prescriber. Patients have to pay for weekend call-outs and this
was considered as a possible reason for the increase in prescribing on a Friday.63
This study showed a 23.3% increase in antibiotic prescribing before the weekend.
The authors of this study considered that there may have been an increase in the
number of patients presenting on Friday with diagnoses that required antibiotics.
However, they found that the number of patients presenting with urinary tract
infection or respiratory infection was almost the same as on other days of the week.
In the UK, patients requiring out-of-hours or weekend treatment are unlikely to be
seen by their own GP, so prescribing may occur as a result of the desire to maintain
continuity of care. While in the UK weekend care does not have a cost implication,
there is perhaps a tendency to prescribe in order that the continuity of care is not
compromised. In a study examining the views of diabetic patients regarding their
consultations with nurse prescribers, continuity of care was noted as important by
almost all of the 41 patients interviewed.64 The mood of the doctor has also been
shown to influence prescribing. A study65 exploring the association of mood on five
behaviours including prescribing found a correlation between negative moods and

increased prescribing.
UNCERTAINTY OF DIAGNOSIS AND PROGRESSION OF ILLNESS

Prescribers may be more likely to give a prescription for an antibiotic on a Friday
because of the lack of services over the weekend.66 It may not be clear that a patient
requires an antibiotic at the time of consultation but there could be the potential for
infection to develop. Prescriptions may be given ‘just in case’, requiring the patient
to make the decision whether to commence treatment. This relies on good infor
mation being given at the time of the consultation and the patient understanding
both the risks of taking an antibiotic if not necessary and the risks of not taking
the antibiotic if the condition becomes worse. In India, patients are known to use
their old prescriptions to obtain a new course of antibiotics when experiencing
similar conditions that resulted in a prescription for antibiotics previously.67 This
is possible in India as prescriptions are not kept by the pharmacist but given back
to patients, which enables reuse. In the UK this would not be possible, as prescrip
tions are retained by the pharmacist. A lack of understanding by patients of the
role of antibiotics can lead to inappropriate prescribing. Prescribers may be pres
sured to prescribe in circumstances when a patient experiences similar symptoms
to those that have previously resulted in a prescription being issued. Some patients
may even visit a specific doctor who has previously prescribed. A small study68
describes instances where nurse practitioners have issued delayed prescriptions
despite their better judgement, to ‘keep the peace’ for children with suspected otitis
media, despite guidelines that suggest antibiotics provide little benefit. The risks
of antibiotic resistance and the effect on individual patients have been identified
through a systematic review.69 The authors reviewed 24 studies that explored the
effect of antibiotic resistance in individuals. They found strong evidence to suggest
that those patients who were prescribed an antibiotic for a respiratory or urinary
tract infection developed resistance. The resistance was strong in the first month
following treatment but could last for up to a year. A ‘vicious cycle of resistance’
is described, and the authors suggest the way of breaking the cycle is to avoid the
prescribing of antibiotics in the first place. By highlighting the effect on individual
patients, prescribers may be less likely to consider prescribing an antibiotic where
the clinical presentation is uncertain.
LACK OF KNOWLEDGE OR UNDERSTANDING OF THE ROLE OF

ANTIBIOTICS
Patients
There is a global need to raise awareness of the role of antibiotics. The United States-
based CDC has been running campaigns focused on appropriate antibiotic use since
1995. In 2003 they renamed the campaign ‘Get Smart: Know When Antibiotics
Work’.70 The campaign aims to reduce AMR, targeting healthcare providers and
the general public by:
• promoting adherence to appropriate prescribing guidelines among providers
• decreasing demand for antibiotics for viral upper respiratory tract infections
among healthy adults and parents of young children
• increasing adherence to prescribed antibiotics for upper respiratory tract
infections.
The efforts of the CDC are reflected across the globe. The ‘Get Smart about
Antibiotics’ week is supported across the United States by organisations such as the
Alliance for the Prudent Use of Antibiotics. In November 2015 the campaign will
coincide for the fourth year with similar week-long campaigns in Australia (NPS
Medicine Wise), Canada (Antibiotic Awareness) and across Europe (European
Antibiotic Awareness Day). The UK is one of 28 European countries participating
in the campaign. These campaigns provide online resources for healthcare workers
and the public aimed at educating people about the appropriate use of antibiotics.
They also provide advice for treating minor ailments such as coughs and colds at
home, and explain that in these cases people do not require a visit to the doctor. A
range of posters, videos, webinars, factsheets and advice sheets are available from
these providers for public and professional use. Campaigns raise awareness of the
risks associated with taking antibiotics and how to take them responsibly. They
are targeted at the general public, healthcare workers and prescribers in hospital
and primary care. Interestingly, in 2009, the UK Department of Health found that,
in general, people were confused about bacteria and viruses and what conditions
could be treated with antibiotics. The autumn antibiotic campaign was cancelled
as a result of this lack of understanding, as well as lack of knowledge in the general
public; there was a view that due to the use of antibiotics for secondary infections it
may not be the best time to run the campaign, as the public was already confused.71
It appears there may be little change in public perception of the role of antibiot
ics since 2009, as more recent qualitative research72 revealed that of 1767 patients
surveyed regarding the use of antibiotics in respiratory infection, 24% of patients
believed antibiotics would work for coughs and colds and 38% thought antibiotics
would kill viruses. This lack of understanding of the role of antibiotics for certain
illnesses has the potential to further increase the misuse of antibiotics. It is possible
for the general public across the world to purchase antibiotics over the Internet,
although import of prescription-only drugs is illegal in the UK and the United
States, and in some countries illegal sale of antibiotics over the counter persists.73,74
It has been noted75 that the media, the Internet and other non-credible sources of
information are used extensively by patients when searching for information about
healthcare-associated infection, which may account for the apparent lack of under
standing about the role of antibiotics in infection and the rise of resistant bacteria.
Information was viewed as generic with little specific, understandable information
available. However, comprehensive advice for patients is available through websites
such as NHS Choices76 and Patient UK77 in the UK, CDC78 and the US Department
of Health and Human Services Food and Drug Administration79in the United States
and the European Centre for Disease Prevention and Control,80which would seem
to address the issue of specificity by providing clear advice aimed at reducing the
number of antibiotics prescribed for viral throat infection, for example. Another
problem related to understanding that has been identified is that patients may stop
taking an antibiotic when they feel better.81,82 Patients who do not complete a full
course of antibiotics could be at risk of prolonged infection and this could contrib
ute to the rise in resistant bacteria.83
Prescribers
Not all prescribers themselves are knowledgeable and up to date with current
practice guidelines for the use of antibiotics. Numerous guidelines exist for the
treatment of infection that are designed to assist the prescriber in their decision
that an antibiotic is necessary, but there is evidence to suggest that such guidelines
are not always adhered to. In 1998 a report by the UK Standing Medical Advisory
Committee84 stated that many cases of otitis media did not need antibiotics. It was
reported later85 that it was not clear that this had any influence over GP prescrib
ing and that declines in antibiotic prescribing has stabilised since 2000. It has been
reported86 that a similar study undertaken in 2009 showed the continual use of
broad-spectrum antibiotics despite guidelines that recommend penicillin V as first
choice in acute respiratory tract infection. This study also noted that the higher the
number of consultations, the higher the use of antibiotics. In one study87 designed
to explore equality in prescribing across race and insurance status in the United
States, it was discovered that despite guidance in 2004 that recommended ‘watch
ful waiting’ for acute otitis media, little change in the level of prescribing has been
noted, although doctors are using the first-line recommended antibiotic.
It would seem that all health professionals have a role in ensuring the mes
sage about the risks of overuse and misuse of antibiotics is clear and consistent.
Prescribing of antibiotics should be accompanied with clear instructions and
advice about how to take them for the best effect. Prescribing influences should
be recognised and acted upon, prescribers must be aware of existing guidance and
policy related to antibiotic prescribing, and action to reduce the threat of resistant
bacteria should taken. Prudent prescribing requires a multifaceted approach by all
healthcare practitioners.
ANTIMICROBIAL STEWARDSHIP
Antimicrobial stewardship aims to reduce inappropriate antibiotic prescribing,
therefore reducing the risks of antibiotic-resistant infection and improving out
comes for patients.88 Antimicrobial stewardship is a worldwide initiative for both
hospital and outpatient or primary care settings. This initiative is supported in the
United States by the ‘Get Smart for Health Care’ campaign CDC,89by the Australian
Commission on Safety and Quality in Health Care,90 and across Europe.91 and in
the UK, ‘Start Smart - Then Focus’92 reminds practitioners of the legal obligation
to ‘ensure procedures are in place to ensure prudent prescribing and antimicrobial
stewardship’. The publication provides clear extensive guidelines for antibiotic pre
scribing and ongoing management.
The clear message in this document for UK practitioners is only to start antibi
otics where a bacterial infection has been clearly identified: once culture has been
obtained. Once started, the prescription should be reviewed. Antibiotics should
be switched as quickly as possible if necessary when treatment has started prior to
cultures being obtained. Intravenous antibiotics should be changed to oral as soon
as possible. The programme is focused on use of guidelines, education and audit of
practice. Similar guidance is available from the CDC website in the United States.
A small study93 suggests that ‘introducing the policy maker’ to the decision to pre
scribe may damage the doctor-patient relationship. The study, while not focused
on antibiotic prescribing, found that doctors may wish to preserve the relationship
with the patient by using a flexible approach to guidelines. A study undertaken94
in five European countries and Argentina examined the use of antibiotics in acute
exacerbation of chronic obstructive pulmonary disease. The study explored the
predictors for prescribing an antibiotic and whether the use of C-reactive protein
(CRP) testing reduced prescribing. They found that GPs who used the CRP test
were less likely to prescribe an antibiotic. CRP was used as a supplementary test and
resulted in fewer antibiotics being prescribed. Tests such as these could be useful
in reducing the rate of antibiotic prescribing through clinical presentation alone.

Purulent sputum was the highest indicator for a prescription.
There have been calls for all primary care nurses in the UK to be involved in
increasing awareness in patient groups of the risks associated with inappropriate
antibiotic prescribing.95 Nurses working in primary care and community are well
placed to educate patients about alternatives to antibiotics because nurses were seen
as key practitioners, as they spent more time with patients than other healthcare
workers.96 It is indicated that if antimicrobial stewardship programmes are to be
successful, they need to take into account the underlying influences that affect pre
scribing behaviour and not be focused on policy and guidelines.97 Prescribers want
to do the best for patients, to protect them from the harmful effects of infection, to
preserve their unique relationships and to ensure practice is responsive to patient
need. It is clear that prescribing is a complex process and that many factors influence
the decision to prescribe. This is supported by a systematic review98 undertaken to
determine the most effective method of improving antibiotic prescribing in primary
care. The review noted that lectures, providing literature and giving feedback did
not improve prescribing. Meetings improved prescribing, but it was not clear if
visits by educators had any effect. It was noted that the use of delayed prescriptions
did decrease antibiotic use. The review concluded that no one intervention was
particularly successful on its own but that using different methods together could
be successful. Interestingly, a review of the literature relating to interventions for
effective antibiotic stewardship in hospitals in 201399 revealed that restriction (e.g.
needing additional agreement for prescription) and persuasion (e.g. giving feedback
or advice on how to prescribe) did improve antibiotic prescribing. The review found
that the restrictive methods seemed to have a greater effect.
Much evidence exists to imply that antibiotics are a hindrance in infection
control; indeed, it has been stated: ‘Control of prescribing would probably be just
as effective a measure in our fight against healthcare-associated infection as con
ventional infection control measures’,100 prescribers need to be supported if we are
to ‘beat the bugs’. Much more needs to be learned about the factors that influence
the decision to prescribe antibiotics; it seems to be clear that there will not be a ‘one
size fits all’ solution.
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C H A P TE R 9
The impact of C lo s t r id iu m d i f f ic ile

infection on patients and
their families
Graziella Kontkowski
In July 2005, shortly after arriving for Sunday lunch with my family, my grand
mother was admitted to hospital. She was taken by ambulance to the nearest
accident and emergency, where she was examined and blood and urine samples
were taken. I was informed that it seemed she was suffering from a severe urinary
tract infection and that she was required to be admitted for intravenous antibiotics.
Granny responded well to the treatment, but after about 5 days of being in hospital
she suffered a setback - she had developed a further infection (osteomyelitis), which
was to delay her discharge.
I was visiting her in hospital every day, and on first impressions the ward looked
like any other ward providing care of the elderly. There were five beds to each bay.
Two of the beds opposite my Granny were occupied; one of these women never
seemed to have any visitors and the other had a constant stream of visitors who
were present with her most of the time. One of the things that I do clearly remember
about one of these women was the smell that travelled through the bay after she
opened her bowels: it was foul and offensive, and being July the temperature was
too high, which didn’t help the situation. I noticed more and more people were
coming to see her and I soon realised that this was because she had become very
unwell. Sadly, she died. At the time, I didn’t know what caused her death; little did
I know I was soon to find out.
During one of my evening visits I was greeted by a nurse who informed me that
111
my Gran had ‘a little bug. I didn’t think too much about it - I knew tummy bugs
lasted a couple of days, so I wasn’t too worried. A couple of days passed but Granny
wasn’t getting any better; in fact, she looked worse. At this stage I was informed
that she would have to be put into one of the isolation rooms. I asked questions but
no one was telling me what was wrong. I was promised some information and, in
passing, one of the senior house officers told me that the bug Granny was suffering
from was Clostridium difficile. Granny was now experiencing constant diarrhoea. It
was relentless; she could not control her bowels and she often had accidents in the
bed while waiting for the bed pan to be brought to her. She started to suffer from
bed sores. She had no appetite and would only drink when someone pushed her to,
resulting in her becoming dehydrated and then her kidneys began to fail. How on
earth was this happening? Why was no one ensuring that she was drinking when
I wasn’t with her to do this?
There were so many things that worried me about her care, with the casual
approach of the nursing staff being number one on my list. In fact, there were one
or two nurses who really should not have been working in a profession that is sup
posed to care for others, because there was nothing about them that conveyed to
me that they cared about their patients. I found tablets on the floor - tablets that
were supposed to be given to my Granny; soiled linen left in a corner of her room
time and time again; dirty bed pans being brought in for her to sit on; and on one
occasion I found her intravenous line hanging out of her arm with the pump still
pushing fluids through, resulting in the floor being covered with saline, the list went
on and on. I was disgusted and upset that in this day and age I was witnessing such
a poor standard of care here in the United Kingdom.
The environmental cleaning was another issue that concerned me greatly. While
there were cleaners who would come in to clean the room, most of the time they
looked half asleep. I witnessed them give the room a very superficial clean - the
dust was so thick in places it could have made a blanket. The curtains were dirty and
there were visible stains on the walls. It was clear that these staff were not fulfilling
their basic duties. I felt helpless and I didn’t know what to do. I was so unhappy
about leaving my Granny in this environment but I felt there was very little I could
do. I couldn’t bring her home, because she was too unwell, but I couldn’t just sit
back and watch what was happening on the ward. Like many relatives who have to
leave their loved ones in the care of healthcare staff, I was at a loss: I didn’t know
what to do. I considered complaining but I was anxious that Granny was vulnerable
and completely dependent on the staff to care for her; however, I decided I had no
alternative. I had to complain. This wasn’t just for my Granny: this was for other
patients too, other patients who had no one to speak up for them.
THE IMPACT OF C L O S T R ID IU M D IF F IC IL E INFECTION ON PATIENTS 113
What staff have to remember is that the patients they look after are someone’s
mother, father, brother, sister, son or daughter and in my case my grandmother.
They are in hospital because they have to be, because they are ill. Often they are
very vulnerable and frightened being in an environment that is alien to them.
Therefore, it is important that staff do their utmost to ensure that the patients they
care for are always treated with the dignity and respect they deserve. One final thing
to remember is that, one day, that patient could be one of your own loved ones or
perhaps even yourself; therefore, never give care that you yourself would not be
prepared to accept.
My dear Granny wasn’t doing well at all. She had become a shadow of her former
self. This larger-than-life Italian woman was now transformed into a very frail, very
sick old lady who was going to die from an infection she contracted in hospital on a
dirty ward with uncaring staff. It broke my heart watching her. I felt so guilty - guilty
about so many things. Why did I allow the ambulance to take her to this particular
hospital, the hospital where my mother had died at the age of 49 from complications
of cholecystitis, and where we hadn’t set foot for the 15 years that had followed? I
felt guilty about not being able to be with her as much as I wanted to. I felt guilty
that I couldn’t do more to alleviate her suffering, and I felt guilty that it took me so
long to speak up, something that I should never have had to do if the care she was
given were of a good standard.
After my complaint, Granny was moved back onto the open ward because it was
now being used as a cohort ward, with 30 patients infected with C. difficile. I felt
that at least she would not be as neglected on the open ward as she had been in the
isolation room, but how wrong I was. It made no difference, because the staff on
the ward could not to cope with such a huge outbreak. It was complete chaos. Staff
could not keep up with the volume of patients suffering with diarrhoea; the smell
on the ward is something that I will never forget.
It was such a distressing time for me: my Granny had been a huge part of my
life for so long and now I was watching her die and I felt I could do nothing to help
her. You may say that she was 93, that she had lived her life, that we all have to go
one day - and of course we do - but it was watching her suffer in the way she did
that was heartbreaking and which left me feeling helpless.
In September I went in to visit her and at this time I knew that Granny had lost
her fight. The look on her face as she saw me approaching the bed is an image that
I will never forget. She held her hand out to me and tried to speak, yet words were
not coming out. She looked so frightened. There were nurses in the bay but they
did not seem to see how distressed she was. Her hands were so cold, she looked
pale and her body was shutting down, yet nobody seemed to be doing anything. I
asked the nurses to get a doctor to come to see her. In my heart I knew that she was
dying, but I still wanted someone to tell me she would be OK. The doctor came but
she didn’t do very much: she had a quick look at Granny and spoke about giving
her some fluids, but I could see it was now just a matter of time. I called my brother
to join me at the hospital. I made arrangements for my children to be looked after
and, between my brother and I, we sat with her day and night until she took her
last breath at 4.30 p.m. on Monday 26 September 2005.
Yes, my grandmother was old and had lived a full life, but no one should have to
go through what she went through, and die in the way she did, with a lack of dignity
and compassion. So many illnesses that were once a death sentence are now treat
able. We have so many technologies and new methods in many parts of healthcare
to detect problems before they happen, yet here I witnessed a preventable infection
kill someone I loved. I constantly search for answers to the question: ‘Were there
things that could have prevented my grandmother from contracting C. difficile?’ I
know now that the answer to this question is yes, and I feel the overuse of antibiotics
has played a major part in the explosion of these lethal infections. However, in my
grandmother’s case she needed antibiotics to treat what was fast becoming a life-
threatening sepsis. While antibiotics may have played a part in my grandmother’s
condition, I firmly believe that a lack of basic hygiene was also a major factor. It
seemed that no one at the hospital was taking the problem seriously until it was too
late, and by this time the infection was rampant on the ward. Simple things such
as good hand hygiene and careful environmental cleaning could have helped to
prevent infection for not only my grandmother but also many other patients. This
outbreak of C. difficile contributed to a very tough workload for staff. My grand
mother was not mobile, so it is highly likely that the infection had been passed on
to her from the hands of a healthcare professional, something that could have been
avoided if staff had taken the time to wash their hands. Something so simple could
have prevented the spread of this lethal infection.
Since 2005 there have been many improvements in infection prevention and
control and the numbers of infections have been falling. However, I would urge all
healthcare professionals to think over my words as they provide their care and treat
ment to vulnerable patients, and in particular to remember to always do the right
thing: cleaning your hands at the right time and making sure wards are clean and
safe. Always remember to follow your infection control protocols, because I am sure
no one would want to be responsible for passing an avoidable infection to a patient.
Something as simple as cleaning your hands can make a big difference to the
outcome of your patient’s care; therefore, I would urge everyone who cares for
patients to never become complacent and to never think that hand hygiene can be
THE IMPACT OF C L O S T R ID IU M D IF F IC IL E INFECTION ON PATIENTS 115
overlooked because ‘there isn’t time. Washing your hands takes less than a minute,
so never say, ‘I haven’t got time. Not only will that minute save you time - time
having to look after someone suffering from an avoidable infection - but also, and
more important, that minute really can save lives.
C H A P TE R 10
The challenge we all face together
Derek Butler
In being asked to contribute a chapter for this book I asked myself, what could I
contribute that would make an impact and enlighten those of you in healthcare who
care for others, especially in respect to healthcare-associated infections? Although
I am not a healthcare professional, I have been affected by events surrounding
healthcare infections that could primarily have been avoided.
As you will have already seen in this book, there are many contributions from
eminent people in the healthcare profession and patient groups looking at reasons
why and how we can ensure patients receive clean, safe care, free from the fear of
contracting an avoidable healthcare infection. The effect such an infection has on
pain, suffering and loss of dignity; on patients and their families, is all too apparent.
When the system fails it has a ripple effect that leaves an unwanted legacy.
However, for my own contribution, I would like to dedicate this chapter to the
memory of the most important people concerned within this book: the patients who
have suffered, and their loved ones who lost someone to an avoidable healthcare
infection. I would like to dedicate this chapter especially to my dear friend and step
father, John Crews, whom our family tragically lost at the age of 54. I would also like
to dedicate this chapter to those families who have lost loved ones and with whom
I have met. These include the families of people such as Sue Fallon, who lost her
daughter at the age of 17 and who had to tell her youngest daughter that her sister
would not be coming home from hospital; Paul Kelly, who lost his pregnant daugh
ter Clare at the age of 23 and his unborn grandson; Mavis Law, whose son Colin died
the day before his 33rd birthday when admitted to hospital for tests; 68-year-old
Patricia Galvin, who bravely fought cancer only to succumb to meticillin-resistant
Staphylococcus aureus (MRSA); and Patricia Lloyd, a mother who contracted MRSA
117
and died after treatment from a community dentist. In addition, the many other
families I have come into contact with as chair of MRSA Action UK.
Probably the hardest thing anyone can experience is to lose a loved one. I have
experienced first-hand the effects healthcare-associated infections have on those
who contract them and on the family left behind. Certainly, in life I have learned
there are certain events that shape a person’s life. For me, having my stepfather in
my life helped to develop whom I am today; however, the event that shaped the
life I have now, and which was the hardest thing I have ever done, was to hold my
stepfather in my arms and watch him die. This was a man who was the greatest
influence in my life, a man whom I called my friend, a person whom I could rely on
to turn to for help if I needed to. My stepfather was a man who had helped me all
my life, yet at the moment he passed away I felt helpless in not being able to prevent
his death. However, the aspect of this event that shaped my life the most was that
even at the time my stepfather died, we were never informed that he was profusely
infected with MRSA, despite the staff and the hospital knowing this for 7 days
before his death. Once we discovered the facts and that the staff and hospital knew
of the infections, like all the families I have mentioned, we determined ourselves
to prevent this from happening again to other families.
I questioned myself, how could anyone be lost to an infection in the twenty-
first century with all the modern healthcare facilities, with all the modern drugs
especially antibiotics, the golden bullets and all the knowledge mankind has accu
mulated in combating bacteria? With the help of others, MRSA Action UK was
born to seek answers to our questions. I want to look at this from a more personal
perspective and perception for us all, for future generations and all our families. I
would like to make this thought-provoking and challenging and, more important,
I would like to look to the long view on why it is vital to control bacteria in our
medical and community facilities, and why the loss of the efficacy of antibiotics will
have an impact on all our futures.
Let us remember that the majority of people alive or reading this chapter today
were born in an antibiotic era. If you get an infection today, the answer is simple:
just take an antibiotic. For how much longer will this be the answer? It would be
wise for us to remember that within living memory it was not always like this. In
the early to the middle part of the twentieth century, over 50% of people did not
live past the age of 65. Infection was the leading cause of death and people used to
live in mortal fear of bacterial infections. There was no cure; the only defence was
scrupulous hygiene, both in the home and in hospital. Antibiotics changed all of
that, and their discovery gave mankind the greatest leap in medical science it had
ever known, opening new avenues to treatments once thought impossible.
THE CHALLENGE WE ALL FACE TOGETHER 119
Imagine what it must have been like in our hospitals in the early part of the twen
tieth century, in respect to infection prevention and control before the discovery of
antibiotics. Hygiene and cleanliness was far more stringent then than it is at present.
Ask yourself honestly, could you and your colleagues manage to perform your
duties today as your predecessors did all those years ago but without the current-day
advantages you have, advantages that they could never have dreamed of?
Why is it so important to have effective infection prevention and control sys
tems that leave no gaps for bacteria to infect patients or enter our hospitals and the
community? Let us be under no illusions as to the importance of good infection pre
vention and control and what this means to us, to future generations and, moreover,
to the future of modern medicine. Our failure to take the correct action necessary
now will place the future of modern medicine, as we know it, in jeopardy. Our fail
ure in infection prevention and control will add pressure to our dwindling stocks of
antibiotics, leaving the possibility that resistant bacteria will become dominant and
leaving modern healthcare medicine as we know it consigned to the history books.
This would mean medical procedures that were only dreamed of less than
40 years ago but which we now take for granted would become non-existent. This
would in effect make our healthcare system return to a position not seen by our
generation or even our parents’ generation. Therefore, it is in our own interests to
ensure that we as parents pass on to our children a healthcare system far better than
the one we inherited from our own parents.
Where does infection control fit into all of this? You as infection control staff
have the skills, knowledge, ability and responsibility to alter what many think is
inevitable. If you talk to the families who have lost a loved one to what is, for all
intents and purposes, an avoidable healthcare infection, they will tell you that it
leaves a legacy that cannot be erased. They will tell you it leaves a legacy of helpless
ness and of bewilderment that their loved one has died from something that not
that long ago was treatable with a positive outcome. They then look to the past with
puzzlement as to how we managed to find ourselves in this situation, and they fear
for the future of their children and grandchildren and whether they will receive the
medical care we take for granted.
Those same families and individuals have said to me, do the medical staff not
realise that our concerns are their concerns, our children and grandchildren are
their children and grandchildren, and it is their future healthcare we are putting at
risk when we ignore this problem? They ask me, do the staff have no concerns that
while we erode the use of these magic bullets called antibiotics, we are consigning
future generations to a life that will be far worse than the one we have lived?
Therefore, what can be done to try to reverse this situation? Well, you as
healthcare professionals are in the unique position of being able to slow down this
problem of contracting avoidable healthcare infections by your own actions and
thoughts. You do not have to accept that some things are inevitable: they are not,
otherwise we would not have progressed to the point where we are as a species
today. We have progressed because we challenge, we do not accept the inevitable
and we change the norm.
A great American leader once said, ‘If you are aware something is wrong, if you
have the ability to correct that wrong, then you have placed upon you the respon
sibility to correct that wrong’ (Anon). We are all in a battle against the formidable
enemy that is bacteria, an enemy that can mutate and change and spread with
impunity. However, the Achilles heel of bacteria is that many cannot survive in
their own environment and rely on the conditions created by humans. However, if
those conditions are changed and controlled then bacteria will find it very difficult
to cause harm both now and in the future. What words of advice can I give you, a
person who represents those who have been affected by avoidable healthcare infec
tion and one who has seen the effect this has had on my family first-hand?
It doesn’t matter how efficiently the hospital functions; how good the train
ing, supervision and procedures are; or how well the best worker, doctor, nurse,
cleaner or manager performs his or her duties. People cannot perform better than
the organisation supporting them; so ensure that you and your colleagues change
the system to support you, because you don’t just want to succeed, you also want to
excel. While ‘success’ means being the best, ‘excellence’ means being at your best.
The quality of excelling is an ongoing pursuit to continually ensure that you can give
your patients and their families the confidence that everything that can be done to
ensure their safety is being done.
The greatest tribute you can give, in memory of those who have suffered and
been lost to avoidable healthcare infections, is to do all that you can, in spite of all
the difficulties you face, to ensure that no patient contracts an avoidable infection
on your watch. I hope that when you have finished reading this book, you will ask
yourself and your colleagues one simple question: What are we going to do differ
ently when we go back to care for our patients that we are not doing now?
I would like to finish with a few thoughts from our organisation, MRSA Action
UK. Our organisation was born out of the pain we felt at losing a loved one to
an avoidable healthcare infection. However, we must remember that in the final
analysis our most common basic link is that we will all use the same healthcare
system. We all want safe, clean care, and we all cherish our children’s future and
want them to receive the same safe, clean care, but we should also remember that
we are all mortal.
THE CHALLENGE WE ALL FACE TOGETHER 121
My final thought comes from Edmund Burke,1who said:
All that is necessary for the triumph of evil is that good men do nothing.
Let us change this to:
All that is necessary for the triumph of bacteria is that good people do
nothing.
We, the staff in the National Health Service, the patients, their families and patient
support groups such as MRSA Action UK must work together on this, in the
memory of those who have been lost. Failure to do so will leave a legacy for our
children and grandchildren that they will never forgive us for. Let us not throw
away the legacy Sir Alexander Fleming gave us regarding antibiotics, and let us
always bear in mind importance of doing the right thing, first time every time in
combating resistant bacteria.
REFERENCE
1. The Quotations Page. Quotations by Author: Edmund Burke (1729-1797). QuotationsPage.
com. Available at: www.quotationspage.com/quotes/Edmund_Burke/ (accessed 9 January
2015).
PART III
Possibilities for infection

C H A P TE R 11
No stone left unturned: the

relevance of the neurosciences to
infection prevention and control
Julie Storr
We have m apped the human genom e but we still cannot get healthcare
workers to clean their hands at the right time.
It weighs roughly the same as a bag of self-raising flour, is made largely of fat and
water, and is the target of most of what we do in infection prevention and control
(IPC). And right now, it’s sitting inside your head as you read this book. The brain.
The organ that controls everything we do, how we think and perceive the world
around us and, importantly, how we behave. For those of us interested in improv
ing practice it is critical that we understand the determinants of behaviour. Such
an understanding offers much in relation to getting and keeping people’s attention,
getting inside another person’s mind, to influence behaviours, to change or instil
habits, to stimulate a person to do something that will make or keep that person
safe. A full understanding will only enhance the impact of the policies we write,
the training we provide, the social interactions, the advice on the telephone, our
communication. This chapter will pose a series of questions designed to stimulate
those interested in IPC, to consider some of the available disciplines and what they
have to offer in our quest to get better at influencing and changing behaviour in
the pursuit of saving lives.
My first question, one that has niggled away at me for some years is: why is there
such a position of behavioural epidemiologist but not yet one of behavioural IPC
125
nurse or doctor - what does the answer to this question tell us? That there is no such
position suggests that we may need to move a little faster in order to fully integrate
the behavioural and the social sciences within the specialty. In 2012, a systematic
review by Edwards and colleagues1 found that theoretical frameworks from psy
chology, social marketing and other social sciences that address the issue of how
to change behaviour and sustain changes over time are widely underused in IPC.
Elliott2 did much to introduce the concept of the psychosocial aspects of infection
control through his book of 2009, and it’s fitting to mention the WHO Guidelines
on H and Hygiene in Health Care,3 which devoted an entire chapter to behaviour
change. The multimodal strategy that falls out of these guidelines promotes this
strategy as the ultimate ‘bundle’ for improvement. The multimodal strategy is
constructed around a number of theories of behaviour change, drawing on work
relating to motivation from the 1980s and 1990s when colleagues introduced us to
the Theory of Planned Behaviour4 and the Health Belief Model5 as applied to hand
hygiene improvement. In the early days of infection prevention, and potentially
even today, most of what academics describe often seems disconnected to the day-
to-day activities of IPC.
Let’s quickly summarise the essence of IPC. It is an evidence-based multidis
ciplinary specialty that is concerned with putting in place important processes
and interventions that affect patient outcomes. Through surveillance and feedback
of data, IPC practitioners should provide the necessary data to drive action and
alert the organisation to potential outbreaks. Through education and training
programmes, IPC endeavours to provide the requisite knowledge for safe practice,
whether that be about organisational or local guidelines related to the insertion
and maintenance of a urinary catheter or the utilisation and control of antibiot
ics. Ultimately, it exists to reassure patients and the public that healthcare workers
practise in a way that maximises safety and minimises harm. Much of IPC, there
fore, is concerned with implementation of established best practice guidance.
Implementation is about the way people behave. Facilitating the desired behaviour
relies on a combination of methods, not solely a technical understanding of clini
cal microbiology. It is on implementation and behaviour change that this chapter
will now focus.
Recently, Michie and colleagues6 have distilled 19 theories of behaviour change
and packaged them within the progressive and excellent Behaviour Change Wheel.
The Behaviour Change Wheel acts as a fulcrum on which to propose that there
remain as yet unexplored approaches within the social sciences that may contain
additional sources of strength to help us influence change. In fact, I will go deeper to
consider how the world of neuroscience, neurolinguistic programming (NLP) and
NO STONE LEFT UNTURNED 127
hypnotherapy might present some insights that could at least add value to current
approaches. Within the context of motivation, this chapter poses a question to the
infection prevention community: in the quest for impact, has enough attention been
paid to these fields and their possible utility? Do they have something or nothing
to offer us in the twenty-first century?
WHAT CAN WE LEARN FROM THE BEHAVIOURAL SCIENCES?

The Behaviour Change Wheel provides a framework for developing interven
tions that addresses the different influencers and determinants of behaviour and
is increasingly being used in public health and infection prevention. It acts as a
guide to securing the right behaviour change techniques in a certain context. It
addresses the interventions that are developed to change behaviour and the policies
that promote or support them. At its heart it addresses capability, motivation and
opportunity as the sources of behaviour that we need to fully analyse in order to
have the right influence at the policy and political level.
Sources of behaviour
Intervention functions
Policy categories
FIGURE 11.1 The Behaviour Change Wheel (reproduced with permission of BioMed
Central from Michie e t a l.6)
A recent RSA (Royal Society for the encouragement of Arts, Manufactures and
Commerce) report7 reminds us that in order to be clear about the different
approaches to behaviour change it is necessary to understand the two systems of
the human brain, the controlled system and the automatic system. The former is
concerned with thinking, goal seeking and deliberate actions, while the latter is
more intuitive and instinctive. Appreciation of these two systems and attempts to
exploit them is the basis for much of what is termed behavioural economics and
nudge theory.8 Daniel Kahneman’s9 fascinating book provides many insights into
how the two systems work and why we need to understand these in a behaviour
change context. Nudge theory is an extension of behavioural economics and
attempts to influence behaviour through developing social policies informed by
neuroscience and psychology. Application of nudge theory has led to adjusting the
language and simplifying messages used in formal communications to encourage
people to comply, for example, with outstanding debts. There are many examples
of this being successful, although it is not without its critics. Nudge theory is also
being applied in the field of public health, where, for example, changes to the envi
ronment such as designing buildings with fewer lifts encourage people to expend
energy walking up stairs. Building on these examples, to what extent can some of the
not-so-mainstream neuroscience disciplines help influence behaviour by affecting
the capability, opportunity and motivation of our target audience?
Human factors thinking is aligned with some of the ideas of nudge theory. It
is potentially a bridge between the concept of neuroscience and the reality of how
this can be applied in healthcare to address the challenges of practising safely in a
highly complex sociotechnical system.10
DISSECTING THE BRAIN: CONNECTOMES
To move things is all that mankind can do ... for such the sole executant
is muscle, whether in whispering a syllable or felling a forest.
Charles Sherrington, in Sueng 2013
The Human Connectome Project aims to build a ‘network map’ that will shed light
on the anatomical and functional connectivity within the brain. Sebastian Seung,
in his book Connectome: how the brain’s wiring m akes us who we are,11 explains that
any kind of personal change is about changing your connectomes. Seung explains
that, unlike our genome, which is fixed from the moment of conception, our con-
nectomes change throughout life. There are many unknowns on the matter but
it’s largely believed that life experiences and genetics change our connectomes.
Does this matter to our ultimate goals in IPC? Is there a way of influencing peo
ple’s connectomes that we just haven’t found yet? Will the outcome of the Human
Connectome Project be helpful to us in the future? Seung describes the way muscles
work, the axons, the synapses, contractions of fibres - muscles being the final desti
nation of all neural pathways. This is of relevance in instilling habits. Neuroscientists
explain that brain cells found where habits are formed and movement is controlled
have receptors that work like computer processors to translate regular activities
into habits.12
At a philosophical level, isn’t this the ultimate goal of most of what we are doing
in IPC - trying to facilitate, encourage, promote and make it as easy as possible for
people to do certain things with their muscles - open their mouth and communicate
in a certain way, hold a device in a certain way, reach out and press a plunger, put
one hand on top of the other and move them together in a certain way and at the
right time? A key aim of much of IPC is to translate learned behaviour into habitual
behaviour, making it easy to perform certain tasks within a sea of complexity.
Habits provide mental freedom and flexibility by enabling many activities to be on
autopilot while the brain focuses on more urgent matters.13 To date, much of this
thinking is being used for tackling disease processes and addictions. However, in a
field where habitual behaviours are wanted and sought after, there is much to learn
from our colleagues in neuroscience. In the words of Tsien13:
If you know cell circuits controlling a specific habit, it puts you in a better
position to devise strategies to hit different points and selectively facilitate
the formation of a good habit and maybe even reverse a bad one.
This may all seem rather random, but Seung11 suggests that in the future it might
even be possible to change connectomes such that we move away from traditional
training to influence behaviours and thoughts, and move to new, more powerful
approaches to enhance learning regimens. Our community would be foolish to
ignore developments such as these that might aid how we maximise our influence
in the pursuit of safer health and social care.
THE DARK ARTS: HYPNOTHERAPY AND NEUROLINGUISTIC

PROGRAMMING
Hypnotherapy and NLP are often greatly misunderstood, their theoretical base
the subject of question and until recently seen as separate to the mainstream of
healthcare. For example, people confuse the clinical intervention of hypnotherapy

with the entertaining (or not) endeavours of stage hypnotists. NLP is often criticised
as being manipulative.
However, at a simplistic level, the clinical hypnotherapy part of the field of
cognitive neuroscience can be described as the art of securing a person’s attention
and then effectively communicating ideas that enhance motivation and change
perceptions.14 In recent times its utility has grown in prominence as one method
for addressing a range of clinical problems and unwanted habits. A number of high-
profile individuals, from David Beckham to Tiger Woods, have openly talked of
its use as a means of enhancing sports performance. What, therefore, can we learn
from clinical hypnotherapy in our role as teachers, trainers and influencers?
Hypnosis classically refers to a change in baseline mental activity following an
induction procedure15 - more widely described as putting a person into a trance.
The purpose of hypnotic induction is to warm up an individual to be more respon
sive to suggestion, the suggestions often relating to desired or unwanted behaviours.
In relation to performance, a technique known as ‘anchoring’ can be used to instil
a behaviour within a person’s subconscious and associate it with a certain action
so that, when conscious, the action will bring back the desired performance in an
automatic way.
I am not suggesting that we use mass trance-inducing sessions as part of the
routine training of health workers or, indeed, any aspect of conventional clinical
hypnosis within IPC. What I am suggesting is that those of us interested in taking
the next steps in terms of understanding human behaviour and habit formation and
breaking, should be exposed to the art and science of hypnotherapy. I believe it has
much to offer in how we influence colleagues, how we talk, how we teach and the
words we use and how we say them.
NLP is equally fascinating in its potential to strengthen what we do and how we
do it. Described as an emerging technology in healthcare, NLP is a relatively new
approach to communication and personal development that has been increasingly
used in education and teaching.16 However, as with hypnotherapy, up until recently
there has been little academic work in this area. Tosey et at.16 describe NLP as an
innovation and explain that it is concerned with the connections between a person’s
internal experience (neuro), their language (linguistic) and their patterns of behav
iour (programming). In essence, NLP is a form of modelling that has meaningful
implications for training. It offers a communication framework using techniques
to understand and facilitate change in thinking and behaviour by proposing that a
person’s internal representations of the world show a bias for a particular sensory
modality (visual, auditory, kinaesthetic, olfactory or gustatory).17
WHAT CAN WE DO WITH THIS?

The relevance and application of behavioural theories per se in IPC is context
specific. Some of the alternative approaches described here require further devel
opment. However, the intention is to stimulate thinking beyond the conventional
comfortable world that we exist in and consider how some of the techniques that
are used in hypnotherapy and NLP might enhance part of what IPC does to influ
ence behaviour.
Drawing on the Behaviour Change Wheel and elements of the World Health
Organization’s multimodal strategy, and considering the role that hypnotherapy and
NLP might have in influencing behaviour, consider the following three questions:
1. How might we enhance education and training?
2. How might we stimulate action at the bedside, e.g. with reference to hand
hygiene or insertion of an intravenous device?
3. How might we engage our colleagues in day-to-day conversation amidst the
competing demands and general ‘noise’?
In Table 11.1 I propose a number of suggestions, but you might have your own;
neither is wrong.
TABLE 11.1 Some suggestions for applying neuroscience to infection prevention and
control
Question Suggestion
H ow m ig h t w e e n h a n c e U sin g te c h n iq u e s o f h y p n o th e ra p y to re in fo rc e b e h a v io u rs ,
e d u c a tio n a n d tra in in g ? e .g. use o f la n g u a g e , re p e titio n a n d to n e o f v o ic e , to
d e liv e r s h o rt (5 0 -s e c o n d ) e ffe c tiv e e d u c a tio n a l s e s s io n s
s u c h as p o d c a s ts , s h o rt Y ouTube c h a n n e l v id e o s
D ra w on th e p rin c ip le s o f h y p n o th e ra p e u tic e g o
s tre n g th e n in g te c h n iq u e s to m o tiv a te p e o p le to fe e l go o d
a b o u t d o in g th e rig h t th in g
H o w m ig h t w e s tim u la te H y p n o th e ra p e u tic in s ta lla tio n o f c u e s to p e rs u a d e p e o p le
a c tio n a t th e b e d s id e , to p e rfo rm a s e t a c tio n in re s p o n s e to a s p e c ific s tim u lu s :
e .g. w ith re fe re n c e — e .g. e v e ry tim e yo u . . . se e a p a tie n t a s yo u e n te r th e
to h a n d h y g ie n e p a tie n t zone, yo u w ill im m e d ia te ly , w ith o u t th in k in g ,
o r in s e rtio n o f an re a c h o u t a n d c le a n y o u r h a n d s
in tra v e n o u s d e v ic e ? — e .g. e v e ry tim e yo u go to p e rfo rm a c le a n o r a s e p tic
ta s k y o u w ill im m e d ia te ly .
T h e s y s te m as a c u e to a c tio n , e .g . in s ta ll c u e s s o th a t
e v e ry tim e a h e a lth w o rk e r se e s a c e rta in p h y s ic a l p ro d u c t
a d e s ire d a c tio n is s tim u la te d
(continued)
Question Suggestion
H ow m ig h t w e e n g a g e • T ra in in g on NLP m o d a litie s o r o th e r e ffe c tiv e
o u r c o lle a g u e s in d a y - c o m m u n ic a tio n a p p ro a c h e s b a s e d on h o w th e b ra in
to -d a y c o n v e rs a tio n fu n c tio n s , to e n c o u ra g e th e rig h t la n g u a g e fo r im p a c t,
a m id s t th e c o m p e tin g d e p e n d in g on th e ta rg e t a u d ie n c e
d e m a n d s a n d g e n e ra l
'n o is e '?
Each of the questions posed in Table 11.1 are concerned to varying degrees with
affecting the capability, opportunity and motivation of the target audience as per
Michie et a l’.s6 Behaviour Change Wheel. My suggestions are designed to stimulate
thinking in those of you who are looking for new ideas to explore. At this stage
these remain ideas, but based on my understanding and experience of clinical
hypnotherapy and NLP I think these two disciplines have much to teach us in IPC.
They are not the solution, but some of the insights they provide are at the very least
fascinating and at best could be of practical use.
KEY REFLECTIONS
In concluding this chapter I present a number of points for your reflection.
• Do we have the right skills to develop policies, protocols, training materials and
messages to affect behaviour of our multiple target audiences?
• Is it necessary to develop a field of science that covers neuro-IPC or behavioural
IPC?
• If so, how far are we from appointing the first neuro- or behavioural infection
preventionist?
• How could undergraduate and postgraduate training of all disciplines be
improved to incorporate neurosciences and behavioural IPC?
• Are we clear which of the behaviours that we need to influence are open to
modification?
• Do we design the workplace to take account of the brain and behaviour and its
influence on habits?
I’m not sure what percentage of the nearly 3000 words that precede the one you’re
reading right now hold any sort of key to unlocking some of the answers that have
as yet eluded us in the specialty of IPC. However, I suggest that some of the prin
ciples and techniques associated with, in particular, NLP and hypnotherapy may
have a place in enhancing IPC. Relying on conventional methods and placing too
much weight on training and policy writing without appreciating the complexity
of behaviour change is folly. As one author reminds us, the brain really is wider
than the sky18 and what is certain is that conventional approaches have as yet failed
to provide all of the answers. If you really want to penetrate even a handful of the
100 billion neurons that make up the brain of the next person you’re trying to influ
ence, pause for a moment to consider how much of the social sciences have formed
the foundation of the advice you give, the policy you have written or the training
package you’ve recently constructed.
REFERENCES
1. Edwards R, Charani E, Sevdalis N, et al. Optimisation of infection prevention and control
in acute health care by use of behaviour change: a systematic review. Lancet Infect Dis. 2012;
12(4): 318-29.
2. Elliott P. Infection Control: a psychosocial approach to changing practice. Oxford: Radcliffe;
2009.
3. World Health Organization (W HO). WHO Guidelines on Hand Hygiene in Health Care.
Geneva: W HO; 2009.
4. Jenner EA, Watson PW B, Miller L, et al. Explaining hand hygiene practice: an extended
application of the theory of planned behaviour. Psychol Health Med. 2002; 7(3): 311-26
5. Curry V, Cole M. Applying social and behavioral theory as a template in containing and
confining VRE. Crit Care Nurs Q. 2001 Aug; 24(2): 13-19.
6. Michie S, van Stralen MM, West R. The Behaviour Change Wheel: a new method for char
acterising and designing behaviour change interventions. Implement Sci. 2011; 6: 42.
7. Grist M. Steer: mastering our behaviour through instinct, environment and reason. London:
RSA; 2010.
8. White C. Nudging, fishing, and improving the public’s health. BMJ. 2011; 343: d8046.
9. Kahneman D. Thinking, Fast and Slow. London: Penguin Books; 2012.
10. Storr J, Wigglesworth N, Kilpatrick C. Integrating Human Factors with Infection Prevention
and Control. Thought Paper. London: The Health Foundation; 2013. Available at: www.
health.org.uk/publication/integrating-human-factors-infection-prevention-and-control
(accessed 25 June 2015).
11. SeungS. Connectome: how the brain’s wiring makes us who we are. New York, NY: Houghton
Mifflin Harcourt; 2013.
12. Wang LP, Li F, Wang D, et al. NMDA receptors in dopaminergic neurons are crucial for
habit learning. Neuron. 2011; 72(6): 1055-66.
13. Georgia Health Sciences University. H abit Formation is Enabled by Gateway to Brain
Cells. ScienceDaily. 2012 Jan 13. Available at: www.sciencedaily.com/releases/2011/12/
111221140448.htm (accessed 14 March 2015).
14. Crasilneck HB. H andbook o f Hypnotic Suggestions and Metaphors. New York, NY: W W
Norton; 1990.
15. Oakley DA, Halligan PW. Hypnotic suggestion and cognitive neuroscience. Trends Cogn
Sci. 2009; 13(6): 264-70.
16. Tosey P, Mathison J. Neuro-Linguistic Programming: its potential fo r learning and teaching
in form al education. Paper presented at the European Conference on Educational Research,
University o f Hamburg, 17 -2 0 September 2003. Available at: www.leeds.ac.uk/educol/

documents/00003319.htm (accessed 14 March 2015).
17. Sturt J, Ali S, Robertson W, et al. Neurolinguistic programming: a systematic review of the
effects on health outcomes. Br J Gen Pract. 2012; 62(604): e757-64.
18. Appleyard B. The Brain is Wider than the Sky: why simple solutions don’t work in a complex
world. London: Weidenfeld & Nicolson; 2012.
C H A P TE R 12
Infection prevention and control

education and training: research
findings and an electronic learning
experience for undergraduate
students
Debra Teasdale and Paul Elliott
We would like to start by asking you to reflect on the following three questions.
1. To what degree do you feel the education and training you have received, if any,
into infection prevention and control (IP&C) has influenced the way you adhere
to standard precautions within your professional practice?
2. To what degree do you feel the education and training you have received, if
any, into IP&C has served to enhance your understanding of the importance of
adopting standard precautions?
3. On a broader perspective, to what extent do you feel IP&C education has con
tributed to reductions in cross-infection?
Historically, the importance of appropriate IP&C education and training as a

means of facilitating safe practice has been well documented.1-5 Further, it has
also been documented that IP&C education and training has been deficient in its
frequency and methods of delivery as a means of producing identifiable reductions
in cross-infection,67 and that many of those involved in the provision of health and
social care have been significantly negligent in their undertaking of safe IP&C. A
135
disturbing case in point within the British National Health Service being high
lighted within the ‘Francis Report’,8 where it appears that IP&C violations were
occurring over an extended period of time. In some ways it would seem that we
have progressed little over the past 200 years, as is borne out by the immortal words
of Florence Nightingale:
I take leave to give the facts, we wait for the rates of mortality to go up
before we interfere and when enough have died we enter the results of
our masterly activity neatly in tables, but we do not analyse and tabulate
the saddened lives of those who remain .. .9
Further, Miss Nightingale believed in the importance of education as something

that would serve to promote appropriate standards of hygiene.9 Yet, some 200 years
on it would seem that education and training around IP&C and the subsequent
undertaking of, for example, standard precautions, is paid little more than lip ser
vice where some health and social care professionals are concerned!* With this in
mind, two examples from personal experience are given below.
( \
Experience 1
While attending a psychology conference several years ago I had a conversa
tion with a psychologist who pronounced that they did not need to worry about
IP&C because they did not touch their clients and that they saw no need for
psychologists to learn about IP&C, as it bore no relevance to their role.
V___________________________ __ ___________________________ J
( \
Experience 2
Some years ago as a part of my lecturing role I had a conversation with an
undergraduate student regarding IP&C. Part of this conversation involved
the importance of undertaking appropriate IP&C practice. As a part of this
conversation, the student stated that, as they were not a nurse, they did not
need to worry about IP&C. They reasoned that this was because, first, they did
not touch their clients; second, their tutor had told them that infection could
Where reference is made to health and social care it is intended to include such professions as psychology,
sociology, environmental and occupational health, and health promotion.
INFECTION PREVENTION AND CONTROL EDUCATION AND TRAINING 137
only be spread by touching someone; and third, there was little point in them
bothering with any IP&C education and training, as it would not be needed.
Such perspectives not only demonstrate limited thinking but are inherently
dangerous where the potential for cross infection is concerned.
V_________________________________________________________ J
With regard to both of these experiences, although it is acknowledged that they
are subjective in nature, it would seem reasonable to identify a complete lack of
understanding regarding the nature of cross-infection on the part of all three indi
viduals (the psychologist, the student and the tutor). Further, regarding the apparent
attitudes and beliefs of these individuals, the word irresponsible would seem to
constitute somewhat of an understatement, bearing in mind that they would be
placing not only themselves and those they allegedly care about at risk but also
their colleagues and the general population at large. Clearly, both the undergradu
ate student and the psychologist appeared to perceive IP&C education and training
as being of little value.
In 1989, Elliott10 identified, from a participant-administered survey relating to
undergraduate nursing, medicine and the allied health professions, that the empha
sis placed upon hand hygiene education was inconsistent and lacked any uniformity,
although some respondents did acknowledge that hand hygiene was covered at
some point during their programme of professional education. In 1994, Gould and
Chamberlain11identified the importance of clinically based education around IP&C
and that such education should be a collaborative venture between academia and
practice. In 1996, Elliott12undertook a further participant-administered survey, this
time within a Welsh district general hospital where staff were asked from whom
their hand hygiene was first learned following the commencement of their under
graduate programme of professional education. O f the 350 individuals surveyed,
63 (or 18%) identified they had received no education at all. In other words, they
made it up as they went along! Although 63 out of 350 may seem a small number,
consideration must be given to the potential that these 63 individuals may have con
tributed to cross-infection rates, and that these individuals received no education at
all might infer that those responsible for the provision of education failed in their
duty of care by default. Further, as a part of the same research, 20 centres of nurse
education were contacted with regard to their policy on hand hygiene education,
to which there were three overriding responses (see List 12.1).
( “ A
LIST 12.1 Overriding responses12
• Education was undertaken through researching recent literature with no lec
turer or IP&C specialist input.
• Education was undertaken through constant reminders but these were infre
quent and not evidence based.
• Hand hygiene education was allocated between 3 and 21 hours over the
period of their undergraduate programme of professional education.
V____________________________ ______________________________ J
Clearly none of these overriding responses could be perceived as being either valid
or reliable where reducing the risk of cross-infection was concerned. Further, the
findings of this survey identified that, for the most part, clinical practitioners were
excluded from the IP&C educational process.
In 2000, Sherertz et al.13identified that instruction into IP&C varied widely. They
further indicated that the principle of ‘see one, do one, teach one’ can lead to incon
sistencies in the ways procedures are undertaken. Further, Hallett14 has indicated
that education may create a sense of ambivalence and uncertainty with regard to
infection control, and particularly so where wound care is concerned. Clearly, the
negating of such ambivalence and uncertainty is vital if IP&C is to be undertaken
appropriately, which must in part have implications for the methods used to facili
tate such learning. For example, the ‘see one, do one, teach one’ method could well
have inconsistencies between what is perceived to be appropriate by those adopting
such a method of learning. Certainly, Rosenthal et al.15 showed that education and
clinical training could result in improved levels of compliance with regard to IP&C.
In light of the findings mentioned and the development of a new curriculum
within the Faculty of Health and Wellbeing at Canterbury Christ Church University,
an electronic participant-administered survey where 20 centres of nurse education
within the United Kingdom were contacted to ascertain the emphasis they placed
upon the education and clinical training of IP&C, and who, if anyone, undertook
such with regard to their undergraduate students.16 From this survey a number of
principle findings were established (see List 12.2).
From that outlined within List 12.2 it was deduced at the time (2008) that the
knowledge base of student nurses - during their programme of professional edu
cation, upon initial qualification and initial entry to the Nursing and Midwifery
Council’s Professional Register - in relation to IP&C might well be somewhat
concerning. Further, some of the findings identified within List 12.2 would seem
to reflect those found by Elliott in 199612 some 11 years earlier.
LIST 12.2 United Kingdom centres of nurse education16

• Overall the provision of IP&C education was significantly lacking.
• The approach to IP&C was:
— no education at all
— once at the beginning of year 1
— left solely to the mentors and staff within clinical placements
— student-led, self-directed study
— through a single lecture with no skills laboratory practical time
— IP&C knowledge and skills not assessed
— IP&C clinical specialists generally excluded from any type of education
that did occur.
V______________________________________________________________ )
LIST 12.3 ICPLE overview1
Year 1
The aim of this was to provide students with a grounding in the principles of
infection prevention and control.
Year 2
The aim of this was to introduce students to the psychological and social
aspects of infection prevention and control.
Year 3
During this year students undertook a project of their own choosing and were
required to present the project to their personal tutor at the end of year 3.
V______________________________________________________________ )
Following these findings (List 12.2) and the recognition at Canterbury Christ
Church University that there needed to be put in place some form of IP&C learning
experience, the findings were presented to the Faculty of Health and Wellbeing, and
those with responsibility for IP&C within the School of Nursing developed as a part
of a new curriculum for 2009 such a learning experience. Subsequently, in 2009 an
electronic Infection Control and Prevention Learning Experience (ICPLE)17 went
live for pre-registration health and social care students (see List 12.3).
In 2012, after the ICPLE element of students’ professional education had run
for 3 years, Teasdale and Elliott undertook a pilot study to investigate the degree to
which undergraduate students complied with the five-stage hand hygiene process,18
which is a vital element of the ICPLE. The essential elements of this study are out
lined in Tables 12.1, 12.2, 12.3 and 12.4.
TABLE 12.1 Pathway of professional education

Pathway Num ber of students
A d u lt N u rs in g 56
C h ild N u rs in g 17
S p e e c h a n d L a n g u a g e T h e ra p y 14
M id w ife ry 11
O p e ra tin g D e p a rtm e n t P ra c titio n e r 2
O c c u p a tio n a l T h e ra p y 1
R a d io g ra p h y 1
Total 1 02
TABLE 12.2 Year of professional education

Year Num ber of students
Y ear 1 75
Y ear 2 26
Y ear 3 1
Total 1 02
TABLE 12.3 Ethnic origin as indicated by the student

Ethnic origin Num ber of students
B ritis h 79
A fric a n 5
Iris h 4
E u ro p e a n 3
C a rib b e a n 2
C a u c a sia n 2
In d ia n 2
D a n ish 1
(c o n tin u e d )
Ethnic origin Num ber of students

F ilip in o 1
N e p a le se 1
S o u th A m e ric a n 1
No re s p o n s e 1
Total 10 2
TABLE 12.4 Age and gender

Age Female M ale Total
1 7 -2 0 33 33
2 1 -2 5 26 3 29
2 6 -3 0 11 2 13
3 1 -3 5 11 11
3 6 -4 0 8 8
4 1 -4 5 3 3
4 6 -5 0 4 4
50+ 1 1
Totals 97 5 1 02
ETHICAL APPROVAL
Ethical approval was sought and obtained through the Faculty of Health and
Wellbeing Ethics Committee at Canterbury Christ Church University, and students
were recruited on a volunteer basis through posters and electronic media. Having
volunteered, the aim of the pilot study was fully explained and students then had
the option to withdraw if they wished; none did so. For the 102 students who took
part in the study, they were each given a £3 voucher that they could spend within
any of the university’s cafeterias.
METHODOLOGY
The study was undertaken within one of two skills laboratories, depending upon
where students were based. Each student was simply instructed by an observer to
undertake hand hygiene as he or she would normally do while working within
a clinical practice setting. Following that, no further communication took place
between the observer and the student. While the student undertook his or her hand
hygiene, the observer completed a prepared record sheet (see List 12.3).
( A
LIST 12.3 Hand hygiene process adherence checklist
Observer instructions
1. You should observe the participant undertaking hand hygiene and record
the participant’s adherence to the hand hygiene process as identified in the
checklist.
2. As the observer you are not looking to assess the participant’s hand hygiene
technique, only his or her adherence to the stages of the hand hygiene pro
cess identified.
3. Place a number from 1 to 5 in the ‘stage’ boxes to indicate the sequence in
which the participant adopted the stages of the hand hygiene process.
4. Adherence to the process is only determined if the participant follows the five
stages of the process in the correct sequence.
5. If the participant deviates in any way from the correct sequence, then that
should be classed as non-adherence.
6. At the bottom of the sheet circle either Adherence or Non-Adherence, in
accordance with the participant’s undertaking of the hand hygiene process.
Prelim stage: removes watch, rings and rolls sleeves up?

Watch: Yes/No
Rings: Yes/No
Sleeves rolled up: Yes/No
Stage 1: wetting of the hands and wrists with running water

Stage 2: application of the cleansing solution
Stage 3 : washing of the hand and wrists (minimum time of 15 seconds) □
Stage 4 : thorough rinsing of the areas washed under running water
(including under rings if not removed) □
Stage 5 : thorough drying of the areas washed with disposable hand
towels □
Additional information
Note the number of disposable towels used to dry the hands □
Shake hands with participant to determine if hands are dry or still wet
(D = dry; W = wet) D
Overall result
ADHERENCE_______________NON-ADHERENCE________________
V______________________________________________________________ )
RESULTS
Adherence to the five-stage hand hygiene process
O f the 102 students who took part in the study, 81 adhered fully to the five-stage
hand hygiene process in the correct sequence, while 21 students deviated from the
correct sequence.
Effective drying of the hands

O f the 102 students who took part, 20 were deemed to have dried their hands
appropriately, while 82 were deemed to have failed to do so. The method of drying
was disposable paper towels. The effectiveness of hand drying was ascertained by
the observer shaking the hands of the students afterwards. If the student’s hands
were anything other than felt to be completely dry, this was recorded as a failure to
dry the hands thoroughly.
Removal of wristwatches prior to commencing hand hygiene

O f the 102 students who took part and wore wristwatches, 15 removed them prior
to commencing hand hygiene, while 13 students failed to remove their wristwatches
prior to commencing hand hygiene. The remaining 74 students were not wearing
wristwatches and this is indicated by the word ‘None’ within the wristwatch column
in Table 12.5.
Removal of rings prior to commencing hand hygiene

O f the 102 students who took part and were wearing rings, 14 removed them prior
to commencing hand hygiene, while 25 students failed to remove their rings prior to
commencing hand hygiene. the remaining 63 students were not wearing rings and
this is indicated by the use of the word ‘None’ within the rings column in Table 12.5.
Sleeves above the elbow

O f the 102 students who took part and had sleeves below the elbow, 67 rolled the up
above the elbow prior to commencing hand hygiene, while 17 students undertook
hand hygiene with their sleeves below the elbow. The remaining 18 students were
already wearing clothing that had sleeves above the elbow and this is indicated by
the use of the word ‘None’ within the sleeves column in Table 12.5.
TABLE 12.5 Complete data set
No. Age Gender Location Pathway Education Ethnic Watch Rings Sleeves S1 S2 S3 S4 S5 No. of Hands Adherence to the
origin towels hand hygiene
process
1 2 6 -3 0 F Canterbury Midwifery Year2 Caucasian None No Yes 1 2 3 4 5 2 Wet Yes

2 3 6 -4 0 F Canterbury Midwifery Year2 British None None Yes 2 1 3 4 5 2 Wet No
3 2 6 -3 0 F Canterbury Midwifery Year2 European None No Yes 1 2 3 4 5 2 Dry Yes
4 2 1 -2 5 F Canterbury Midwifery Year2 British None None Yes 1 2 3 4 5 3 Wet Yes
5 2 1 -2 5 F Canterbury Midwifery Year2 British Yes Yes Yes 1 2 3 4 5 2 Wet Yes
7 1 7 -2 0 F Canterbury Midwifery Year2 British None Yes No 1 2 3 4 5 4 Wet Yes
8 1 7 -2 0 F Canterbury Midwifery Year2 British No No Yes 1 2 3 4 5 3 Dry Yes
9 2 1 -2 5 F Canterbury Midwifery Year2 British No None Yes 1 2 3 4 5 2 Wet Yes
10 1 7 -2 0 F Canterbury Midwifery Year2 British None None None 1 2 3 4 5 3 Dry Yes
12 1 7 -2 0 F Canterbury Child Nursing Yearl British None None None 0 1 2 3 4 4 Wet No
13 1 7 -2 0 F Canterbury Child Nursing Yearl British None None None 1 2 3 4 5 4 Wet Yes
14 1 7 -2 0 F Canterbury Child Nursing Yearl British None None None 1 2 3 4 5 5 Dry Yes
15 1 7 -2 0 F Canterbury Child Nursing Yearl Not Given None None None 1 2 3 4 5 2 Wet Yes
process
INFECTION PREVENTION AND CONTROL EDUCATION AND TRAINING

26 2 1 -2 5 F Canterbury Child Nursing Yearl African None None None 1 2 3 4 5 3 Wet Yes
27 1 7 -2 0 F Canterbury Adult Nursing Year2 British None None None 1 2 3 4 5 4 Wet Yes
28 1 7 -2 0 F Canterbury Adult Nursing Year2 British Yes Yes Yes 1 2 3 4 5 3 Wet Yes
29 1 7 -2 0 F Canterbury Adult Nursing Year2 British Yes Yes None 1 2 3 4 5 3 Wet Yes
30 1 7 -2 0 F Canterbury Adult Nursing Year2 British None None Yes 1 2 3 4 5 4 Dry Yes
31 2 6 -3 0 F Canterbury Radiography Year2 British Yes Yes Yes 1 2 3 4 5 3 Wet Yes
32 4 6 -5 0 F Canterbury Occupational Year2 British None No Yes 1 2 3 4 5 3 Wet Yes
Therapy
33 50+ F Canterbury Adult Nursing Year2 Caucasian Yes Yes Yes 1 2 3 4 5 5 Wet Yes
34 3 1 -3 5 F Canterbury Adult Nursing Yearl European Yes Yes Yes 1 2 3 4 5 2 0 Yes
35 2 1 -2 5 F Chatham Adult Nursing Yearl British None No Yes 2 1 3 4 5 5 Wet No
36 2 1 -2 5 F Canterbury Adult Nursing Yearl British No No Yes 1 2 3 4 5 2 Wet Yes
37 3 6 -4 0 F Chatham Adult Nursing Yearl Danish Yes None Yes 1 2 3 4 5 2 Wet Yes
38 3 6 -4 0 F Chatham Adult Nursing Yearl British None None Yes 1 2 3 4 5 4 Wet Yes
39 4 6 -5 0 F Chatham Adult Nursing Yearl British Yes No No 1 2 3 4 5 5 0 Yes
40 2 6 -3 0 M Chatham Adult Nursing Yearl British None None Yes 1 2 3 4 5 5 Wet Yes
41 3 1 -3 5 F Chatham Adult Nursing Yearl British None None Yes 1 2 3 4 5 4 Wet Yes
145
146
INFECTION PREVENTION AND CONTROL

process
42 4 1 -4 5 F Chatham Adult Nursing Yearl British No No Yes 1 2 3 4 5 2 Wet Yes

43 4 6 -5 0 F Canterbury Adult Nursing Yearl British No No No 1 2 3 4 5 5 Wet Yes
44 2 1 -2 5 F Canterbury Adult Nursing Yearl British None None Yes 1 2 3 4 5 1 Wet Yes
45 1 7 -2 0 F Canterbury Adult Nursing Yearl African None None Yes 1 2 3 4 5 3 Wet Yes
46 2 6 -3 0 M Canterbury Adult Nursing Yearl Indian Yes No Yes 0 1 2 4 5 2 Wet No
48 2 1 -2 5 F Canterbury Adult Nursing Yearl British None Yes Yes 1 2 3 4 5 2 Wet Yes
49 2 1 -2 5 F Canterbury Adult Nursing Yearl Nepalese None None Yes 1 2 3 4 5 2 Wet Yes
50 2 1 -2 5 F Canterbury Adult Nursing Yearl British None No Yes 1 2 3 4 5 3 Wet Yes
51 1 7 -2 0 F Canterbury Adult Nursing Yearl British Yes Yes Yes 1 2 3 4 5 2 Wet Yes
52 1 7 -2 0 F Canterbury Adult Nursing Yearl British None None No 1 2 3 4 5 3 Wet Yes
54 2 1 -2 5 F Canterbury Adult Nursing Yearl British None No Yes 1 2 3 4 5 2 Wet Yes
55 2 1 -2 5 M Canterbury Adult Nursing Yearl British Yes None Yes 1 2 3 4 5 4 Dry Yes
56 2 1 -2 5 M Canterbury Adult Nursing Yearl British None None Yes 1 2 3 4 5 3 Wet Yes
57 1 7 -2 0 F Canterbury Adult Nursing Yearl British No No No 0 1 2 3 4 3 Wet No
58 2 6 -3 0 F Canterbury Adult Nursing Yearl South None No Yes 1 2 3 4 5 2 Wet Yes
American
59 2 6 -3 0 F Canterbury Adult Nursing Yearl Filipino None None Yes 1 2 3 4 5 2 Dry Yes
60 4 1 -4 5 F Canterbury Adult Nursing Yearl Caribbean None No No 1 2 3 4 5 3 Dry Yes
61 2 1 -2 5 F Canterbury Adult Nursing Yearl British None None No 0 1 2 3 4 2 Wet No
process
64 1 7 -2 0 F Canterbury Adult Nursing Yearl Irish None No Yes 1 2 3 4 5 4 Wet Yes
65 2 1 -2 5 M Canterbury Adult Nursing Yearl British None None Yes 1 2 3 4 5 3 Wet Yes

66 3 6 -4 0 F Canterbury Adult Nursing Yearl British None No Yes 1 2 3 4 5 3 Dry Yes
67 3 6 -4 0 F Canterbury Adult Nursing Yearl British None No Yes 1 2 3 4 5 4 Dry Yes
69 2 1 -2 5 F Canterbury Adult Nursing Yearl African None None No 1 2 3 4 5 2 Wet Yes
70 1 7 -2 0 F Canterbury Adult Nursing Yearl African None None Yes 1 2 3 4 5 4 Dry Yes
72 1 7 -2 0 F Canterbury Adult Nursing Yearl Irish None None Yes 1 2 3 4 5 3 Wet Yes
73 1 7 -2 0 F Canterbury Adult Nursing Yearl Irish None None No 1 2 3 4 5 2 Dry Yes
77 1 7 -2 0 F Canterbury Adult Nursing Yearl British None Yes Yes 1 2 3 4 5 3 Wet Yes
78 3 1 -3 5 F Canterbury Adult Nursing Yearl British Yes Yes Yes 1 2 3 4 5 2 Dry Yes
79 2 1 -2 5 F Canterbury Adult Nursing Year3 Irish None None Yes 0 1 2 3 4 4 Wet No
80 3 6 -4 0 F Chatham Adult Nursing Year2 British None No No 1 2 3 4 5 2 Wet Yes
81 3 1 -3 5 F Chatham Speech and Yearl British No None No 1 2 3 4 5 2 Dry Yes
Language
Therapy
82 3 1 -3 5 F Chatham Speech and Yearl Indian None None No 0 1 2 3 4 3 Wet No
147
Language
Therapy
148
INFECTION PREVENTION AND CONTROL

process
83 2 1 -2 5 F Chatham Speech and Yearl British None No Yes 0 1 2 3 4 2 Wet No

Language
Therapy
84 4 1 -4 5 F Chatham Speech and Yearl British No No No 1 2 3 4 5 3 Dry Yes
Language
Therapy
85 2 1 -2 5 F Chatham Speech and Yearl British None None Yes 0 1 2 3 4 4 Wet No
Language
Therapy
86 2 6 -3 0 F Chatham Speech and Yearl British Yes No Yes 1 2 3 4 5 2 Wet Yes
Language
Therapy
87 4 6 -5 0 F Chatham Speech and Yearl British None None Yes 0 1 2 3 4 3 Wet No
Language
Therapy
88 2 1 -2 5 F Chatham Speech and Yearl African Yes None Yes 1 2 3 4 5 2 Wet Yes
Language
Therapy
89 2 1 -2 5 F Chatham Speech and Yearl British No No Yes 1 2 3 4 5 2 Wet Yes
Language
Therapy
90 2 6 -3 0 F Chatham Speech and Yearl British None None Yes 1 2 3 4 5 2 Dry Yes
Language
Therapy
91 2 1 -2 5 F Chatham Speech and Yearl Caribbean No None No 0 1 2 3 4 2 Wet No
Language
Therapy
process
92 2 1 -2 5 F Chatham Speech and Yearl British No None No 0 1 2 3 4 2 Wet No

Language
Therapy
93 3 1 -3 5 F Chatham Speech and Yearl British No Yes No 0 1 2 3 4 3 Wet No

Language
Therapy
94 2 6 -3 0 F Chatham Operating Year2 British Yes Yes Yes 1 2 3 4 5 2 Wet Yes
Department
Practitioner
95 3 1 -3 5 F Chatham Speech and Yearl British No No Yes 1 2 3 4 5 4 Wet Yes
Language
Therapy
96 3 1 -3 5 F Chatham Operating Year2 European None None Yes 1 2 3 4 5 2 Dry Yes
Department
Practitioner
97 1 7 -2 0 F Chatham Adult Nursing Year2 British None None Yes 1 2 3 4 5 6 Wet Yes
98 3 1 -3 5 F Chatham Adult Nursing Yearl British None No Yes 0 1 2 3 4 3 Dry No
99 3 1 -3 5 F Chatham Child Nursing Year2 British None Yes Yes 1 2 3 4 5 2 Wet Yes
100 2 1 -2 5 F Chatham Child Nursing Year2 British None None No 0 1 2 3 4 2 Wet No
101 3 6 -4 0 F Chatham Adult Nursing Year2 British None None Yes 0 1 2 3 4 3 Wet No
Notes: S1, S2, S3, S4, S5 = stages of the hand hygiene process. (Stage 1 = wetting of the hands and wrists under running water; Stage 2 = applying of the cleansing solution to
the hands; Stage 3 = washing of the hands and wrists for a minimum of 15 seconds; Stage 4 = rinsing of the hands and wrists with running water; Stage 5 = drying of the hands
with disposable paper towels.) Within S1-S5, if a ‘0 ’ is presented, this means that this activity was not undertaken at all. The presentation of numbers within S1-S5 indicates the
sequence in which the hand hygiene activities were undertaken. Within the gender column, F = female student, M = male student. Within the education column, the year = stage
of professional education.
149
LIMITATIONS OF THE STUDY

• It is acknowledged that the Hawthorne effect could have been an influencing
factor regarding the students’ hand hygiene behaviour, and particularly so as the
two observers were lecturing staff.
• It is also acknowledged that the method used to assess drying of the students’
hands was a subjective measure and open to personal interpretation of the two
observers.
• The sample size was very small and as such could not be taken as representative
of the undergraduate health and social care student population.
• It is acknowledged that the £3 voucher could have had an influencing effect upon
those students who agreed to take part.
FOLLOW-UP
Following completion of this study it was recognised that although the hand
hygiene-related practice of some students was acceptable, there were others who
clearly did not adhere to a safe approach to undertaking the hand hygiene process
as set out in Table 12.5. Therefore, in view of these deviations from appropriate
practice and following discussion among those with a remit for IP&C within the
School of Nursing, the following points in List 12.4 were developed as a means of
further facilitating appropriate adherence.
r ; \
LIST 12.4 Actions to facilitate enhanced IP&C
knowledge, skills and attitudes
1. A full review of the existing ICPLE should be undertaken and the content
modified and updated where appropriate.
2. The ICPLE should become a part of the working agenda of the Undergraduate
Programme Management Committee and the Curriculum Implementation
Group, and regular reports should be presented to both of these groups by
the Director of Clinical Practice within the School of Nursing.
3. The ICPLE should become an integral part of designated clinical practice-
related modules within years 1, 2 and 3 of the students’ programme of
professional education.
4. The ICPLE should become part of the summative assessment of these des
ignated clinical practice modules.
5. During the initial part of the students’ professional education, prior to starting
their clinical practice experience, and in conjunction with the module (see
point 3), students will spend time in the university’s skills laboratories, where
they will be given the opportunity to put theory into practice within a simula
tion setting under the supervision of both lecturing and clinical practitioners.
6. An IP&C committee should be established, with the membership consisting
of both academics and clinical practitioners.
V___________________________ ______________________________ J
f 'A
LIST 12.5 Examples from the revised ICPLE content17
Year 1
• Defining IP&C
• Standard precautions including hand hygiene
• Risks and sources of cross- infection
• Types of infectious agents
• The nature of cross- infection
• Sources of cross- infection and modes of transmission
• The chain of infection versus a unified approach to cross-infection18
• The impact of communication upon IP&C
• Legal issues in IP&C
Year 2
• Defining the psychosocial nature of IP&C
• Biomedical and biopsychosocial19 approaches to IP&C
• Psychosocial theories that underpin IP&C
• The impact of attitudes, beliefs and stereotyping upon IP&C practice
• Factors that affect safe IP&C practice
• Cognition and IP&C behaviour
Year 3
During this final year of the programme of professional education, students
should carry out an IP&C project.
• Project Part 1: Outline the project you intend to undertake.
• Project Part 2: Outline the methods you used to undertake your project.
• Project Part 3: Present the results of your project and how you intend to use
your findings to enhance IP&C.
V__________________________________________________________ J
CONCLUSION
For all 3 years of the ICPLE17 there is an integration of theory and practice, and
students are expected to involve both relevant lecturers at the University and their
mentor(s) in clinical practice. Students are also expected to reference elements of
the work they produce, which must then be presented to their personal tutors at
the end of each academic year. In addition, students’ ICPLE work will be sum-
matively assessed both in both theory and practice within a specifically designed
and established Skills Laboratory Ward area at the University. In the years that the
ICPLE programme has been running as an integral part of students’ professional
education, all undergraduate students have had access to such, but only Adult
Nursing has embraced it as a means of facilitating their knowledge, skills and atti
tudes toward IP&C.
In concluding this chapter, it has been our intention to undertake a brief review
of IP&C education and to reflect upon the nature of the IP&C education and clinical
training that undergraduate health and social care students have available to them
at Canterbury Christ Church University. In doing this, an evidence-based approach
has been adopted that involves practitioners from both academia and clinical prac
tice, with the aim of providing undergraduate health and social care students with
both a good working knowledge of IP&C at the end of their 3-year programme
and the opportunity to present or publish their year 3 project findings. Currently,
based upon available information for 2014, Canterbury Christ Church University
is a leading centre of professional education with regard to offering their health
and social care students with such an extensive learning opportunity around IP&C.
REFERENCES
1. Gallagher R. Infection control: public health, clinical effectiveness and education. BrJNurs.
1999; 8(18): 1212-14.
2. Eggimann P, Pittet D. Overview of catheter-related infections with special emphasis on
prevention based on educational programs. Clin Microbiol Infect. 2002; 8(5): 295-309.
3. Voss A, Allerberger F, Bouza E, et al. The training curriculum in hospital infection control.
Clin Microbiol Infect. 2005; 11(Suppl. 1): 33 -5 .
4. Ward D. The role of education in the prevention and control of infection: a review of the
literature. Nurse Educ Today. 2011; 31: 9-17.
5. Pfaff S. Education: past, present and future. Am J Infect Control. 1982; 10(4): 133-7.
6. Cohen H, Kitai E, Levy I, et al. Handwashing patterns in two derm atology clinics.
Dermatology. 2002; 205(4): 258-361.
7. Wu C, Gardner G, Chang A. Nursing students’ knowledge and practice of infection control
precautions: an educational intervention. JA dv Nurs. 2009; 65(10): 2142-9.
8. Francis R. The Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Mid
Staffordshire NHS Foundation Trust; 2013. Available at: www.midstaffspublicinquiry.com/
report (accessed 9 January 2015).
9. Ridgely Seymer L, editor. Selected Writings o f Florence Nightingale. New York, NY: Macmillan;
1954.
10. Elliott P. To wash or not to wash? Nurs Standard. 1989; 36(3): 21-3.
11. Gould G, Chamberlain A. Infection control as a topic for ward-based nursing education.
J Adv Nursing. 1994; 20: 275-82.
12. Elliott P. Handwashing practice in nurse education. P rof Nurse. 1996; 11(6): 357-60.
13. Sherertz R, Ely E, Westbrook D, et al. Education of physicians-in-training can decrease the
risk for vascular catheter infection. Ann Intern Med. 2000; 132: 641-8.
14. Hallett C. Infection control in wound care: a study of fatalism in community nursing. J Clin
Nurs. 2000; 9: 103-9.
15. Rosenthal V. Effect of education and performance feedback on rates of catheter-associated
urinary tract infection in intensive care units in Argentina. Infect Control Hosp Epidemiol.
2004; 25(1): 47-50.
16. Clark S, Elliott P. Report and Recom m endations on Infection Prevention and Control
Knowledge and Skills Acquisition fo r a New Pre-registration Curriculum in 2009. Kent: Faculty
of Health and Wellbeing, Canterbury Christ Church University; 2008.
17. Elliott P; Faculty of Health and Wellbeing, Canterbury Christ Church University. Infection
Prevention and Control Learning Experience (ICPLE). Kent: Faculty of Health and Wellbeing,
Canterbury Christ Church University; 2014.
18. Elliott P, editor. Infection Control: a psychosocial approach to changing practice. Abingdon:
Radcliffe; 2009. pp. 12-14, 69.
19. Ogden J. Health Psychology: a textbook. 5th ed. Maidenhead: McGraw-Hill/Open University
Press; 2012. pp. 4 -7 .
C H A P TE R 13
Increasing the value and

influence of infection prevention
and control specialists
Annette Jeanes
INTRODUCTION
Infection control is perceived by some as a one-issue service or specialty. Many
infection control practitioners are narrowly focused on their specialty - in par
ticular, compliance with controls and responses to infection-related events. In this
chapter, the potential for infection prevention and control specialists (IPCSs) to
have a wider influence on standards in healthcare services and add value to their
role will be explored.
This chapter is designed to provide a starting point to improving the influence
and value of IPCSs. The following issues will be covered:
• barriers and opportunities
• the potential for synergy in working practice
• upholding standards or ‘being there’
• increasing influence
• super specialists
• self-efficacy
• value of influence.
155
BARRIERS AND OPPORTUNITIES

Translating the potential to influence change into the delivery of improved outcomes
is a recognised challenge.1 One of the barriers is that some ICPSs are comfortable
working in a specialty with clear boundaries and so avoid encroachment into other
areas such as risk and quality. Emersion in the specialism can act as a justification
for not commenting, interacting, reflecting, making judgements or suggesting
change in other areas of practice. ICPS may believe they have insufficient expertise
or experience to influence areas of practice outside their specialty. Equally because
they limit their scope this becomes a self-fulfilling prophesy.
It could also be argued that there is quite enough in this specialty to keep spe
cialists occupied. Indeed, the number of IPCSs has grown considerably in the last
decade, in response to the increased requirements and expectations of healthcare
organisations.2 The imposition of numerous guidelines, standards, audit and targets
consume considerable time and effort, not just to produce them but also to translate
them into changes in practice.3
As a specialty that frequently covers whole organisations, including many non
clinical areas that support care delivery, IPCSs are in a unique position. Few other
healthcare workers are able to legitimately access such a broad range of services
and staff with relative ease. Services can range from general practitioner surgeries,
dentists, operating theatres, mortuary, hospital wards, laboratories, engineering
plant, waste disposal collection bays, kitchens, sterile services department, out
patients and radiology. There is also a range of opportunities to interact with staff
from numerous areas or organisations on visits, consultations and meetings - such
as major incident planning groups, product selection groups, building planning
groups, and risk and quality meetings.
The ability of infection prevention and control staff to respond to numerous
and various situations may result in questions poised to infection prevention and
control practitioners or observations made that are not directly related to infection
prevention and control. For example, How do I report a leaking pipe? How do I
escalate the lack of toilet paper? How long has this room been out of action? Do we
really need to put the new machine here? As an accessible or present knowledgeable
expert, there may be a risk of others assuming IPCSs know everything, particularly
if the IPCSs are perceived to be problem solving and proactive. In response, IPCSs
may tire of this aspect of their role and reiterate their core purpose and distance
themselves from other issues. It could be argued that the IPCSs should facilitate and
enable staff to find the solutions, but often it is easier to just do it yourself.
INCREASING THE VALUE AND INFLUENCE OF INFECTION PREVENTION 157
THE POTENTIAL FOR SYNERGY IN WORKING PRACTICE

There are several aspects of healthcare delivery that influence infection prevention
and control outcomes, such as product selection, building and design. In addition,
numerous aspects of care delivery may enhance value by improving attention to
infection prevention and control issues such as cleaning, patient education, patient
transport and drug administration.
There are also many aspects of care that could potentially benefit from special
ties working synergistically to improve patient outcomes. An example in infection
prevention and control is nutrition. Ensuring a patient has adequate nutrition is a
fundamental and basic requirement in healthcare. The quality of the food and the
food service is a key factor in patient satisfaction.4
There are also benefits associated with patient outcome. There is evidence in
gastric surgery, for example, that patients who are adequately nourished throughout
the surgical journey have improved healthcare outcomes.5 This includes a reduction
in post-operative infection. Nutritional status also influences the immune response
of individuals in response to an infection and malnutrition is a risk factor in the
acquisition of infection.6 The nutrition of patients is important in infection preven
tion and control and ensuring the nutrition of patients is of interest to the IPCS.
This is not just to ensure patients do not acquire an infection from the food or food
handler, but also to ensure the patient receives adequate nourishment to support
immune response, reduce susceptibility to infection and promote recovery from
illness. Therefore, it is beneficial if the IPCS champions, supports and facilitates
initiatives to improve nutrition.
The same argument applies to many fundamental aspects of care, including sleep
and rest, hydration, nausea and vomiting, warmth, stress and anxiety, information,
pain control, wound healing, incontinence, prevention of falls, and prevention of
pressure sores. The IPCS can, by promoting and supporting other aspects of health
care delivery with common goals, improve patient outcomes and the value of care
delivered. This may be done in many ways and the point will now be illustrated by
two examples.
Example one: length of stay

It is well established that the length of time patients stay in healthcare facilities
increases their risk of complications such as the acquisition of infection.7 Generally
when this point is made it refers to patients in a hospital bed, but the same princi
ples apply to waiting rooms in clinics or general practitioner surgeries. Therefore,
reducing the opportunity time for transmission to take place is beneficial to the
patient in reducing his or her risk of infection.
The IPCS can support the process and systems design in clinics, surgeries and hos
pitals by minimising the impact of infection-related assessment and documentation.
This may be as simple as enquiring what information is already known and available
and if further assessment is really required. The IPCS can, in addition, support other
initiatives from other stakeholders that similarly reduce the time the patient stays
in a healthcare facility, such as reducing waiting times for porters, improving early
or rapid discharge, or advocating home delivery of prescription drugs.
Example two: diagnostics

It has been established that reducing system delay from initial assessment to final
diagnosis and treatment is potentially beneficial to patient outcomes.8 In part this is
reliant on appropriate assessment and the laboratory diagnostic support. The IPCS
can support the development of assessment algorithms, ensure staff are clear what
tube is required for which test, enquire about all turnaround times of results, ask
about delays in specimen deliveries or processing, and use the information to help
improve several diagnostic services by highlighting the issues. In acting to optimise
the diagnostics associated with infection, by widening the work to include others,
the potential benefits are maximised.
UPHOLDING AND MAINTAINING STANDARDS

As mentioned earlier in this chapter, IPCSs often work in many areas of care deliv
ery or other areas supporting delivery. They are therefore in a position to observe
care delivery and the standards achieved. While it is not as straightforward as it
may appear to determine standards in areas outside your expertise, some aspects of
care, such as patients calling out for help or because they are in pain, should prompt
IPCSs to make enquiries of the staff. It is not difficult to observe and report issues of
safety such as trip hazards, fire risks, lack of security, or lack of privacy and dignity.
Most infection control staff have a background as qualified healthcare workers
with a professional responsibility for maintaining and promoting standards of care.
Therefore, there is a professional obligation to act on information or observation of
poor practice. It is not sufficient to assume that working in a specialty allows staff
to ignore or not act on instances that are not within their sphere of control. The
expectation is that staff would respond by escalating issues of concern to the appro
priate manager and, if this has no effect, to continue to escalate it until it is resolved.
Unfortunately, this is at times problematic for IPCSs. As ‘visitors’ to an area, they
are reliant on the goodwill and cooperation of staff to enable them to identify issues
of infection and prevention concern and facilitate the required actions. There is an
element of trust involved in a good relationship. This includes openness about a

potential lack of knowledge, and the opportunity to ask for help is part of a mutually
beneficial and dynamic relationship. To disrupt this by whistleblowing or making
complaints may lead to a loss of trust and confidence in the relationship. Therefore,
the way this is done is important.
Ultimately, the aim is to highlight and prompt improvement, rather than to
irritate and alienate. This is generally easier when there are established and strong
relationships with staff in an area. In most instances the role of the IPCS is to reflect
back observations (both good and bad) to the appropriate manager or member of
staff and to explain the difference between expectations and observed performance.
When this is not sufficient, a more formal process of documentation and escalation
is required. Sometimes, unfortunately, professional or friendly relationships may be
damaged and rebuilding is required. However, if staff are clear that the IPCSs are not
habitually trivialising or nitpicking about issues of patient care, then when a concern
is raised the IPCSs are more likely to be listened to and their comments valued.
Sometimes, inadvertently, the IPCS becomes aware of an issue that requires
action and by highlighting the issue may cause disruption.
Example: causing disruption through highlighting an issue

In a teaching session on basic infection control for delivery drivers in primary care,
the IPCS summarised the basic principles of standard precautions and informed the
drivers of the risks of blood-borne virus transmission. It was mentioned that any
cuts or abrasions on hands should be covered with a plaster. The role of the drivers
was to collect and transport used commodes, beds and other patient equipment
from patient homes to a centre for cleaning and decontamination prior to reuse. The
drivers informed the IPCS that they could not put a plaster on cuts and abrasions,
as they had no access to first aid kits, and that they were until that session unaware
of the risks to themselves. The manager who is present at the session disputed the
need for the provision of first aid kits in vehicles, the drivers called their union
representation and a dispute ensued that disrupted the service.
Unfortunately, it is not always possible to avoid this kind of response, particularly
in areas that are unfamiliar. Preparation and running through the key elements with
managers of the information to be passed on can avoid confusion.
INCREASING INFLUENCE
Three key elements are important in increasing influence and impact:
1. the language and terminology used
2. accurately targeting a consistent message or information

3. understanding the processes required.
Understanding the language to use and the process for making changes or improve
ments in organisations is important. Each organisation is unique and it is worth
making the effort to understand how it functions. It can be very demoralising to
fail in efforts to influence change.
A starting point is recognising and understanding the organisational values and
objectives. This will indicate the likely priorities and focus of the organisation. If
organisational values and objectives, for example, focus on preventing harm and
increasing patient satisfaction, then, in explaining the rationale for change, a patient
satisfaction and harm-reduction focus in arguments is more likely to be successful
in achieving change. Alternatively, in organisations where finance and performance
are more important, the language used should include business and finance termi
nology. However, just because it is not stated in the organisational value statements,
do not assume it is not a core value. An example is given in Box 13.1.
r ^
BOX 13.1
Problem: Patients get cold walking along a corridor from changing rooms to
day surgery and you would like the organisation to provide patients with a warm
dressing gown for the journey.
Organisational with primary focus on patient satisfaction

Explanation to organisation: Patients have complained that they get cold in
the corridor and it would improve their experience if they were warmed on the
journey. If they are warmed they will be less stressed, more comfortable and
normothermic. This will increase their satisfaction and reduce their risk of surgi
cal complications.
Organisation with primary focus on value for money and performance

Explanation to organisation: Maintaining a normothermic patient reduces the
risk of surgical complications, which thereby reduces length of stay and cost of
care. It also increases patient satisfaction with the theatre experience, as they are
less stressed and warm, which increases their likelihood of recommending this
organisation to others. A cost-benefit analysis indicates that this is cost-effective.
V___________________________ ______________________________ J
The same approach is useful for communicating with individuals. Using their
terminology and understanding their values is crucial. If, for example, you need
to influence a staff group with a scientific background who require evidence, the
explanation should reflect their language and terminology.
r ^
BOX 13.2
Using the same patient warming initiative
Explanation: There is considerable peer-reviewed research evidence that
indicates ensuring preoperative and intraoperative normothermia reduces
post-operative complications. A number of randomised control trials have dem
onstrated statistically significant improvements in outcomes.
V___________________________ _____________________________ J
Understanding the organisational structure is also important, as time may be saved

by targeting the message appropriately. This often entails an unravelling of the
power rather than managerial structure. In many organisations, although it is clear
who is nominally in charge, there is frequently a group of staff who heavily influ
ence the decisions and strategies. Identification of the key influencers and decision
makers is an early step in targeting information appropriately and effectively. Time
spent on identifying who will be the person who makes the decision saves time in
repeating the message to only find you need to speak to someone else.
Determining the required processes, forms, meetings and other organisational
controls is also important to success. While this may appear tedious and long
winded at times, most processes associated with organisational change have devel
oped to prevent harm or damage and to constrain and manage changes which
could disrupt the status quo. It may be difficult to recognise their value while
ploughing through the process, but this may be faster than bypassing the system
only to encounter failure by not having been through the right process. A fast way
of getting this right is to ask someone who has done it successfully before to share
his or her knowledge with you.
SUPER SPECIALISTS AND EMBEDDED SPECIALISTS

A particularly effective way to influence change in infection prevention and control
is by the development and nurturing of team members with specialist knowledge.
This enables staff to understand and speak the language of other specialists in the
organisation and, because of their special interest, develop relationships with others
with similar interests. This can effectively fast-track conversations and decisions.
Examples of this include IPCSs with specialist knowledge or experience in subjects
such as decontamination, ventilation, water, environment, blood-borne virus,
information technology, and so on.
There are a few IPCSs who now have roles that are predominantly focused on
quite narrow aspects of infection prevention and control. An example is an environ
mental infection control practitioner. The benefits of such roles are manifold, as they
have in-depth and current knowledge of the specialty, they can talk the language of
engineers, know who to speak to in the organisation about the issues, know how
to frame the questions required, understand the answers and are a credible expert.
They can also act as a translator of the jargon and act as mediator.
Embedding IPCSs in departments or areas is another way to effectively influence
infection prevention and control practice. Specialist areas such as intensive therapy,
theatres and dentistry may require particularly focused work to gain engagement
and an understanding of the specialty. It can be particularly helpful if the IPCS is
working in the area and is part of the team. It is then possible to influence from
within, acting as a credible presence. In time the IPCS may be able to utilise the local
structures and system within the specialty to promote the infection prevention and
control agenda. The embedded IPCS helps to tailor infection prevention and control
responses and practice to the constraints of the particular specialty.
There is a potential danger in super specialist and embedded specialist roles that
post holders will become so engrossed in the other specialty that they lose sight of
their infection prevention and control agenda and become deskilled in the original
specialty. To avoid this, job descriptions and plans should make it clear that the
super specialist role is one part of the job. Post holders should be supervised and
supported to ensure their work output relates to the role expectations.
SELF-EFFICACY
Self-efficacy is an important aspect of increasing influence and value, as frequently
the momentum required to influence is dependent on the individual IPCS or the
strength and support of the team. Improving self-efficacy can make individuals
more effective, which increases their value and in turn boosts their confidence and
job satisfaction.
The theory of self-efficacy was first described by Albert Bandura.9 It is essentially
a form of self-confidence in various situations where you have the belief that you
are competent to respond appropriately. Bandura9 described four sources of self
efficacy, as follows.
1. Perform ance accomplishments, which is essentially that by succeeding in experi

ences you gain confidence in your ability. An example of this could be delivering
a lecture or making a presentation; if you do this frequently, you usually gain
confidence.
2. Vicarious experience, which is that observing people who are similar to you suc
ceeding or failing affects your belief in your own ability to succeed. An example
of this would be observing one of your peers competently handling a very diffi
cult conversation with an angry staff member. If they can do it, then you can too.
3. Verbal persuasion, which is that people can be persuaded to believe they have
the potential or ability to succeed. This could be as simple as a colleague telling
you that they believe you are good at something or have the potential to be good
at something and that you should try it.
4. Psychological states, which is related to people’s moods and predisposition that
affects their confidence in their ability to succeed. An example of this is people
who are in a low mood or are anxious who generally have a more negative per
spective on their potential abilities.
Many IPCSs are involved in promoting self-efficacy but are probably unaware of the
psychological theory behind it. An example is teaching people to clean their hands
and promoting compliance, which is summarised in Table 13.1.
TABLE 13.1 Teaching hand hygiene techniques and promoting compliance

Action Aspect of self-effica cy theory
S e ttin g up a h a n d h y g ie n e tra in in g s e s s io n in P s y c h o lo g ic a l s ta te
a n a p p ro p ria te e n v iro n m e n t th a t is q u ie t, th e
rig h t te m p e ra tu re a n d w h e re e v e ry o n e is a b le to
p a rtic ip a te e a s ily
P ro v id in g an e x p la n a tio n o f th e v a lu e a n d b e n e fit o f V e rb a l p e rs u a s io n
h a n d h yg ie n e
D e m o n s tra tin g h a n d h y g ie n e te c h n iq u e s V ic a rio u s e x p e rie n c e
P a rtic ip a n ts p ra c tic e a n d d e m o n s tra te te c h n iq u e s V ic a rio u s e x p e rie n c e
P a rtic ip a n ts g e t it rig h t a n d b e in g p ra is e d fo r go o d P e rfo rm a n c e a c c o m p lis h m e n t
te c h n iq u e
P a rtic ip a n ts re p e a tin g th e le a rn e d te c h n iq u e in P e rfo rm a n c e a c c o m p lis h m e n t
p ra c tic e s itu a tio n s
OTHER WAYS TO BE MORE EFFECTIVE

There are a number of other simple ways to be more effective by managing time
and effort. Some brief examples are:
• avoid duplicating the work already done by others
• plan work and set measurable goals
• prioritise
• minimise trivial or time-wasting activities
• simplifying information to ensure comprehension and avoid confusion.
THE VALUE OF INFLUENCE

It is not always easy to measure the value of influence in the workplace. A person
in a position of power may have more opportunities than more junior staff to
exert influence, and that person’s value to the organisation is often reflected by the
rewards he or she is offered in salary, status and autonomy.
Infection prevention and control influence may result directly from, for example,
education or advice given, or indirectly from, for example, the use of policies and
guidelines. The impact of IPCSs is not always immediately obvious and, if success
ful, it is embedded in practice.
Perhaps the simplest way to assess your own impact is to ask others around you
to give you some feedback. There are a number of tools and methods of doing this,
but some simple areas to focus on would be as follows.
• Are your views really listened to by others?
• Do people seek your views on issues?
• Have your views and/or actions made a difference?
• Are you asked to collaborate with others?
• Do you receive recognition for your contribution?
• Does the work you do generally achieve positive results?
Another way is to examine the impact and outcomes of work and initiatives. For
example, a project to improve invasive device documentation led to a significant
reduction in healthcare-associated infections in patients with intravenous devices;
or an audit of soap dispensers led to recognition that many were broken and they
were subsequently all replaced.
Value and influence may also be perceived as negative. In infection prevention
and control it is not uncommon that the requirements are seen as barriers - for
example, delaying opening new buildings until they are clean, restricting visiting
during outbreaks, removing jackets to wash hands and not eating food in theatres.
While this aspect of the role may not be popular, it is still valuable and it has a
positive impact on patient outcomes by contributing to the reduction of healthcare-
associated infections.
CONCLUSION
ICPS have opportunities to positively influence practice in healthcare beyond the
narrow spectrum of their own specialty. Providing more than the infection preven
tion and control perspective in a professional and positive way can make a positive
contribution to the entire healthcare delivery agenda. This increases the value of
their role and optimises their contribution.
REFERENCES
1. Bahamon C, Dwyer J, Buxbaum A. Leading a change process to improve health service
delivery. Bull World Health Organ. 2006; 84(8): 658-61.
2. National Audit Office. Reducing Healthcare Associated Infections in Hospitals in England:
report by the Comptroller and Auditor General. London: The Stationery Office; 2009.
3. Griffiths P, Renz A, Rafferty AM. The Impact o f Organisation and Management Factors on
Infection Control in Hospitals: a scoping review. London: King’s College London; 2008.
4. Woodside AG, Frey LL, Daly RT. Linking service quality, customer satisfaction, and behav
ioural intention. J Health Care Mark. 1989; 9(4): 5-1 7 .
5. Fearon KCH, LuffR. The nutritional management of surgical patients: enhanced recovery
after surgery. Proc Nutr Soc. 2003; 6(4): 807-11.
6. Schaible UE, Kaufmann SHE. Malnutrition and infection: complex mechanisms and global
impacts. PLoS Med. 2007; 4(5): e115.
7. Delgado-Rodriguez M, Bueno-Cavanillas A, Lopez-Gigosos R, et al. Hospital stay length
as an effect modifier of other risk factors for nosocomial infection. Eur J Epidemiol. 1990;
6(1): 34-9.
8. Olesen F, Hansen RP, Vedsted P. Delay in diagnosis: the experience in Denmark. Br J Cancer.
2009; 101(Suppl. 2): S5-8.
9. Bandura A. Self-efficacy: the exercise o f control. New York, NY: WH Freeman; 1997.
C H A P TE R 14
The use of marketing in infection

Annette Jeanes
Marketing is used widely in everyday life. This chapter will introduce simple mar
keting concepts and explain how these can be applied in infection prevention and
control.
MARKETING
Marketing is the process through which products, ideas or behaviours are promoted
to a customer or audience. This includes market research and advertising, and it is
used widely to sell or influence choices. The basic elements are the 4 Ps of marketing:
Product, Price, Place and Promotion. This may be expanded to the 7 Ps by adding
People, Process and Physical evidence.
These elements of marketing are summarised briefly here.
1. Product: to be marketable the product should be something that people will
want or need.
2. Price: the product should be value for money and affordable, or the price peo
ple are willing to pay. It may be priced to be extremely expensive and this may
increase the desirability.
3. Place: the product should be accessible, in the right or convenient place and at
the right time for the user or purchaser.
4. Promotion: this is the communication to the customer about the product and
includes advertising; promotion may also include straplines and images.
167
5. People - this generally applies to the people promoting and or selling the prod
uct. It could also include the endorsement of reputable experts.
6. Process: this relates to how the product is delivered to the customer. This
includes how the product comes to the customer’s attention, the way it is selected
and ordered, and how it is delivered.
7. Physical evidence: this relates to feedback from customers and evidence about
the product, the process, the price and the people involved. This information
is used to modify the product, promotion, price, process, and so forth, but also
to demonstrate to others that the product is being used and acquired by others.
An example would be: ‘8 out of 10 people use ..
There are so many examples of marketing in healthcare that you are probably
barely aware of it most of the time. Every product purchased and used is marketed
to some degree as part of the procurement process. This includes the flooring of a
healthcare facility, the paint on the walls, the bulbs in the lights, the water in the
taps, the disposable gloves, the uniforms and more.
TABLE 14.1 Examples of the 7 Ps in use

Elem ent Example
P ro d u c t S a fe ty -e n g in e e re d p h le b o to m y k it
P rice P re fe ra b ly th e s a m e p ric e o r less th a n n o n -s a fe ty d e v ic e s
Place E asily a c c e s s ib le fo r p h le b o to m is ts (i.e. on th e ir s ta n d a rd
w o rk s ta tio n s e t-u p )
P ro m o tio n C le a r la b e llin g a n d logo; p o s te rs , e d u c a tio n a n d in fo rm a tio n
a b o u t p re v e n tin g s h a rp s in ju ry
P e ople O c c u p a tio n a l h e a lth s ta ff, s a le s re p re s e n ta tiv e s
P ro ce ss In tro d u c tio n o f p ro d u c t to use rs, s ta ff w h o o rd e r it a nd
tra in in g in h o w to u se th e p ro d u c t s a fe ly
P h ysica l e v id e n c e F e e d b a c k fro m u s e rs a n d ra te s o f s h a rp s in ju rie s
The techniques used to market products range from the obvious shouting of a
market trader to the more subtle or subliminal advertising campaigns. Many com
panies employ highly paid and highly skilled experts in marketing. Usually the
marketers have a vested interest in the success of the product and the success of the
marketing strategy. It is unusual for established organisations and institutions to
ignore the value of marketing, as it creates and nurtures the brand and contributes
to the success, value and sustainability of the products produced. Marketing and
THE USE OF MARKETING IN INFECTION PREVENTION AND CONTROL 169
the associated issues of image, profile, market share and profit are closely linked in
many companies.
Unfortunately, in healthcare, marketing is often not perceived to be a high pri
ority and may be particularly poorly resourced at a local level. Consequently, in
infection prevention and control, practitioners frequently resort to a ‘do it yourself’
methodology, which can sometimes be brilliant but is often not, and which can
appear amateurish in comparison with professional campaigns.
At a national level, marketing is frequently used to change health-related behav
iours. This is usually referred to as social marketing.
SOCIAL MARKETING
Social marketing uses marketing techniques to change or influence behaviours for
the good of all.1 Essentially, it is an approach aimed at selling attitudes, behaviours
and ideas. It is used extensively in healthcare. Examples of social marketing are:
• anti-smoking campaigns
• anti-alcohol campaigns
• breast cancer screening
• condom use promotion.
Social marketing varies from standard marketing in several ways. While there is
generally a financial benefit in promoting a physical product for profit, in social
marketing the benefit is accrued and measured by the effect on behaviours and
attitudes. Social marketing is often linked to public policies and strategies that may
be linked to a resource to fund the marketing. The audience may be very wide and
variable. Social marketing may also be aimed at influencing policymakers and it
may seek to alter social and cultural norms. Examples of this include campaigns
about the disabled and racism. In these instances, different organisations with
similar aims will collaborate to support these marketing campaigns.
The 4 Ps are used, but as a starting point often the campaigns and techniques
attempt to increase awareness that there is a problem. The product then becomes
the solution. An example would be: ‘smoking can cause lung cancer; therefore, the
solution is to stop smoking’.
In social marketing, hard-hitting images and messages may be used when previ
ous, softer messages have not worked on some of the target audience. Advertising
relating to preventing road traffic accidents is a good example of progressively
hard-hitting campaigns. Initially, these aimed at increasing alertness to traffic when
crossing a road and at reducing speed. Later campaigns were progressively more
explicit for some target audiences; in some there were images of death and dying.
The product is about road safety but the method of delivering the message is to
frighten and to make people identify with the victims. Similar approaches are used
in anti-smoking and anti-hunting campaigns.
The price element associated with social marketing is usually the benefit gained
by individuals or society, but it can deliver public savings such as a reduction in
patients admitted following road traffic accidents or a reduction in patients dying
of lung cancer. Therefore, the saving and benefit is largely for society as a whole.
The place of the product in social marketing may relate to how consumers get
help or advice or how the message reaches the target audience. This process requires
a clear understanding of who are the target audience and how likely they are to use
or have contact with various media formats. It would be ineffective to promote the
value of a website to people with no access to the Internet, for example. The place
ment of the product or message is heavily dependent on understanding the target
audience. This may result in numerous methods of product placement, including
posters, television adverts, Internet messages, newspaper and magazines, food
wrappers, and so on.
Social marketing also has to contend with the fatigue of the audience, when
they eventually ignore and grow bored with the message being promoted. In
campaigns funded by industries selling products, the sale of the product can then
generate more resource for marketing and the campaign is subsequently changed
and updated. In social marketing, as a problem becomes less of an issue or an issue
less of a problem, funding may become scarce and campaigns may not be refreshed
regularly - particularly as there is competition for other issues and causes.
MARKETING CAMPAIGNS
Many in infection prevention and control will be motivated to run a campaign or
launch an initiative or promote an idea, concept or behaviour. This could be related
to the service provided or to a particular initiative. To do this effectively you may
decide to develop a marketing campaign. There are numerous detailed examples
of marketing campaigns on the Internet. This section provides a short guide that
briefly summarises how to set up and run a marketing campaign.
The first step is to understand why you are doing it. What is the purpose of your
campaign? If you are not clear, then others will not be clear either.
Associated with the purpose, you need to decide who your campaign or ini
tiative is aimed at. Who are you marketing to? This may include children, adults,
families, healthcare workers, general public, non-English speakers, and so on. The
characteristics of the target audience will influence your approach, the ideas you
develop, the language you use and the method of communication you select.
Next are the budget and/or resource. If this venture is likely to require significant
resource then you may need to develop a business case or proposal for funding. In
some organisations this sort of budget is included in the departmental running cost.
You may have to decide if sponsorship is an option. Resource is not just about the
money. It is also about the available talent and enthusiasm and the use of facilities
or resource (e.g. photocopiers). You may have to market your proposal to potential
marketing recruits (colleagues) or the people responsible for the resources you hope
or plan to use.
Then you need to decide on a strategy and plan. This will be constrained by the
resource and time you have available. Key elements to include are not only how will
you do it and who will you aim it at, but also:
• What are your targets or goals?
• How will you measure success?
• What is your backup plan if your efforts fail or falter?
• What are the risks?
It is essential that you are clear and realistic about your focus and aspiration, as
to be too ambitious with poorly thought-out ideas will mean you are less likely to
succeed. In addition, test your underlying assumptions and your propositions to
ensure they are robust. A popular method is to create a focus group to test these
and ensure others agree with you and your approach.
Box 14.1 shows an example from a hand hygiene compliance improvement
campaign.
In response to feedback from staff and patient groups, the campaign was modi
fied to focus on how easy it could be to transmit infection. The patients in particular
were keen to ensure all healthcare workers understood that they could pass on
infections by not cleaning hands. It was agreed that this was unacceptable and
avoidable. This led to a campaign idea: ‘Don’t be the one to pass it on, which was
aimed at provoking an emotional response from staff and the public.
How you then develop your initiative or campaign may vary, but a simple,
engaging and consistent approach may be more successful than one that confuses
or alienates. A slogan or strapline is often used but is not essential, although it is
helpful if you produce something that is memorable.
There must be a plan for a launch and a communication strategy. This is often
an opportunity for leaders in an organisation to give a supportive statement, and to
have a picture taken promoting the campaign or project. Although this may seem
r ;
BOX 14.1 Hand hygiene compliance improvement campaign
A
Assumptions
• Everyone is potentially at fault
• We need to change behaviour and attitudes
• Parallels exist between hand hygiene and other public health campaigns that
have been tackled successfully
• Everyone needs to talk openly about the importance of hand hygiene
• Raising awareness will lead to greater personal responsibility
Propositions
• Failure of staff to clean their hands is unacceptable, irresponsible and
negligent
• The public should not be afraid to challenge staff about hand hygiene
V___________________________ _____________________________ J
like the end of the work, it is important that the people involved are fully briefed and
are clear about what is going to happen. Although by this point you may be tired of
the message yourself, it is important to ensure it is repeated at every opportunity.
An evaluation of the campaign is useful in understanding what went well and
what could be improved in a subsequent campaign. This could be through a sim
ple questionnaire, interviews or measuring product uptake (e.g. soap, for hand
hygiene).
The following questions summarise these basic elements of a marketing
campaign:
• What is the purpose of your marketing?
• What are your targets and goals?
• Who is the target audience and what are their characteristics?
• What budget or resources are available?
• What is the timescale?
• What is your idea/s or initiative?
• What is your strategy and plan?
• Do you have a contingency plan?
• Have you tested your marketing propositions and assumptions?
• Have you modified your campaign ideas in response to feedback?
• What is your communication and launch plan?
• What was learned from the evaluation?
FINALLY
Key aspects of the work of infection prevention and control practitioners is to pro
mote and change behaviours, to introduce new products and to improve practice.
Marketing is therefore a useful tool. The basics of marketing methods are simple
and can be adapted; a good starting point is to reflect on how you market yourself
and your services.
REFERENCE
1. Kotler P, Zaltman G. Social marketing: an approach to planned social change. JM ark. 1971;
35(3): 3-12.
C H A P TE R 15
Patient and healthcare worker

empowerment
Maryanne McGuckin
Fifteen years ago when my colleagues and I introduced the concept of empower
ing patients to ask their healthcare workers (HCWs) to wash their hands as a way
to increase hand hygiene (HH) compliance, there was a great deal of doubt that
this would be possible. Our programme, Partners in Your Care,1was embraced by
many, and yet there was some scepticism that unfortunately continues among some
colleagues, despite the evidence for success. Those who do not fully embrace this
concept are looking for the double-blind controlled study as proof of efficacy, rather
than alternative methods for testing such as developing and evaluating pilot pro
grammes with the professionals most likely to know the environment in which the
programmes will be applied: the HCW and specifically the infection preventionist.
Doubters continue their trend of identifying barriers to patient and HCW empow
erment rather than keeping their focus patient centred. As a pioneer of this concept,
and the author of over a dozen peer-reviewed articles in which patient empower
ment was studied using a standardised quantitative measurement model, there is
evidence to support patient empowerment in our HH programmes. It is time for us
to stop looking for reasons why patient empowerment may not work and to encour
age creative programmes and share our successes. There will always be patients and
HCWs who will not embrace the concept of patient empowerment, just as there are
still HCWs who do not embrace sanitiser usage or the World Health Organization’s
(WHO) Five Moments for Hand Hygiene, but that should not be a reason for not
including patient empowerment in our (HH) programmes. We would not think of
stopping the use of sanitiser until we find out the psychological or social issues of
175
why some HCWs are not using sanitiser or following the five moments. We must
focus on the pros of patient empowerment and not the cons. Waiting for the perfect
study that will say patient empowerment and HH compliance works or does not
work will not change the fact that our patients are demanding to be empowered
and to participate in their care, and it is our responsibility as HCWs to provide
them with skills and knowledge to be empowered. In addition, several regulatory
organisations are recommending, and for some rewarding, patient participation. As
the author of a recent review of patient empowerment and HH, there is evidence
that, in principle, patients are willing to be empowered. However, there is variation
in the actual number of patients who practise empowerment for HH, ranging from
5% to 80%. A key factor driving lower numbers is the lack of having an interven
tion using programmes that include education, measurement, feedback and explicit
permission from HCWs to patients to be empowered.2
Therefore, the objective of this chapter is to help the infection preventionist
develop programmes that empower both HCWs and patients so that they become
more comfortable in their roles. Barriers will be presented as a way for you to be
aware of them and should not be used as reasons for not including patient empow
erment in your programmes. We can no longer wait for that perfect study that
identifies all barriers, and while we wait, cast doubt among HCWs. Yes, it is time
to embrace patient empowerment, as it is the right thing to do for patient safety.
INTRODUCTION
When you need hospital care, it’s comforting to know that you’ve chosen a good
hospital and a good doctor who will look out for your welfare. However, as health
care providers, we should not expect that patients will just lie back and wait to get
better. Patients and HCWs have definite rights and responsibilities for the delivery
and outcome of care. As early as 1977, WHO advocated that patients participate
in their healthcare.3 We now know that empowering both HCW and patient can
have a significant effect on the prevention of healthcare-associated infections
(HCAIs).4 Empowerment has been defined as a process in which patients under
stand their opportunity to contribute, and are given the knowledge and skills by
their healthcare provider and other educational sources to perform a task in an
environment that recognises community and cultural differences and encourages
patient participation.2
You will notice that whenever possible, I prefer using the term empowerment
and not softer terms such as patient involvement, patient participation, and patient
engagement. Although these alternative terms have been used in the hope that
PATIENT AND HEALTHCARE WORKER EMPOWERMENT 177
patients would be more likely to feel safer with these words, one needs to realise that
in order to participate, be involved or be engaged, one first needs to be empowered
with knowledge, skills and, most important, an environment that encourages their
involvement.
WILLINGNESS OF PATIENTS TO BE EMPOWERED

In 2004, WHO launched the World Alliance for Patient Safety to raise awareness
and political commitment to improve the safety of care in all its member states.5
A specific area of work, Patients for Patient Safety, was designed to ensure that
the wisdom of patients, families, consumers, and citizens, in both developed and
developing countries, is central in shaping the work of the alliance.
The extent to which patients wish to be empowered is still a matter of debate, as I
explained in the opening section. For example, Longtin et al.6 discussed the reasons
why patients would not ask about HH, based on an open questionnaire given to
194 patients. The main reasons were the perception that caregivers already know (or
should know) when to perform HH, the belief that asking about HH is not part of
the patient’s role, and a feeling of embarrassment or awkwardness associated with
asking about HH. However, we must realise that an important part of empower
ment is to first give knowledge. Without this knowledge, one would expect a patient
to not see the value of participation. This is supported by a 2010 study in Sweden,
looking at patients’ understanding of patient participation. The study found that
patients reported and described participation mainly as sharing knowledge and
sharing respect. They wanted to have knowledge rather than just being informed,
and they wanted to interact with health professionals, rather than merely partak
ing in decision making.7 Another survey of over 2000 consumers found that 91%
thought they could prevent medical errors occurring in hospitals, and 98% thought
that hospitals should educate patients in this regard.8 One can conclude from these
findings that consumers understand they can make a difference in preventing errors
but still have their own perceived ideas of what are the most important patient safety
errors. It is the HCW’s role to give this knowledge and permission to participate.
Reflection 15.1 is an example of how one HCW learned what advocacy means.
REFLECTION 15.1 Daughter, healthcare worker and advocate10

I have been a healthcare professional for more than 25 years, and now I am also
a healthcare patient advocate. Throughout my nursing career, I always acted as
an advocate for my patients. That often meant going against the usual routine
within the work environment and trying new care practices to protect patients.
Then my father developed pneumonia due to resistant bacteria called
meticillin-resistant Staphylococcus aureus (MRSA) infection. He almost died
because of a lack of basic infection control practices in the hospital where he
was treated. That is when the need for a different kind of advocacy hit closer
to home. Until that time, I was always advocating for safe care, but I was not
specifically focused on preventing infections.
While my Dad was hospitalised, I began to see what hospital care was like
from a patient’s perspective. Basic infection control practices were lacking. No
one performed the patient care practices that are designed to prevent pneumo
nia, such as oral care and elevating the head of the bed.
The most important failure was the lack of hand washing. We contacted
the infection control department as well as the chief nurse and were told that,
‘We are aware of the problems and are working on them.’ I realised that asking
about hand washing was not going to make an impact on patient care, because
there were so many offenders. Instead, I placed a sign on the door to my Dad’s
hospital room that said, ‘Wash hands’. At this point, I needed no additional
evidence that it is the responsibility of an advocate (often a family member) to
monitor infection control practices together with the healthcare team and take
direct action to protect a loved one’s health and safety in the hospital.
A patient’s willingness to be empowered is dependent on having gathered enough

information, understanding how to use the information, and being convinced
that this knowledge gives them shared responsibility with their HCWs. However,
in their review of materials given to patients to empower them, Coulter and col-
leagues9 found that relevant information was often omitted, many doctors adopted
a patronising tone, and few actively promoted a shared approach. Studies have also
shown that patients prefer information that is specific, given by their HCWs, and
printed for use as prompt sheets if necessary. How many of the steps outlined in
Reflection 15.2 do you or your colleagues include in your patient empowerment
programmes?
REFLECTION 15.2 What patients need is empathy and empowerment

(courtesy of Kerry O’Connell, infected patient and advocate)10
• Tell us how we [the patients] can be empowered to take an active part in our care
• Always tell the patient what organism he has been blessed with
• Tell the patient the most likely ways he contracted his infection
• Lay out in detail the good, the bad and the ugly prognosis
• Spend time with patients in the isolation ward (the loneliest place on earth)
• Give us some solid clues on how to prevent this next time
• Learn to express genuine remorse
• Never ever send survey form letters to known victims
• Love thy infected patient (even the very difficult ones)
In addition to having knowledge as part of empowerment, patients also need

skills, and an important one is what we call self-efficacy. Although there are several
components of the concept of self-efficacy, verbal persuasion is probably the most
relevant to a patient being empowered. Verbal persuasion affects an individual’s
perceived ability to believe that he or she can in fact be empowered.11 Another con
cept that affects a patient’s willingness to be empowered is health literacy, which is
the ability to understand health information and to use that information to make
good decisions about health and medical care. Health literacy is fundamental to
patient empowerment.12
In summary, a patient’s willingness to be involved, empowered or engaged is
dependent on the overall environment of the organisation and its attitudes toward
patient safety and patient involvement.
APPLICATION TO INFECTION CONTROL

In studies undertaken in the United States and the United Kingdom, McGuckin
and colleagues11314 reported on the willingness of patients to be empowered and
involved in HH by asking their HCWs to clean their hands. They documented that
80% -90% of patients will agree to ask in principle, but the percentage of those who
actually asked their HCW is slightly lower, at 60%-70%. This was further reinforced
by the findings of the evaluation of the pilot testing of the National Patient Safety
Agency of England’s Clean Your Hands campaign.15 They reported that the major
ity of patients believed the public should be involved in helping staff increase their
HH compliance.
A survey of consumers on their attitudes about HH found that four out of five
consumers said they would ask their HCW, ‘Did you wash/sanitise your hands?’ if
their HCW educated them on the importance of HH.16 Longitin and colleagues17
presented a conceptual model of patient empowerment looking at factors of knowl
edge and applicability to patient safety. For infection control, especially HH, they
believe that patients can be a source of education to staff. They state, ‘organizing
a campaign that encourages patients to ask HCWs about HH would draw HCWs
attention to its importance and raise their adherence without patients having to
intervene’.17
WILLINGNESS OF HEALTHCARE WORKERS TO BE EMPOWERED

In patient empowerment, the HCW strives to promote and enhance the patient’s
abilities to feel in control of his or her health. Education and decision aides - for
example, leaflets, computer programs, interactive videos, websites and group
presentations - are useful to healthcare providers in the process of empowering
patients.18 The aim of these tools is to help patients reflect on and identify their
own skills and needs and realise that these skills will have a benefit in their lives.19
However, the healthcare professional’s perceptions of patient knowledge influence
how patients are involved in decision making and being empowered. Patients who
can communicate health knowledge involve themselves in ways that are perceived
as beneficial, but patients who lack that ability may be active and engaged but are
excluded from decision making or being empowered. By being aware of that bias,
healthcare professionals may be able to be more effective in empowering all patients.20
A review of patient engagement and what works by Coulter21 states that (a) con
trary to popular belief there is a great deal of published evidence on the likely
effectiveness of patient engagement strategies and (b) there is a compelling case for
reviewing and, where necessary, adapting healthcare delivery and practice styles
to enable active engagement of patients in planning and shaping their healthcare.
The message is very clear that a significant part of patient empowerment is HCW
empowerment and the HCW’s role in giving patients explicit help in becoming
involved. Yvonne Birks and colleagues22 carried out a series of studies to examine
how patients and their representatives might promote their own safety in healthcare
and identified the following four factors as important to patient empowerment.
1. Patients are likely to need the support of healthcare professionals to participate
in contributing to safer healthcare initiatives.
2. Nurses are well placed to support patients to voice concerns about the safety of
their care.
3. Patients may feel reluctant to express concern where nursing staff are perceived
to be unreceptive to concerns.
4. Organisations should support nursing staff to enable patient involvement in
patient safety in a number of ways.
Similar findings were reported in 2007 when WHO conducted a two-part survey on
patient empowerment to gain further knowledge and to incorporate geographically
and culturally diverse perspectives related to empowerment into the final version of
the WHO Guidelines fo r H and Hygiene in Healthcare.2 One of the key findings was
that HCWs’ active encouragement to the patient to remind HCWs about HH had
a significant impact on a patient’s willingness to be empowered.
The issue remains on the best approach to empower HCWs so that they in turn
can empower their patients. There are three prerequisites that HCWs require if they
are expected to help patients be seen as able to be empowered.23 These are (1) a work
place that promotes empowerment; (2) a personal belief that patients, regardless
of their knowledge of healthcare issues, can be empowered; and (3) acknowledge
ment that the relationship and communication of HCWs with patients can be
powerful and result in trust and encouragement to be proactive in their role as an
advocate for patient safety. It is important to remember that a HCW cannot create
personal empowerment in another individual. However, the partnership of HCWs
and patients can facilitate or bring about a sense of being able to be empowered. If
patients are given knowledge and resources in an environment of mutual respect
and support, then a facilitating environment for empowerment will develop.
APPLICATION TO INFECTION CONTROL

There are many opportunities for HCWs to empower their patients on a daily basis
about clinical issues such as diabetes control, hypertension medication and nutri
tion. Although these are empowerment concepts, HCWs have often seen them more
as education tools as opposed to concepts aimed at underpinning the facilitation of
empowerment. However, when one considers infection prevention and control, the
most frequently studied example of patient empowerment relates to HH improve
ment, and here lies the task of making sure the HCW is first empowered. Patient
and HCW empowerment programmes for HH should be part of any basic multi
modal HH improvement strategy. The strategy proposed by WHO to implement
the Guidelines on Hand Hygiene includes five key elements and should be reviewed
before one considers patient empowerment.2,4 The foundation of the strategy must
be ownership, accountability and shared responsibility. Just as patients need to be
part of the development of materials and programmes for patients, HCWs must
see that they have a shared responsibility and ownership in the development of
patient-empowerment programmes. For example, one cannot start a programme
of encouraging patients to ask their HCWs to wash or sanitise their hands unless
there has been buy-in from key stakeholders and input from HCWs into the pro
gramme. The value of involving HCWs has been supported by the work of Longtin
et al.24 in a survey of 277 HCWs on their perception of patients asking them about
HH. They found that 29% did not support the idea of being reminded by patients
to perform HH - even though 74% of respondents said they believed that patients
could help prevent HCAIs. The researchers also found that 44% of respondents said
they would feel guilty if patients discovered they skipped HH, and 43% said they
would feel ashamed to disclose such a fact. This survey gives us some important
information on how HCWs may believe that an empowered patient is important
to patient safety, but lacking a personal belief that they should be empowered can
result in a belief that it is not the patient’s role to ask about HH.
Empowerment programmes for infection control and specifically for HH can
be categorised into educational (including Internet), motivational (reminders and
posters), and role-modelling within the context of a multimodal approach. The
WHO Guidelines2 and McGuckin and Govednik25 provide an excellent overview
of the research for each of these categories and should be reviewed before decid
ing on a specific process. It is essential that an evaluation component be part of all
empowerment programmes.
OVERCOMING BARRIERS TO EMPOWERMENT

There are several different theories from various disciplines that provide insight into
the potential barriers to patient empowerment in healthcare. These theories include
cognitive, behavioural, social marketing and organisational theories that may be
valuable when considering barriers to be overcome, or a strategy to involve and
engage patients.26 It is important to remember that the foundation of an empower
ment programme is ownership and shared responsibility. Therefore, barriers are
better addressed if we acknowledge different views on patient empowerment and
deal with them in the context of an organisation, culture or community. The UK
National Patient Safety Agency surveyed the public, inpatients and HCWs - par
ticularly front-line clinical staff and infection control nurses - in five acute care
hospitals to determine whether they agreed on a greater level of involvement. A key
finding was that most HCWs surveyed (71%) said that HCAIs could be reduced to
a greater or lesser degree if patients asked HCWs if they had cleaned their hands
before touching them.27 Following publication of the findings of this work in the
academic press, a follow-up letter to the editor from a HCW presenting details
following her hospitalisation presents yet another barrier to empowerment. She
voices concern that we may be moving the responsibility of HH from HCW to
patient and that not all patients want and can be empowered.28 Here we see the
continued focus on barriers and reasons why empowerment will not work, rather
than developing programmes for high-dependency patients. For example, a study
in an intensive care unit in the United States used voice prompts developed by
administrative and medical leadership reminding HCWs to wash or sanitise their
hands, and the prompts were played from the nursing stations. In this model, the
voice prompts served as the advocate for the non-communicative patients. They
reported a significant increase in HH compliance using this model.29 One of the
hand-washing pioneers, Semmelweiss, never gave up and we cannot give up on
encouraging patient empowerment. Reflection 15.3 addresses why we must face
each barrier with a solution and that solution can no longer be ‘why it will not work.
REFLECTION 15.3 Guilt to empowerment10

My mother was a registered nurse. She walked daily for exercise, enjoyed gar
dening, and was a very active 70-year-old woman. So what went wrong?
On Thanksgiving (25 November 2004, 6 weeks after her surgery), my mother
began complaining of nausea. She didn’t have fever, diarrhoea or vomiting, so I
thought she might have food poisoning. I called her surgeon, who didn’t seem
alarmed. He never suggested that I should take my mother to a hospital, but
the next morning, I took her to the hospital myself. She died there 10 hours later
from a massive infection.
This began my search to find out what went wrong. How had she acquired
that infection? How could it have been prevented? It was only after I requested
her autopsy report that I learned the results from her laboratory culture. It was an
MRSA infection. Looking back at my mother’s ordeal, I now realise many things
that would have been helpful to know and steps that could have been taken to
prevent the tragedy of her untimely death. Like most people, we assumed that
reputable hospitals take every precaution necessary to ensure that their patients
are cared for in a safe and sanitary way. After our mother’s death, we found that
this is not always the case.
In retrospect, I now understand what I should have been told by the HCWs to
reduce her risk of MRSA infection. Knowing what I know now about the dangers
of HCAIs after surgery, particularly MRSA, I would have insisted that greater
precautions be taken to ensure that proper sterile techniques were used during
each step of her care. We would have insisted that each person entering my
mother’s hospital room would be required to wash or sanitise his or her hands
and that all equipment in my mother’s hospital room be adequately disinfected.
Knowledge is power, and unfortunately I wish that I had the knowledge then,
so that I could have protected my mother from the thing she feared the most:
a hospital error.
TRENDING: EASY ACCESS TO INFORMATION AND SOCIAL MEDIA

Healthcare social media can be defined as the interactive engagement through
use of electronic platform(s) for the multidirectional exchange of user-generated
information, knowledge, data and wisdom including anecdotal experiences among
patients, their families, healthcare professionals, health researchers and healthcare
administrators.30 Advocates of the use of social media in healthcare suggest that
these applications allow for personalisation and participation - key elements that
make them highly effective.31 Content can be tailored to the priorities of the users,
and the collaborative nature of social media allows for a meaningful contribution
from all user groups. Clearly these qualities are ideal for empowering our patients,
with capabilities of doing so in real time, giving them the knowledge and skills they
need to be active participants in their care.
The evidence is growing in support of this new trend. A study in the United
Kingdom found 51% of adults go online for health tips, compared with 20% going to
a doctor for advice.32 Similar results were found in the United States: 59% of adults
in the United States say they have looked online for health information in the past
year.33 In another study, 52% of US ‘smartphone’ (phones with Internet capability)
owners gather health information on their phones. Cell phone owners who are
Latino or African American, are between the ages of 18 and 49, or hold a college
degree are also more likely to gather health information this way.34 Although not
all consumers have Internet access or use it to seek health information, it is clearly
one of the primary modes of information sharing. These studies document the
potential of online communities, online peer groups, and social networks can have
on an individual consumer’s decision. By 2012, 24% of respondents to a US survey
reported posting a health experience or update to a social network; 16% posted
reviews of medications or treatments of doctors or insurers.35 We anticipate the
numbers will increase with time. Access to the Internet, use of smartphones (mean
ing access all the time), and information-seeking activity on health experiences
might be the next source for momentum in our empowerment direction. How will
HCWs who participate in consumer peer networks allow for consumers to freely
share their experiences while maintaining a standard of quality? These are the chal
lenges we face as consumers are seeking information more from the Internet than
from qualified professionals.
Will patient satisfaction - or, how we like to say, ‘happy patients, good outcomes’
- help us empower patients through social media and make them participate in
their care? Is patient satisfaction really patient safety and empowerment, or is it
a way for hospitals to generate revenue by getting good scores on their surveys
and therefore additional revenue. There is, however, the potential to adopt these
programmes for HH and empowerment. Giving patients an opportunity to voice
a complaint at the time HH does not occur, through some form of social media
device, and get a response can be a surrogate for empowerment and at the same
time generate compliance data.
AWARENESS, ENGAGEMENT AND INTENTION

There is no doubt that both consumers and patients are aware of this silent epi
demic of HCAIs, but how aware are they that the single most important factor
in preventing HCAIs is HH and that compliance is still less than 50% of the time
among HCWs? Do we tell our patients this fact when they are admitted as a way
to engage them? No, but we are eager to survey them on their intention on asking
their HCW to sanitise his or her hands and then we are surprised to find out that
patients think this is being done and why should they need to be concerned. There
lies the fault. We need more transparency about HH compliance rates. I am sure if
we first told patients the facts, their responses would be different.
You will recall in the reflections, the message was always the same: ‘if only I
knew’. A recent study of adult patients who had HCAI and were placed in contact
precautions were surveyed about their willingness to learn about multidrug-
resistant organisms and HCAIs and their preferred ways of education about
multidrug-resistant organism HCAIs. Ninety-eight per cent of patients thought
that their involvement in learning about multidrug-resistant organisms was very
important or important. Most of the patients thought that receiving information
about multidrug-resistant organisms would probably or definitely help them to
make choices that would improve their healthcare. The authors concluded that
patient preferences must be incorporated into education to increase engagement for
prevention of HCAIs.36 Similar research was done with consumers and their inten
tion to use public reports of HCAIs in their decision to choose a doctor or hospital.
The authors found that only 36% of consumers knew their states had reports (aware
ness), of which only 12% looked up the report (engagement), and only 52% had
intention of using the reports in the future.37 In 2012, the Agency for Healthcare
Research and Quality, as part of their programme Closing the Quality Gap, states
that patient and families are just not aware that quality information is available.38
Patient empowerment can take on many forms, depending on the culture, envi
ronment and resources, but we must keep in mind that making our patients aware
of the need to ask and to give permission will remove barriers.
ACKNOWLEDGEMENTS
I wish to thank Ms Kyan Chuong, library science graduate student from Drexel
University and the University of Pennsylvania, Philadelphia, for her assistance in
the literature review process, and Mr John Govednik, MS, Research Associate/
Education Coordinator for McGuckin Methods International, for his assistance in
the review and editing of the manuscript.
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C H A P TE R 16
The role of healthcare culture

in patient safety
Dave Grewcock, Aidan Halligan and Yogi Amin
There is often something close to outrage in the political and media debates that
surround high-profile safety failures in the National Health Service (NHS) - a
sense of disbelief that nationally regulated, publicly funded, twenty-first-century
organisations can apparently fail to apply even the most basic safety checks to
those in their care. How can a hospital staffed by compassionate, highly educated
individuals manage to execute an audacious surgical procedure, only for the patient
to succumb to a deep vein thrombosis for want of some routine observations and
a pair of compression stockings? How is it that a clinical team can invest so much
effort in stabilising a frail, elderly man after a fall, and then send him to a ward
that seemingly fails to ensure he has enough to drink? Why do patients succumb
to infections when in many cases all that is needed is some low-cost handwash and
good hand hygiene practice?
In a broad sense, we now understand much more about how failure originates
in and propagates through complex systems.1In some instances this understanding
has driven the innovation of new medical devices that ‘design out’ the risk of failure.
The practice of adopting ‘designed incompatibility’ can now make it impossible,
for example, to connect an air pump to a patient’s intravenous line. However, such
examples remain inevitably in the minority. Most healthcare processes are more
critically dependent on components that cannot be fundamentally redesigned:
human beings.
Thanks largely to progress in other domains, particularly aviation, we now
understand much more about the ‘human factors’ that constrain our individual
189
performance - our cognitive biases, the limits on our memory and attention, the
effects of tiredness and distraction, the ambiguity inherent in our communica
tion2 - but even that leaves us well short of a comprehensive description of what
determines patient safety. To a large degree, patient safety is a function of the atti
tude, judgements, beliefs and behaviour of healthcare staff because, ultimately, it is
these factors that determine whether policy and procedure are adhered to, whether
professional standards of practice are applied, and whether shortcomings in care
become tolerated as ‘unavoidable’ or ‘insignificant’. How an individual behaves
is, of course, contingent not just on his or her own particular beliefs or cognitive
characteristics, but also on the beliefs, attitudes and behaviours of those around the
individual. From this subtle, shifting complex of interactions between the individual
and the group emerges a set of shared but unwritten - and often unconscious and
usually unspoken - set of behavioural standards that shape how work is done and,
in healthcare, how patients are treated and cared for. This is ‘organisational’ or
‘workplace culture’, and over the last 2 decades it has come to be understood both as
the most intractable limit on the quality and safety of care and as the richest source
of potential improvement.3
Most of the reports into serious healthcare care failure in the last 20 years -
Bristol Royal Infirmary4 and Mid Staffordshire NHS Foundation Trust5,6 being
seminal examples - have identified some element of ‘poor’ or ‘dysfunctional’ organi
sational culture as a significant contributory factor, and the creation of a ‘good’
culture is the imperative behind much of what is written about good leadership.7
Most healthcare staff will now readily acknowledge that ‘workplace culture’ is a
critical determinant of how safe our patients are - even if they cannot describe with
any great rigor or precision what culture is, the mechanism of its impact on safety,
or how culture can be changed. Although formal definitions of culture exist - the
Francis report refer to ‘the predominating attitudes and behaviour that characterise
the functioning of a group or organisation’5 - most of us have become comfortable
with the informal shorthand that culture is ‘the way things are done around here’;
not least because it often resonates with our own personal experience. We have all
witnessed teams being endlessly and silently creative in subverting or undermining
change initiatives that they perceive as ‘unacceptable’. For those concerned with
maintaining or enhancing patient safety - and in fact any change programme - the
conclusions are obvious, and a little sobering: to ignore the cultural dimension of
our efforts is fundamentally to jeopardise them.
Yet the cultural aspects of safety and quality improvement are routinely dis
regarded, even by senior, experienced leaders. In our own NHS careers, we have
witnessed a number of safety- and quality-related initiatives launched and brought,
THE ROLE OF HEALTHCARE CULTURE IN PATIENT SAFETY 191
sadly, to compromised or incomplete conclusion, all without any considered effort

to address, or even assess, the cultural dimension to the change. There are a variety
of reasons.
Some managers and leaders hold fast to the view that although culture and its
impact are significant and real, it is nonetheless not a legitimate topic for ‘real work.
For them, culture is too nebulous a concept to engage with directly, or even describe.
They would hold that culture is an entirely emergent property; it arises from a par
ticular place and group and can be tolerated or accommodated but, except at the
extremes, cannot essentially be changed.
Others argue that culture can indeed be shaped, at least approximately, and that
a set of familiar managerial interventions is sufficient for the purpose. Often this
translates to a belief that merely describing the desired culture - for instance, in
the form of a ‘values’ or ‘mission’ statement - will be enough to bring that culture
into being. Or they believe that it can be ‘instructed’ into existence through a set of
policies and procedures that determine how individuals and groups should behave.
For this constituency of thought, shaping workplace culture is a matter of reviewing
and refining policies, issuing information and instructions, and closer management.
However, for most the disinclination to address cultural issues has a much
simpler explanation: they seem overwhelmingly, impossibly complex to tackle. If
culture is that set of collective attitudes and behaviours that emerge from all the
actions and interactions of an often heterogeneous group of individuals, then surely
the dynamics of ‘cultural intervention’ are simply too complex to compute? Better,
then, to set aside culture as a given, focus on those things we feel we can change
more predictably - money, resource, system design - and satisfy ourselves that we
have done the best we can in the circumstances of a complex world.
While they are understandable, such conclusions encourage leaders to discount
and disregard issues of culture too frequently, and thereby to tolerate and legitimise
lower standards of safety and quality than might otherwise be achieved: our view
is that these conclusions need to be challenged.
The phenomenon of culture is not so nebulous that it cannot be described. In our
own work we return repeatedly to the concept of the ‘high reliability organisation’,8
an idea that is familiar to some in healthcare but which has yet to fully penetrate the
thinking of health service leaders.9 While not a complete description of an ‘ideal’
healthcare culture - it says nothing about the qualities of compassion and kind
ness that most of us would wish to see - it does describe the attributes of cultures
that assure demonstrably high levels of safety in complex, safety-critical domains
- aircraft carrier operation, air traffic control and nuclear power generation being
examples. The ‘high reliability organisation’ model describes, for instance, how
safety-critical cultures foster a ‘preoccupation with failure’ - an intense focus on

why and how individual failures occur and what can be learned from them. The
form of this ‘preoccupation’ is more than simply the creation of processes to cap
ture, record and analyse failure; it is a cultural ‘stance’, an automatic, reflexive and
dispassionate interest in the diagnostic value of failure. Sometimes, the contrast
with the cultural attitude to failure in healthcare could hardly be more distinct.
For all the formal incident reporting systems that exist in healthcare, except in the
most serious instances the common cultural response is not to scrutinise failure,
but simply to survive it, compensate and carry on. The contrast is instructive, but
our real purpose for now is simply to help dispel the misconception that culture is
too nebulous to engage with: cultures do contrast between sectors and organisations
and can be described with some rigor.
The second misconception, that culture can be ‘engineered’ into being through
the right set of systems and policies, is harder to deconstruct and proves seduc
tive to many of those charged with improving safety. The near iconic infection
control work of Peter Pronovost and his collaborators,10 provides ample example.
Convinced that intravenous catheter-related infections in his intensive care unit
could be cut, Pronovost began to research best practice in line insertion and man
agement, and compared it both with his own practice and that of colleagues. He
settled on five evidence-based practices - simple measures such as properly draping
the patient and using the most effective hand-cleaning products before the proce
dure - that significantly reduced the risk of line infection. At that point, on average,
only 30% of line insertions on his unit adhered to all five of these measures; there
were issues with the supply of hand sanitiser, the location of equipment, and the
individual understanding and behaviour of some of his colleagues. Pronovost and
his colleagues designed an intervention to improve adherence to good practice.
Equipment trollies were relocated and properly organised, senior executives were
lobbied to ensure that the organisation bought the right hand hygiene products,
and short educational sessions were run to ensure staff understood the significance
of the measures. The five practices were assembled into a checklist, and nursing
staff were asked to ensure that their medical colleagues applied the checklist for
all non-emergency line insertions. The results were astonishing by any measure.
In the space of 3 months, the catheter-associated infection rate fell to near zero
and although it later rose slightly, it was undeniable that Pronovost’s intervention
had had a sustained impact. It was reckoned that some 1500 lives and $200 million
in healthcare costs were saved in the state of Michigan during the first 18 months
of the project. Understandably, the programme generated huge excitement and,
ultimately, was successfully transplanted into other organisations in the same state,
across the United States, and beyond. However, the transplant was never straight
forward. In trying to replicate his work, other teams adopted the mechanics of his
intervention, but not always its ethos. New collaborators focused on the tangibles
of the programme - the principles of equipment organisation, the type of hand
sanitisers and, above all, the checklist of measures. In fact, as part of his programme,
Pronovost and his team had been engaged in a sophisticated and often challenging
programme of cultural change. Medical peers who were reluctant to implement his
changes were engaged in robust debate. The nursing staff who had been asked to
challenge the practice of senior medical staff when they were failing, for instance,
to use the checklist, inevitably found themselves set against established cultural
norms about the relative authority of nursing and medical staff. The nurses were
given senior executive support, and instructions to bleep Pronovost personally if his
fellow medics were unwilling to comply. These aspects of the intervention seemed
less palatable to those organisations seeking to adopt Pronovost’s programme.
These new, but selective, adopters had chosen to discount or recoil from the
cultural aspects of the programme and gravitated instead toward the apparatus of
change - checklists, educational programmes, better systems of organisation, and so
forth. There was nothing wrong with that apparatus and, indeed, part of Pronovost’s
intervention was a staff programme on the ‘science of safety’ that dealt with the
theoretical basis of safety and change. However, fundamentally, new adopters were
succumbing to the notion that their organisations were machines that could best
be steered by the right combination of managerial inputs. This view owes much to
the nineteenth- or twentieth-century image of the organisation such as a factory or
production line, where, historically, relatively simple shifts in input, time, resource
and manpower could have a predictable, linear effect on ‘output’. Always a simplifi
cation, this image holds even less well for modern knowledge-based organisations,
especially healthcare organisations, but it nonetheless has a tenacious hold on our
imaginations.
The organisational ‘response’ of modern enterprise is more contingent on the
choices made by its individual staff. The levers of command and control now have
rather narrow, easily exceeded limits. We are, more than ever, expected to decide
individually or locally what work needs doing, how it should be done and how we
invest our energies. These choices are obviously influenced by our own personal
values and principals, and by the loyalties we hold. They can be distorted by the
mistaken assumptions we make and by similar ‘self-imposed’ limits.
This is particularly and profoundly true of healthcare organisations, populated
as they are by independently minded, sophisticated thinkers, at least originally
motivated by a deep sense of personal vocation, and schooled in professions that
have strong histories and traditions. Our healthcare organisations are actually often
complex mosaics of subcultures, each one a reflection of a particular group of staff,
their local personalities and leaders, and the immediately local history of their
service. Not surprisingly, then, the cultural response to a given intervention can be
led or guided, but rarely steered by instruction ‘from above.
However, we also dissent from the view that ‘healthcare culture’ - because it
cannot simply be mandated into a particular shape - is simply too complex and
unpredictable to be worth engaging with. Our own contribution to the infection
control effort is to advocate for the routine use of a checklist during hospital inpa
tient rounds and perhaps other key clinical processes such as shift handover and
team briefings.11 The ‘ward safety’ checklist is not dissimilar to the Pronovost initia
tive or the World Health Organization safer surgery checklist12: it aims to encourage
greater uniformity in the checking of known inpatient risk factors - does the patient
have the correct deep vein thrombosis prophylaxis, have fluid balance and drug
charts been checked, is the patient at risk of falls, and so on? There are a number
of infection control-related items on the list - meticillin-resistant Staphylococcus
aureus status, infection risk and antibiotic control, for instance - but we cite it
here not so much as a solution to infection control, but rather as an example of an
alternative view of culture and culture change. The checklist provides a succinct
summary of routine, daily inpatient checks, and, if no other preference exists, an
entirely serviceable template for the structure of a ward round. However, the ward
round is a complex process, having to accommodate an enormous range of circum
stances, disciplines and patient needs, and the checklist is not a prescription. To
rigidly dictate a particular style and approach to the checklist would be to cut too
crudely across the autonomy of the individuals and teams involved. It would risk
disrupting the custom and practices of teams that already deliver safe and effective
rounds, and it would discount and ignore some of the difficult constraints under
which staff work. Edicts would at best encourage superficial compliance, and at
worst outright and irreversible rejection by the staff involved, perhaps resulting in
a net loss rather than a gain in patient safety. So while the checklist offers a style
and structure for rounds, it does not mandate one: there are no signature spaces,
and no boxes to check. Instead, teams are encouraged to discover their own best
implementation of the checklist.
The checklist is simply a token, a prompt for individuals and teams to begin to
assess issues of attitude to risk, variation in practice, human factors, communica
tion and professional dynamics. It is about helping staff to appreciate that safety
is improved through systematic attention to the basic, often unglamorous aspects
of, in this case, inpatient care. Ultimately, the aim is to challenge staff to assess and
perhaps revise their individual and shared assumptions about why the ‘system’
is preventing them from delivering the standard of care they instinctively feel is
achievable.
For us, the ward safety checklist is not merely a checklist but, rather, a culture
change effort, one that departs from the common assumptions about culture change
that we have described here, and it is fundamentally more optimistic. It is predicated
on the belief that healthcare culture change enjoys one critical advantage when
compared with other domains: the very deep values base of its staff. Only a small
minority of the failures in healthcare stem from casual negligence, lack of care,
or bad intent; for the most part, healthcare staff have an instinctive sense of what
should be done to protect their patient, and a genuine desire to deliver the best care
possible. What perturbs them from that course are the perceived constraints that
our healthcare organisations appear to place on their actions - constraints that often
transpire to be self-imposed and which are often learned, mistakenly, as the key to
professional and career survival.
We would do nothing to suggest that culture change is anything but difficult. The
shared pattern of assumptions, beliefs and behaviours can, indeed, be incredibly
complex, and reshaping them is beyond any simple process engineering. However,
healthcare culture can be changed. It is a matter of understanding the natural
attractors that shape individual decisions and guiding individuals and groups back
to their natural, originally motivated instincts. It may involve some organisational
engineering to remove overt barriers, but more often than not it means designing
an environment - which may be something as simple as, in our case, a checklist -
that cues and facilitates the behaviour that healthcare staff want, instinctively, to
engage in.
It is with great regret that we share with you the loss of Aiden who sadly passed
away before the publication of this book. There is no doubt that Aiden will be very
much missed and that the preceding chapter will form one very small part of the
monumental contribution he made to the field of safety and quality both nationally
and internationally.
REFERENCES
1. Reason J. Managing the Risks o f Organizational Accidents. London: Ashgate; 1997.
2. Carthey J, Clarke J. Implementing Human Factors in Healthcare: ‘how to’ guide. London:
Patient Safety First Campaign; 2010. Available at: www.patientsafetyfirst.nhs.uk/ashx/Asset.
ashx?path=/Intervention-support/H um an+Factors+H ow -to+Guide+v1.2.pdf (accessed 4
4 June 2015).
3. Halligan A. Patient safety: culture eats strategy for breakfast. Br J Hosp Med (Lond). 2011;
72(10): 548-9.
4. Kennedy I. Learning from Bristol: public inquiry into children’s heart surgery at the Bristol
Royal Infirmary 1984-1995. CM 5207. London: The Stationery Office; 2001.
5. Francis R. Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation
Trust January 2005-March 2009. London: The Stationery Office; 2010.
6. Francis R. Report o f the Mid Staffordshire NHS Foundation Trust Public Inquiry. London:
The Stationery Office; 2013.
7. Halligan A. The need for an NHS staff college. J R Soc Med. 2010; 103(10): 387-91.
8. Weick KE, Sutcliffe KM. Managing the Unexpected: resilient performance in an age o f uncer
tainty. 2nd ed. San Francisco, CA: Jossey-Bass; 2007.
9. The Health Foundation. High Reliability Organisations. London: The Health Foundation;
2011. Available at: www.health.org.uk/public/cms/75/76/313/3070/High%20reliability%20
organisations.pdf?realName=PngyC6.pdf (accessed 4 June 2015)
10. Pronovost P, Vohr E. Safe Patients, Smart Hospitals: how one doctors checklist can help us
change healthcare from the inside out. New York, NY: Plume Books; 2010.
11. Amin Y, Grewcock D, Andrews S, et al. Why patients need leaders: introducing a ward safety
checklist. J R Soc Med. 2012; 105(9): 377-83.
12. Haynes AB, Weiser TG, Berry W R, et al. A surgical safety checklist to reduce morbidity and
mortality in a global population. N Engl J Med. 2009; 360(5): 491-9.
C H A P TE R 17
Is outcome surveillance of
healthcare-associated infections
really necessary?
Nizam Damani
The word ‘surveillance’ comes from a French phrase meaning ‘watching over’.1 The
word surveillance has negative connotations, as nobody likes to be watched over,
either as an individual or as a group. Surveillance is an essential component of the
infection prevention and control (IPC) programme, as its main aim is to reduce
the risk of patients getting healthcare-associated infections (HCAIs).2 Surveillance
of HCAIs can be performed by counting infections (outcome surveillance) and/or
monitoring processes (process surveillance) (see Figure 17.1).
It has been estimated that about 5% -10% of patients admitted to modern hospi
tals in the developed world acquire one or more HCAIs; the proportion can exceed
25% in low- to middle-income countries. The risk of acquiring HCAIs in developing
countries is 2 -20 times higher than in developed countries.3 It has been estimated
that if good IPC practices are applied, more than 70% of HCAIs are preventable.4-6
LIMITATIONS AND PITFALLS OF OUTCOME SURVEILLANCE

Active versus passive surveillance
A surveillance process can be active, with a process for seeking out HCAI cases, or
it can be passive, which is dependent on a third party to fill out a form or chart and
send it in to the IPC team for analysis. Reliance on passive surveillance has been
clearly demonstrated to underestimate cases.8 However, active surveillance requires
197
FIGURE 17.1 The difference between process and outcome surveillance (adapted, with
modifications, from Damani7)
CVC, central venous catheter; CLA-BSI, central line-associated bloodstream infection
a substantial amount of time and, consequently, fewer resources are directed toward
the implementation of good IPC practices to prevent HCAIs in the first place!
Reliance on good-quality laboratory service

The implementation of outcome surveillance requires the support of a good-quality
laboratory service, which can be a major issue, especially in low- to middle-income
countries.2,9 In addition, most definitions of HCAIs require standardised methods
of processing of microbiology specimens and, because of a lack of internationally
agreed methodology, this may not always be achievable.
Problem with definitions

There are no internationally agreed definitions on outcome surveillance, and vari
ous countries have developed their own definitions and surveillance systems. The
definitions developed by the Centers for Disease Control and Prevention (CDC)/
SURVEILLANCE OF HEALTHCARE-ASSOCIATED INFECTIONS 199
National Healthcare Safety Network10 and the European Centre for Disease
Prevention and Control11 have been most commonly used in the United States and
Europe, respectively. In addition, there is also a discrepancy between the epidem io
logical and the clinical diagnosis of HCAIs. Recently, a prospective study compared
CDC ventilator-associated pneumonia (VAP) infection rates with VAP infection
rates calculated using the American College of Chest Physicians’ definition of
VAP. The study involved 2060 ventilated patients; 12 cases of VAP were identified
using CDC criteria, whereas 83 cases were identified using the American College
of Chest Physicians’ criteria - that is, 1.2 versus 8.5 cases per 1000 ventilator days,
respectively.12
It is well recognised that the application of HCAI definitions is com plex and
requires subjective judgement for interpretation - the correct application for the
diagnosis of VAP is notoriously difficult and it is recommended that the measure
ment of processes should be used to reduce VAP.13 Therefore, it is essential that the
personnel who are responsible for collection of data require substantive training
and practice to develop proficiency to help reduce subjectivity and promote con
sistency. A recent study has highlighted the need for an independent validation of
outcome data, as it observed that CDC / National Healthcare Safety Network cen
tral line-associated bloodstream infection (CLA-BSI) surveillance definitions are
prone to misinterpretation, and it reported overall sensitivity of hospital reporting
of CLA-BSIs as 72%.14
Although autom ated surveillance is more cost-effective and may provide more
consistent information, its applicability depends on the way in which healthcare
is provided in a particular region or country, making comparison even more
difficult.15
Risk stratification of data

Since the patient populations and procedures vary substantially from hospital to
hospital,15 it is essential that HCAI rates are risk-adjusted for the most important
known confounding factors, as reporting crude data will not explain variations
between various healthcare facilities and it is essential for public reporting of
HCAIs. It is important to note that the current methods of risk-adjustment for
various patient categories represent a compromise and do not account for all
known potential confounding variables. In addition, collecting data is very time
consuming, because data must be collected on the entire population at risk (the
denominator), rather than on only the fraction with a HCAI (the numerator);
therefore, it can be argued that if the number of HCAIs in a unit is low, risk adjust
ment may not be worthwhile.16
Follow-up of patients
Current medical advances and change in the delivery of healthcare have allowed
shorter stays in hospital with higher throughput of patients.17 Therefore, most
HCAIs will not be identified during the hospital stay and will appear after the
patient has been discharged. It has been estimated that between 14% and 70% of
surgical site infections (SSIs) occur after discharge.17 Therefore, post-discharge
surveillance of all HCAIs is essential to obtain accurate data; however, the best way
to conduct post-discharge surveillance in a manner that is both efficient and cost-
effective remains a matter of debate and is rarely performed, even in high-resource
countries where surveillance programmes have been well established for decades.
Does feedback of data on outcome surveillance really reduce HCAI

rates?
Published data in the literature cite examples where feedback of outcome surveil
lance to the clinical team has resulted in a reduction of HCAI rates, but these
reductions are modest and the exact reasons for these reductions have not been
rigorously studied. The most reliable study cited in the literature on the impact of
reduction of SSIs was led by Professor Peter Cruse, a professor of surgery.18 It is
important to note that this study was not led by an epidemiologist or an infection
control practitioner. After conducting outcome surveillance, his team analysed the
data and spearheaded changes in surgical practice (process change), which led to a
substantial reduction of SSIs. Currently, in almost all countries, the individuals who
collect the outcome surveillance data worldwide have neither full understanding
and/or knowledge of the processes nor any influence to change the clinical practice.
It is well recognised that the reporting of surveillance data can increase aware
ness and this pressure to ‘look good’ could motivate hospitals to under-report HCAI
rates. For example, there is evidence that some of the reduction in CLA-BSI rates is
due to reinterpretations of surveillance definitions in the post-surveillance period.19
In addition, the US players such as the Centers for Medicare and Medicaid Services
increasingly use patient safety indicators to reward hospitals with lower complica
tion rates in pay for performance initiatives, and introduction of these measures
may introduce bias with temptation to under-report HCAIs. Furthermore, publi
cations in literature are biased toward success stories, often missing possibly more
frequent failures due to lack of submission or rejection.20
TABLE 17.1 Process versus outcome surveillance: summary of advantages2,5-7,15-17
Process surveillance Outcome surveillance

O b je c tiv e P re v e n t in fe c tio n by C o u n t in fe c tio n s
im p le m e n tin g a n d b y a p p ly in g a g re e d
m o n ito rin g g o o d IPC d e fin itio n s fo r HCAIs
p ra c tic e s
N eed s u p p o rt o f g o o d -q u a lity No Yes
m ic ro b io lo g y la b o ra to ry to
d ia g n o s e HCAIs
E d u c a tio n a n d tra in in g Yes Yes
E d u c a tio n a n d tra in in g is E d u c a tio n a n d tra in in g
re q u ire d to im p le m e n t a n d is re q u ire d to in te rp re t
m o n ito r s ta n d a rd is e d IPC a n d a p p ly d e fin itio n
p ra c tic e s c o n s is te n tly
H elp e m b e d g o o d IPC p ra c tic e s Yes No
in th e u n it o r h o s p ita l
Im m e d ia te ly id e n tify b re a k in Yes No
g o o d IPC p ra c tic e s
C lin ic a l ju d g e m e n t No c lin ic a l ju d g e m e n t is C lin ic a l ju d g e m e n t is
re q u ire d , a s c o m p lia n c e is re q u ire d s u b je c t to
m o n ito re d a g a in s t b e s t IPC in te rp re ta tio n o f ca s e
p ra c tic e s (e.g. b y u s in g d e fin itio n s o f HCAIs
c h e c k lis t o r HCAI c a re
b u n d le s )
R is k a d ju s tm e n t o f d a ta is No Yes
re q u ire d
D a ta a re a ffe c te d by p a tie n t No Yes
c h a ra c te ris tic s , c a s e
a s c e rta in m e n t, d e fin itio n s a n d
ris k fa c to rs
A p p lic a tio n o f s ta tis tic a l te s t is No Yes
n e c e s s a ry b e c a u s e HCAI ra te s
a re s u b je c t to ra n d o m v a ria tio n
a n d a re in flu e n c e d by n u m b e r
o f c a s e s a n d fre q u e n c y w ith
w h ic h o u tc o m e o c c u rs
R a te a ffe c te d by e a rly No Yes
d is c h a rg e o f p a tie n ts
M e a s u re m e n t o f d a ta M o re s e n s itiv e L e s s s e n s itiv e
( continued)
Process surveillance Outcome surveillance

D ata is re la tiv e ly e a s ie r a nd Yes No
le s s c o s tly to c o lle c t a n d
in te rp re t
A s p e c ts o f c a re A s p e c ts o f c a re q u a lity A s p e c ts o f c a re a re
a re m e a s u re d b y m e a s u re d b y ra te
im p le m e n ta tio n o f g o o d o f H C A Is in s e le c te d
IPC p ra c tic e on a ll p a tie n ts p a tie n ts
IPC, infection control and prevention; HCAI, healthcare-associated infections
Table 17.1 summarises the advantages of process versus outcome surveillance. In

addition, effective implementation of process surveillance has the following added
advantages.
• Monitoring compliance is more effective, as ‘people do what you inspect, not
necessarily what you expect’.29
• The introduction of standardised protocols, procedures and good IPC practices
help avoid variation in practices caused by high turnover of clinical staff in the
unit and/or hospital.
• Process monitoring allows the clinical team to understand, learn and implement
good practices that not only serve as an educational tool but also are applied to
every eligible patient.
• Lapses and breach in the protocol are recognised and addressed more quickly
before an increase in the infection rate has occurred.
• Failure in process measurement focuses on the analysis and investigation of
the individual infection rather than seeking to interpret statistical variations in
HCAI rates.
ADVANTAGES AND LIMITATIONS OF PROCESS SURVEILLANCE

Although industry has shown us for decades that reducing process variation directly
influences the fin a l produ ct defect rate,2123 it was only a few years ago that this
concept was translated into clinical practice. This was undertaken through the
introduction of the care bundle by the US Institute for Healthcare Improvement,24
later modified and adopted by the UK Department of Health.25 A care bundle is
described as ‘a grouping of best practices with respect to a disease process that indi
vidually improves care, but when applied together results in substantially greater
improvements’24
It is recommended that compliance with all the elements of the care bundle
should be measured on an ‘all or nothing’ basis.26 This is because the temptation

to pick only easier elements of the care bundle is too great. Although compliance
with all elements of the HCAI care bundle on all patients at all times is ideal, it can
be very difficult to achieve in practice. It has been highlighted that if an average
intensive care unit were to comply with at least one component of the care bundle at
all times, they would experience an estimated 38% decrease in their CLA-BSI rate.19
It is recognised that implementation of HCAI care bundles has its limitations and
they have not been subjected to rigorous scientific scrutiny in published medical
literature. However, their introduction has led to a paradigm shift in IPC practices,
as more emphasis is now being placed on embedding good IPC practices, harness
ing support from senior managers, and addressing and overcoming barriers among
the clinician team to achieve a substantial and sustained reduction in HCAIs.5,6,26-28
However, effective implementation of good practice has its own challenges, and
the question today is not ‘what to do?’ but rather, ‘how to do it?’5 Experience has
shown that the clinical team might develop a ‘tick the box’ mentality to filling in
the checklist. However, this issue can be overcome by monitoring and analysing
the reliability of surveillance data to show a reduction in HCAIs, and if this is not
achieved then it will help to open up discussion with the relevant clinical team and
help them understand the issues and barriers to implementation. Once the units
have successfully achieved these objectives, then only numerator data can be col
lected for outcome surveillance and all preventable HCAIs should be subjected to
root cause analysis (RCA).
ROOT CAUSE ANALYSIS

RCA is based on the concept that adverse events are minimised and/or eliminated
by identifying the real issue and taking corrective action to eliminate the root causes
rather than merely addressing the immediately obvious issues that have resulted in
HCAIs. RCA has been successfully applied in the United Kingdom to reduce and
sustain reduction in both meticillin-resistant Staphylococcus aureus bacteraemia
and Clostridium difficile infections.* The Root Cause Analysis Toolkit and eLearn
ing Programme is available from the UK National Patient Safety Agency website.T
The most common way to perform RCA is to use the ‘5 Whys’ technique,
whereby the person asks a question five times to explore the cause and effect, to
determine the root cause of the problem. Since the failure does not always occur in
a linear pattern and, more often, multiple factors combine in parallel, a fishbone
* www.gov.uk/government/organisations/public-health-england
T http://npsa.nhs.uk
diagram - where the spine of the fish represents the sequence of events leading to an
adverse outcome - can be used. For successful RCA, it is essential that the analysis
is carried out by a clinical team and assertion must be backed up by the evidence.
Information gathered by the RCA over a long period may make it useful as a p ro
active m ethod and, if effectively carried out, it can be used as tool for continuous
improvement to reduce HCAIs.
CONCLUSION
In conclusion, unlike other industries, the approach adopted by the healthcare
institution worldwide historically relied more on measuring outcome only (HCAI
rates), creating benchmarks and national averages, and proudly publishing league
tables comparing various hospitals. This approach has resulted in an acceptance
among clinicians that, among other complications, getting HCAIs is a part of
modern healthcare delivery. However, informing a patient that your hospital has
a lower rate of HCAIs than the national average or benchmark is not satisfactory
from the patient’s perspective, as when a patient gets a HCAI, the rate for that given
patient is 100%!
The primary objective of surveillance is to assist in reducing the risk of pre
ventable HCAIs, and for surveillance to be effective it is essential that the IPC
programme must not rely on outcome surveillance alone. Gathering data on the
outcome indicators is complicated, cumbersome, prone to subjective interpreta
tion, and does not provide information on the proportion of preventable infections,
or provide guidance on what action must be taken to prevent HCAIs in the first
place. For a substantial and sustained reduction of HCAI rates, it is essential for
us to place greater emphasis on implementing and monitoring good IPC practices
(process surveillance) and performing RCA on all preventable HCAIs while main
taining successful traditional features of outcome surveillance. Hospitals which
have successfully implemented and embedded good IPC practice are now counting
‘infection free’ days since the last HCAI, instead of benchmarking their traditional
HCAI rates using outcome surveillance.
REFERENCES
1. Wikipedia. Surveillance. http://en.wikipedia.org/wiki/Surveillance (accessed 7 September
2012).
2. Damani N. Surveillance of health care associated infections in low to middle resource
countries. Int JIn fect Control. 2012; 8: i4.
3. World Health Organization (W H O ). Report on the Burden o f Endemic Health Care-

Associated Infection Worldwide. Geneva: W HO; 2011.
4. Umscheid CA, Mitchell MD, Doshi JA, et al. Estimating the proportion of healthcare-
associated infections that are reasonably preventable and the related mortality and costs.
Infect Control Hosp Epidemiol. 2011; 32(2): 101-14.
5. Zingg W, Walder B, Pittet D. Prevention of catheter-related infection: toward zero risk? Curr
Opin Infect Dis. 2011; 24(4): 377-84.
6. Klompas M. Is a ventilator-associated pneumonia rate of zero really possible? Curr Opin
Infect Dis. 2012; 25(2): 176-82.
7. Damani NN. Manual o f Infection Prevention and Control. 3rd ed. Oxford: Oxford University
Press; 2012.
8. Scheckler WE. Surveillance, foundation for the future: a historical overview and evolution
of methodologies. Am JIn fect Control. 1997; 25(2): 106-11.
9. Damani NN. Surveillance in countries with limited resources. Int J Infect Control. 2008; 4: 1.
10. Horan TC, Andrus M, Margaret A. CDC/NHSN surveillance definition of health care-
associated infection and criteria for specific types of infections in the acute care setting. Am
J Infect Control. 2008; 36(5): 309-32.
11. Hospitals in Europe Link for Infection Control through Surveillance (HELICS). Surveillance
o f Nosocomial Infections in Intensive Care Units. HELICS; 2004. Available at: http://ecdc.
europa.eu /en/activities/su rveillance/H A I/D ocum ents/0409_IP SE _IC U _p rotocol.pdf
(accessed 7 September 2012).
12. Skrupky LP, McConnell K, Dallas J, et al. A comparison of ventilator associated pneumo
nia rates as identified according to the National Healthcare Safety Network and American
College of Chest Physicians criteria. Crit Care Med. 2012; 40(1): 281-4.
13. Klompas M, Platt R. Ventilator-associated pneumonia - the wrong quality measure for
benchmarking. Ann Intern Med. 2007; 147(11): 803-5.
14. Oh JY, Cunningham MC, Beldavs ZG, et al. Statewide validation of hospital-reported central
line-associated bloodstream infections: Oregon, 2009. Infect Control Hosp Epidemiol. 2012;
33(5): 439-45.
15. O’Neill E, Humphreys H. Use of surveillance data for prevention of healthcare-associated
infection: risk adjustment and reporting dilemmas. Curr Opin Infect Dis. 2009; 22(4):
359-63.
16. Tokars JI, Richards C, Andrus M, et al. The changing face of surveillance for health care-
associated infections. Clin Infect Dis. 2004; 39(9): 1347-52.
17. Delgado-Rodriguez M, Gomez-Ortega A, Sillero-Arenas M, et al. Epidemiology of surgical-
site infections diagnosed after hospital discharge: a prospective cohort study. Infect Control
Hosp Epidemiol. 2001; 22(1): 24-30.
18. Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospective study of
62,939 wounds. Surg Clin North Am. 1980; 60(l): 27-40.
19. Furya EY, Dick A, Perencevich EN, et al. Central line bundle implementation in the US ICUs
and impact of blood stream infection. PLoS. 2011; 6(1): e15452.
20. Goldacre B. Bad Science. London: Fourth Estate; 2008.
21. Walton M. The Deming Management Method. New York, NY: Putnam Publishing; 1986.
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23. Mant J. Process versus outcome indicators in assessment of quality of health care. Int J Qual
Health Care. 2001; 3(6): 475-80.
24. Institute for Healthcare Improvement. Infection Prevention Bundles. Available at: www.ihi.
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25. UK Department of Health. Using High Impact Interventions: using care bundles to reduce
healthcare associated infection by increasing reliability and safety. London: Department of
Health; 2007.
26. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream
infections in the intensive care unit. Crit Care Med. 2004; 32(10): 2014-20.
27. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. NEngl JM ed. 2006; 355(26): 2725-32.
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Conclusion
Within this book we have tried to bring to the forefront a range of differing percep
tions and perspectives that are diverse, challenging and thought-provoking. Our
intention has been to present infection prevention and control as an overarching
process, one that goes beyond the simplistic standpoint of it just being about hand
hygiene. Rather, infection prevention and control is a process that affects us all in
many ways with regard to each individual’s right to health, wellbeing and life. In
reading through the differing chapters of this book, we hope you will have started
to realise that infection prevention and control is a multifaceted and highly com
plex combination of physical, psychological, social, socioeconomic and political
processes internationally. No one person, group, organisation or country can
consider itself to exist in isolation where IP&C is concerned. IP&C is a global issue
and, for that matter, problem. Further, infection prevention and control is not
something that can simply be paid lip service; it is not an incidental to be enacted
at the convenience of individuals, management or organisations after something
has gone wrong or, for example, when a visit from an external authority is expected.
Infection prevention and control must always be proactive and preventive in nature,
as opposed to a retroactive and curative set of actions and reactions.
207
Index
5 Whys technique, 203 ‘bare below the elbows,' 18, 32-3, 37, 84,
143
active birth movement, 31 barrier precautions, 20
advocacy, 177-8 bed linen changing, 48-9
agency staff, 41 beds, prohibition of sitting on, 19
alcohol, isopropyl, 87 behaviour
alcohol-based preparations, 47, 54-7, 59, 82, determinants of, 125, 127
84, 86 stereotypes of, 65-6
ambition, setting, 30-1 behavioural economics, 128
ambulances behavioural standards, 190
design, 80, 88 behaviour change, 26, 126, 128, 133, 169
disposal bins in, 87-8 Behaviour Change Wheel, 126, 127, 131-2
hand-washing in, 84 ‘being there’, 155
ambulance staff beliefs, power of, 30, 41
infection control training for, 89 best practices
role of, 91 advancing beyond, 60
amoxicillin, 94 breaches of, 24
ampicillin, 94 debates around, 53-8
AMR (anti-microbial resistance) see antibiotic demonstrating, 44-5, 47
resistance implementation of, 126
antibacterial treatment, 87, 94 introduction of, 52
antibiotic era, 118-19 blood, cleaning up, 87
antibiotic resistance, 93-4, 96-7, 101-2 body fluids, in out-of-hospital practice, 80,
antibiotics 84-5, 87-8
awareness of role, 99, 102-3 brain, 125, 128-9, 132-3
decision to prescribe, 98-101, 103-5 Bristol Royal Infirmary, 190
development of new, 96 broad-spectrum antibiotics, 37, 97, 100,
misuse of, 94, 96-9, 103-5, 114 103
use of, 93-4 ‘burning platform’, 6
antimicrobial resistance, 94-6
antimicrobials cannulation, 81, 86-7
cationic, 53 Canterbury Christ Church University, 138-9,
policy on, 37-8 141, 152
prudence with, 20 carbapenem antibiotics, 95
antimicrobial stewardship, 104-5 care bundles, 202-3
anti-smoking campaigns, 169-70 care delivery
aprons, plastic, 24, 85 and IPC, 157-8
aseptic technique, 86, 131 rights and responsibilities in, 176
assessment, need for, 83, 158 carrot and stick approach, 3, 5
authentic leadership, 9 CDC (Centers for Disease Control and
Prevention), 97, 102-4, 198-9
Balaskas, Janet, 31 ceftaroline, 96
Bandura, Albert, 162 CEO (chief executive officer), 32, 34-5, 40
209
210 INDEX
change empowerment
apparatus of, 193 and guilt, 183-4
failure to, 51 and knowledge, 177, 179
influencing, 126, 156, 160-1 and motivation, 6, 11-12
inspiring, 30 use of term, 176-7
change initiatives, undermining, 190 workplaces promoting, 181
change management, theories of, 6 endotracheal intubation, 87
chlorhexidine gluconate, 87 engagement, cultures of, 36
Christmas decorations, 16-17 Enterobacteriaceae, carbapenemase-producing,
CLA-BSI (central line-associated bloodstream 95
infection), 198-200, 203 environmental infection control practitioners,
cleansing products, anionic, 53 162
clindamycin, 95 ESBLs (extended-spectrum beta-lactamases), 95
clinical placements, 46, 49, 139 Escherichia coli, 94-5
clinical waste bins, 88 European Centre for Disease Prevention and
Clostridium difficile Control, 94, 103, 199
and antibiotics, 94-5 evidence-based research, 55-8
in NHS London, 33, 37, 39-40 excellence, 120
personal account of, 111-14 excuses, stereotypical, 71
and RCA, 203 expectancy, 5
co-amoxiclav, 94 eyewear, safety, 85
Cognitive Continuum, 66 eyewitness testimony, 65
colistin, 95
communications face masks, 85
language used in, 128, 161 failed practices, 56
and leadership, 38-9 failure
communication strategy, 171 in complex systems, 189
complacency, 68, 88, 98, 114 preoccupation with, 192
compliance, monitoring, 202 failure to intervene, 70-1
connectomes, 128-9 feedback, asking for, 164
C-reactive protein (CRP), 104 Fenton, Katherine, 32
cross-infection, 67-9, 73-5, 135, 137-8, fidaxomicin, 96
151 financial debates, 53, 58
Cruse, Peter, 200 fingernails, acrylic, 84
culture fishbone diagram, 203-4
reluctance to deal with, 191-2 flowers, banning, 16, 19, 24
use of term, 190 focus groups, 171
culture change, 192-5 food services, quality of, 157
fosfomycin, 95
deep vein thrombosis, 189, 194 Francis Report, 136, 190
detergent wipes, 84 Freud, Sigmund, 70
developing countries, 177, 197
diagnosis, reducing delay in, 158 Gawande, Atul, 38
diarrhoea, 112-13 gloves
direct-to-consumer advertising, 100 and hand hygiene, 68
doctors, uniforms for, 33-4, 36 in operating theatres, 44-6
Drucker, Peter, 30 in out-of-hospital setting, 84-6
drug administration, 157 for visitors, 24
drying of hands, effective, 143 GPs (general practitioners), reasons for
Duerden, Brian, 37 prescribing, 99-100
Gram-negative bacteria, 59
egocentrism, 74 gut feeling, 69
ego-strengthening, 131
e-learning system, 48 habit formation, 125, 129-30, 132
embedded specialists, 162 hair, in operating theatre, 45
INDEX 211
hand eczema, chronic, 55 compliance with hand hygiene, 4, 54-6,

hand hygiene (HH) 143-50
and C. difficile, 114-15 empowering patients, 177, 178, 180
complaints on social media about, 185 empowerment of, 175, 180-1
education in, 137-8, 141, 163 marketing campaigns to, 170-1
five moments of, 82-3 micropractices of, 16
five-stage process of, 74, 140, 142 motivation of, 5, 11
with gloves, 68 perspective on HCAI, 54
and HCAIs, 185 time spent with patients, 21
marketing campaigns for, 171, 172 health literacy, 179
in operating theatre, 45-6 healthcare information, 89, 186
and out-of-hospital environment, 81-4, 83, High Reliability Organisations, 191-2
86, 90 HIV, 23, 25
patients asking about, 47, 175-7, 179-83 home, elements of, 19
and peer pressure, 5 homelessness, 72
personal reflections on, 178 hospitals
and stereotypes, 72-5 achieving change in, 30-1
hand rubs, 52, 54-5, 59, 81-2 before antibiotics, 119
hands Human Connectome Project, 128-9
as carrier, 60 human factors, 128, 133, 189-90, 194
cuts or abrasions on, 159 human psyche, model of, 70
hand-washing facilities, 83-4 Human Resources Management, 36
hats, 47 hypnotherapy, 127, 129-32
Hawthorne effect, 4, 150
HCAI (healthcare-associated infections) iatrogenic effect, double, 21
care bundles, 201, 203 ICPLE (Infection Control and Prevention
debates on, 53, 54-7, 59 Learning Experience), 139-41, 150, 152
diagnosis of, 198-9 ICPs (infection control professionals), 51-3,
and empowerment, 176 55-8; see also IPCSs
literature on, 51, 58-9 imipenem, 95
patient education on, 103, 185-6 improving practice, 3, 125
patient experience of, 21-2 individuality, maintaining, 73
prevention of, 182, 204 infection
reported rates of, 94, 197, 199-202, chain of, 44, 67, 151
204 pre-hospital transfer of, 81
and stereotypes of patients, 72-3 infection prevention and control see IPC
strategic visioning of, 52, 58 infectious disease, aetiology and transmission
surgical site, 43-4 of, 80
HCAI cycles, 51, 58-9 influence
Health Belief Model, 126 increasing, 155, 159-60, 162
healthcare value of, 155, 164-5
industrialisation of, 10 Institute for Healthcare Improvement, 32,
justice in, 18 38
marketing in, 168-9 instrumentality, 5
synergy between specialties in, 157 intelligence, and stereotyping, 64-7, 72
healthcare assistants, 16, 47-8 Internet
healthcare culture, 190-5 health information via, 184-5
healthcare organisations, 30, 193-5 marketing campaigns on, 170
healthcare practices prescription-only drugs via, 103
teaching poor, 46-7, 49 intravenous antibiotics, 104, 111
unfounded, 16-17 intuition, 66, 68-9
healthcare social media, 184 IPC (infection prevention and control)
healthcare workers (HCWs) and antibiotics, 105
attitudes and beliefs of, 190 and behaviour change, 125-6, 129-31
autonomy of, 194 burning platform model in, 6
212 INDEX
IPC (continued) management

complexity of, 207 and leadership, 10-11
education on, 43-4, 46-9, 91, 135-9, 150, styles of, 4, 8-9
151-2 marketing
essence of, 126 4 or 7 Ps of, 167-9, 168
good practice in, 201, 203 and behaviour change, 169
influence in, 164 see also social marketing
innovation in, 11-12 use of term, 167
justice in, 15, 20-1, 25-6 marketing campaigns, 169-72
leadership and management in, 3, 10 Maslow’s hierarchy of needs, 4
marketing in, 169-70, 173 media
neuroscience in, 131-2 influence on IPC practices, 20
and patient empowerment, 179, 181 information on HCAI, 103
role of specialists in, 161 see also social media
surveillance in, 197 medical hierarchy, 38
transfer of information, 68-9 meropenem, 95
ungrounded practices in, 16-19, 23 microbial policy, 37
IPCSs (information prevention and control microbial spread, dynamics of, 17
specialists), 155-9, 162-5; see also ICPs micro-practices, skilful, 16
Mid Staffordshire NHS Foundation Trust,
jackets, removing, 164 190
jewellery, 45 monetary reward, 5
job satisfaction, 4, 6, 11, 162 motivation
job sculpting, 6 factors influencing, 5 -6
theories of, 3-5, 12
King, Martin Luther Jr., 18 MRSA (methicillin-resistant Staphylococcus
kit bags, 87 aureus)
Klebsiella, 95 and antibiotic use, 95
know-how, embodied, 16 control practices for, 22-3, 24, 54
knowledge workers, 11 current prevalence of, 52
Kotter’s 8-step change model, 6, 7 fatalities from, 117-18
media coverage of, 20, 59
labels, applying subjective, 72 in NHS hospitals, 31-2
laboratory services, 198 and patient empowerment, 178, 183
lamenting, 51-2, 56, 60 and RCA, 203
language MRSA Action UK, 118, 120-1
choosing the right, 132-3, 160 MSSA (methicillin-susceptible Staphylococcus
of specialists, 161 aureus), 52, 57
laryngoscope, portable, 87 multidrug-resistant organisms, 95, 185
lawyers, 51, 55-7, 59
leadership National Institute for Health and Care
and attention, 32, 37 Excellence, 85, 90
collaborative, 9 National Patient Safety Agency, 82-3, 179,
courage and commitment, 37 182
and culture, 190-1 needles, in out-of-hospital setting, 86-7
strategic and operational focus, 34-5 neurosciences, 126, 128-32, 131
styles of, 6-7, 8 NHS (National Health Service)
Lean Management, 35, 41 CEOs in, 34
learning outcomes, xii challenges facing, 40
line insertions, 192 leadership in, 32, 35-6
linen, in out-of-hospital situation, 88 patient safety in, 189-90
unfounded practices in, 18
macrolide antibiotics, 95 zero tolerance for HCAIs in, 80
magazines, 19, 170 NHS Constitution, 56, 88
Make Ready, 88 Nightingale, Florence, 136
INDEX 213
nitrofurantoin, 95 minimising distress to, 48-9

NLP (neurolinguistic programming), 126, perspective on HCAI, 54, 60
129-32 psychological health of, 16-17, 20-1,
non-touch technique, 86 25-6
norovirus, 18 patient safety
nudge theory, 128 and IPC procedures, 19, 26-7, 49
nurses and isolation, 21
antibiotic awareness of, 101, 105 and medical hierarchy, 38
outdated practices of, 15-16 and patient empowerment, 177, 179-80,
uniforms of, 32-3 182
nursing education, 137-9, 152 and patient rights, 22
nutrition, synergies in, 157 and workplace culture, 190-1, 194
patient safety indicators, 200
ODPs (Operating Department Practitioners), Patients for Patient Safety, 177
43-4 patient transport, 157
operating department patient warming, 160-1
daily procedures for, 44-6 peer pressure, 5
practices outside, 47-8 peer-reviewed research evidence, 51, 53, 56, 58,
organisations 60, 161, 175
culture of, 11, 22, 190 penicillins, 94-5, 103
mechanical view of, 193 perceptions, and motivation, 5
structure of, 161 performance accomplishments, 163
values and objectives of, 160 performance metrics, 41
otitis media, 101, 103 personal hygiene, 44, 80-1
outcome debate, 53-4, 58, 60 Planned Behaviour, Theory of, 126
outcome surveillance, 197-8, 200, 202-4 poor practice
out-of-hospital clinical practice, 79-81, 83-7, identifying, 12, 46
89-90 obligation to act on, 158-9
key issues for, 90 power, identifying, 161
PPE (personal protective equipment)
paramedics, 80, 82, 87, 90 in clinical areas, 44
paramedic science, 89 out-of-hospital, 81, 84, 85
Partners in Your Care, 175 and patient visits, 23
patient care, quality of, 35-6 prescriber-patient relationship, 99-100
patient education, 21, 25, 157 prescriptions
patient empowerment for antibiotics, 93-4
barriers to, 182-3, 186 guidelines for, 103-4
and empathy, 179 home delivery of, 158
research on, 175-6 reasons for, 98-101
and social media, 184-5 process monitoring, 202
support for, 180-2 process surveillance, 197-8, 201-2, 204
WHO on, 22 professional education
willingness for, 177-9, 181 of ODPs, 44
patient engagement, 176, 180 programme of, 33, 46, 137-8, 150-1
patient isolation, unintended consequences of, Pronovost, Peter, 192-4
17, 20-3, 25 protocols, standardised, 202
patient knowledge, perceptions of, 180 psychological states, 163
patient participation, 176-7 public health
patients and antibiotic resistance, 93-4
demand for antibiotics, 99-101 behaviour change and, 127-8
effects of infection on families, 113-15, MRSA and, 22
117-21
follow-up of, 200 Quality, Efficiency and Productivity (QEP),
labelling of, 72 40-1
length of stay, 157-8 quinolones, 95
214 INDEX
Ramsden, Stephen, 34 surveillance

rationalisations, dissonance-based, 69-71, 74 active and passive, 197-8
RCA (root cause analysis), 198, 203-4 automated, 199
reflection, 68-9 and compliance, 48
Reinertsen, Jim, 32 in IPC, 126, 204
reinforcement theory, 3 -4 and justice, 20
respiratory tract infection, 94, 100-3 post-discharge, 200
rights, patient’s, 20-2, 26, 56 process and outcome, 198, 201-2
rings, and hand hygiene, 84, 142-3 strengthening, 18
risk adjustment, 199, 201 use of term, 197
risk assessment, out-of-hospital, 81, 84 surveillance definitions, 199-200
risk communication, 17, 25 synergy, 155, 157
ritualistic behaviours, 15, 17, 27, 47
road traffic accidents talcum powder, 16-17
campaigns for preventing, 169-70 target audience, 128, 132, 169-72
infection control at, 79, 86 Taylor, Frederick, 4
teamwork, 12, 30
safety-critical cultures, 191-2 technical debate, 53-4, 56-8
scrubbing up, 45-7 theatre attire, 44-5
scrubs, 33 ‘tick the box’ mentality, 203
self-efficacy, 155, 162-3, 179 tigecycline, 95-6
self-fulfilling prophesy, 5, 32, 156 time management, 164
self-managed teams, 11 touch, comforting, 17
servant leadership, 9-10 tourniquets, disposable, 87
Seung, Sebastian, 128 toys, exclusion of, 17, 19
sharps bins, 87 truth, 73-5
shaving, 45
shoe protectors, 85 UCLH (University College London Health
skin preparation applicators, 87 Foundation Trust), 31, 40-1
sleeve protectors, 85 uniforms, and infection control, 17, 33-4, 36-7,
sleeves, 16, 33, 84, 142-3 84-5
smartphones, 184 urinary tract infection, 100-1, 111
social marketing, 126, 169-70, 182
social media valence, 5
and HCAIs, 58 VAP (ventilator-associated pneumonia), 199
and IPC, 23, 25 vehicles
sharing information via, 184-5 cleaning, 80, 88
specialists, role in IPC, 161-2 first aid in, 159
spinal anaesthetic, 47 verbal persuasion, 163, 179
sponsors, 36 vicarious experience, 163
sponsorship, of marketing campaigns, 171 visibility formula, 35
SSIs (surgical site infections), 43, 46, 200 visitors, restricting, 18, 164
standard precautions, 72-3, 135-6, 151, 159
standards, upholding, 155 ward environment, 48
Stereotype Continuum, 66 ward safety checklist, 194-5
stereotypes, 63-9, 71-3, 75, 151 wedding rings, 84
sterile area, 44-5 weekend treatment, 100-1
sterile cannulation packs, 87 the Whittington, 31
Stevens, Simon, 40 WHO (World Health Organization)
stone soup, 29-31, 41 on antibiotics, 96-7, 99
stress, 21, 69-72, 157 on hand hygiene, 82-4, 126, 175, 181-2
suits, paper, 85 on surgical safety, 194
super specialists, 155, 161-2 workplace culture, 190-1
surface wipes, 88 World Alliance for Patient Safety, 177
surgical safety checklist, 38, 194 wristwatches, 143
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Infection Prevention and Control

PERCEPTIONS AND PERSPECTIVES

CRC Press is an imprint of the

© 2016 Paul Elliott, Julie Storr and Annette Jeanes

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-184619-989-9

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

Foreword by Barry Cookson v

Part I: Perspectives of infectionpreventionand control 1

2 Just infection prevention and control 15

3 Leadership, quality, efficiency and productivity in infection control 29

Part II: Perceptions of infectionprevention andcontrol 61

7 Out-of-hospital infection prevention and control: a paramedic

8 Antibiotics: help or hindrance? 93

9 The impact of Clostridium difficile infection on patients and their

10 The challenge we all face together 117

Part III: Possibilities for infection prevention and control 123

12 Infection prevention and control education and training: research

13 Increasing the value and influence of infection prevention and control

14 The use of marketing in infection prevention and control 167

15 Patient and healthcare worker empowerment 175

16 The role of healthcare culture in patient safety 189

17 Is outcome surveillance of healthcare-associatedinfections really

Healthcare-associated infection and the related issues of antimicrobial resistance

Professor Barry Cookson

Professor Benedetta Allegranzi

change in their environment through good management practices and appreciating

Adj Professor Marilyn Cruickshank RN, PhD, FACN

The adoption of appropriate infection prevention and control practices remains a

Paul Elliott, Julie Storr, Annette Jeanes

NOTE FROM THE EDITORS

Annette Jeanes is currently the Director of Infection Prevention and Control

Yogi Amin Tara Donnelly

Taraneh Azizi Dave Grewcock

Graziella Kontkowski Debra Teasdale

We would like to acknowledge and offer our thanks to:

Motivation and leadership in

In infection prevention and control, practitioners are frequently expected to lead,

The ‘motivational’ factors can be misinterpreted as a rehash of the ‘carrot and

OTHER FACTORS THAT INFLUENCE MOTIVATION

LEADERSHIP AND MANAGEMENT

number of factors, including experience, values, beliefs, preferences, ability, culture

FIGURE 1.1 Kotter’s 8-step change model19

Autocratic Paternalistic Participative Delegative Free reign

A number of styles of leadership or management have been shown to produce poor

It is interesting that a confluence of very diverse endeavours - that of

Organisational constraints and imperatives may not easily support authentic

MANAGEMENT VERSUS LEADERSHIP

• The manager relies on control; the leader inspires trust.

Although twenty-first-century healthcare has its emphasis on efficiency, healthcare

Just infection prevention

Inform ation giving and anxiety reduction should be fundam ental

unnecessary practices on the psychological health of patients, a ‘consumer or future

My first recollection of infection control, as it was then described, was during

HUMANITY, ETHICS, RIGHTS AND CONSEQUENCES

More recently, a World Health Organization Europe document13 considered the

We isolate people as if they have highly contagious TB [tuberculosis], but

In essence, where stereotypes are concerned one individual’s intelligence is argu

‘emergency inserted, resulting in a replacement cannula being used at the receiv