- Email: [email protected]
Infection control and meticillin-resistant Staphylococcus aureus decolonization: the perspective of nursing home staff
Journal of Hospital Infection 81 (2012) 264e269 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Infection control and meticillin-resistant Staphylococcus aureus decolonization: the perspective of nursing home staff P. McClean a, M. Tunney a, C. Parsons a, D. Gilpin a, N. Baldwin b, C. Hughes a, * a b
School of Pharmacy, Queen’s University Belfast, Belfast, UK Northern Health and Social Care Trust, Antrim, UK
A R T I C L E
I N F O
Article history: Received 14 February 2012 Accepted 8 May 2012 Available online 22 June 2012 Keywords: Care homes Nursing homes MRSA Infection control
S U M M A R Y
Background: Infection control and meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes have started to assume greater importance in practice and policy. Aim: To explore infection control and MRSA decolonization in nursing homes in Northern Ireland from the perspective of nursing home staff. Methods: Semi-structured interviews with nursing home managers and focus group discussions with nursing home staff were conducted, transcribed verbatim and analysed via the framework method. Findings: Six one-to-one interviews and six focus group discussions (N ¼ 7, 6, 6, 5, 5 and 4 participants, respectively) were conducted. Three overarching themes with inter-related subthemes were identified as influencing infection control and MRSA decolonization in the nursing homes: organizational factors (e.g. time, financial resources, environment, management and culture), external factors [e.g. hospitals, regulation and general practitioners (GPs)], and residents and families. It was reported that when the workload was unmanageable, aspects of infection control were not adhered to and more financial resources were necessary. There was conflict in maintaining an environment that was both ‘homely’ and clinical, and it was difficult to achieve good infection control practices with confused residents, some families, GPs and members of staff who were resistant to change. Support for MRSA decolonization in nursing homes was tempered by the risk of recolonization, particularly from hospital admissions. Conclusions: Infection control and MRSA decolonization in the nursing home environment appear to be affected by many factors, some of which may be beyond the direct control of staff. Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Address: School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK. Tel.: þ44 (0) 28 9097 2147; fax: þ44 (0) 28 9024 7794. E-mail address: [email protected] (C. Hughes).
It is estimated that the number of beds in UK nursing and residential homes will have to increase by 150% by 2051 in order to cope with future demands from an ageing population.1 Concerns about infection control in nursing homes in the UK are relatively recent compared with the situation in hospitals,2 and routine hospital infection control practices such as
0195-6701/$ e see front matter Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2012.05.005
P. McClean et al. / Journal of Hospital Infection 81 (2012) 264e269 isolation and confinement are not always applicable to nursing homes. Resources for infection control programmes are limited;3 however, infection outbreaks in nursing homes are costly and labour intensive.4 Previously, the authors conducted a cluster randomized controlled trial (cRCT) in nursing homes for older people in Northern Ireland to determine if an infection control education and training intervention programme impacted on the prevalence of meticillin-resistant Staphylococcus aureus (MRSA).5 At the end of the cRCT, only six out of 16 homes from the intervention group were deemed to be compliant with infection control standards. No change in MRSA prevalence rates from baseline was found, and the reasons for this were unclear. Elective and emergency admissions to English hospitals are screened for MRSA.6 In Northern Ireland, MRSA screening in hospitals is reserved for high-risk patients (e.g. history of MRSA; admission to an intensive care, neonatal or renal unit; admission from another hospital or care home).7 No proposals have been made for widespread MRSA screening and decolonization (which involves the application of an antibacterial nasal cream twice daily, and daily bathing in antiseptic solution and laundering of clothing and bed linen for a minimum of five days) in nursing homes. A qualitative study was undertaken with nursing home staff who were participants in the intervention group of the previous cRCT, to explore staff views on factors that may influence infection control and MRSA decolonization in the nursing home environment.
Methods Recruitment Ethical approval was obtained from the Office for Research Ethics Committees Northern Ireland (09/NIR03/57). Sampling was undertaken on a purposive basis in that only those nursing homes (N ¼ 16) and staff which participated for the full duration of the original cRCT study5 were invited to participate. During the cRCT, the manager at each nursing home had nominated at least one member of staff to become an infection control link worker. The link workers received additional training and were responsible for raising the profile of infection control in the homes. Written informed consent was obtained from staff to participate in a focus group discussion, and from managers to participate in a one-to-one semi-structured interview during Autumn/Winter 2009/2010. The ‘privacy of individual interviews’ was considered to be an important factor for managers, whereas the ‘reassurance of a group shared experience’ was thought to be important for nurses and care assistants.8 The sample size was not determined in advance, but was guided by the research objectives and the achievement of data saturation (when no new themes were identified and relationships between data sets were sufficiently explained and explored).
Organization of semi-structured interviews and focus groups Each focus group consisted of either nurses or care assistants for the purpose of facilitating discussion. The exception was the link workers’ focus groups which consisted of a mix of
265
staff, with the common role being that of link worker rather than primary occupation. In each focus group, there were a maximum of two participants from the same nursing home. It was planned to have approximately eight participants in each focus group; however, the number of participants depended on staff availability to attend at the arranged times. Each participant was given £40 as reimbursement for participating in the research during their free time and for travel expenses.
Data collection and analysis Prior to the actual focus groups and interviews, a pilot focus group was conducted to determine the relevance of the topic guide. Topics included: e how the intervention (infection control education and training programme, appointment of infection control link workers, and regular audit and feedback) was implemented and maintained; e benefits and problems with the intervention; e improving the intervention; and e the feasibility of MRSA decolonization in the nursing home environment (previous experience, acceptability to residents and staff, benefits and problems with the process, and ways in which a large-scale decolonization programme could be implemented). Each interview and focus group discussion (held at various nursing homes) commenced with a brief overview of the previous cRCT. All groups were asked the same core openended questions based on the topic guide (developed from a review of the literature and discussion within the research team). However, additional questions were asked and explored further in subsequent groups when relevant themes were generated. The researcher, who had undergone training in qualitative research methods, had not been involved in the original cRCT and was therefore considered impartial. All interviews and focus group discussions were transcribed verbatim. Coding and analysis of themes in the data was facilitated through the use of NVivo Version 9, Melbourne, Australia (a computerized data storage and analysis package) and framework analysis, a five-step approach involving familiarization of the data, identification of the key themes (codes), making comparisons, organizing the data and explaining the findings. All analyses were performed independently by the researcher and another member of the research team, and final consensus was reached by discussion within the whole team.
Results Fifty-nine individuals provided written consent to participate in the study; 39 (66%) were available at the arranged times and took part in a focus group discussion or interview. The participants were from 12 (75%) eligible nursing homes. Five homes were independently owned, three were owned by small companies consisting of two to four nursing homes, and four were owned by large companies (chains; i.e. consisting of more than 400 homes). Six semi-structured one-to-one interviews were conducted with managers, and six focus groups were convened with staff (i.e. two with care assistants, two with nurses and two with link workers). The interviews and focus groups ranged in duration
266
P. McClean et al. / Journal of Hospital Infection 81 (2012) 264e269
from 50 to 110 min (mean 75 min). The participants’ characteristics are summarized in Table I. Three overarching themes with inter-related subthemes were identified as influencing infection control and MRSA decolonization in the nursing homes: organizational factors (e.g. time, financial resources, environment, management and culture), external factors [e.g. hospitals, regulation and general practitioners (GPs)], and residents and families (Figure 1). The following quotations from managers, nurses, care assistants and link workers are represented by the initials ‘M’, ‘N’, ‘CA’ and ‘LW’, respectively, and a number from 1 to 12 has been used to distinguish between participants with the same occupation. The responses from staff working in care homes deemed to be compliant with infection control standards during the cRCT did not differ from the responses from staff working in care homes deemed to be noncompliant.
Organizational factors Time The majority of participants reported feeling under pressure at work, and it was recognized that when the workload was unmanageable, aspects of infection control were not adhered to:
‘Anything to do with infection control is more time consuming... you’re always working short staffed... that’s where bad practice comes in.’(LW10) Some staff felt that decolonization of MRSA in individuals was time consuming, whereas other staff felt that the workload was manageable: ‘It’s quite intense [MRSA decolonization] and it’s acute care, acute needs... you couldn’t do it on a big scale.’ (N8) ‘It [widespread MRSA decolonization] would be time consuming but it could be done.’ (N5) Financial resources Most participants stated that financial constraints were a barrier to performing infection control practices properly: ‘Expenditure would have been the main thing [barrier].’ (M2) Participants discussed how cost would be a barrier to implementing a widespread MRSA decolonization programme in nursing homes: ‘No [GPs are not supportive of MRSA decolonization in nursing homes]... if there was a cost implication, we can’t even get Hibiscrub from them for their patients.’ (M1)
Table I Characteristics of the interview and focus group participants Interview(I)/focus group(FG)
I1e6
FG1
FG2
FG3
FG4
FG5
FG6
Total
Participant codes (M ¼ manager, M1eM6 CA1eCA6 CA7eCA12 LW1eLW4 LW5eLW11 N1eN5 N6eN10 CA ¼ care assistant, LW ¼ link worker, N ¼ nurse) Number of participants 6 6 6 4 7 5 5 39 Gender Female 6 5 5 4 7 5 5 37 Male 0 1 1 0 0 0 0 2 Occupation Manager and nurse 6 0 0 0 0 0 0 6 Care assistant 0 6 6 0 0 0 0 12 Nurse 0 0 0 0 0 5 5 10 Link worker and care assistant 0 0 0 1 2 0 0 3 Link worker and nurse 0 0 0 3 2 0 0 5 Link worker and domestic 0 0 0 0 3 0 0 3 staff/laundry Mean (range) years working 21 (15e30) 8 (2e12) 8 (2e15) 17 (7e22) 12 (3e25) 17 (3e28) 8 (3e25) 13 (2e30) in a nursing home Mean (range) years working 16 (6e25) 7 (2e12) 6 (2e15) 17 (7e22) 9 (3e22) 12 (3e23) 8 (3e25) 11 (2e25) in the current nursing home Mean (range) years qualified as 35 (28e46) N/A N/A 30 (25e38) 19 (13e25) 23 (4e32) 15 (8e27) 25 (4e46) a nurse for three for two nurses nurses Type of nursing home where staff were employed Independent (owner had 3 2 1 2 2 2 0 12 one home) Small company (owner had two 1 2 4 0 3 1 2 13 to four homes) Large company (owner had >400 2 2 1 2 2 2 3 14 homes) N/A, not applicable.
P. McClean et al. / Journal of Hospital Infection 81 (2012) 264e269
Organizational
External
Time
Hospital
Financial resources
Regulation
Environment
General practitioners
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Residents and families
Management Culture
Inter-relationships between subthemes Figure 1. Factors influencing infection control and meticillin-resistant Staphylococcus aureus decolonization in nursing homes.
‘If the Government was prepared [to give] so much money per MRSA patient to go through it [decolonization], I’d say nursing home owners probably would... put the extra staff on.’ (LW10) Environment Participants reported that some of the nursing homes where they worked were not purpose built and that facilities were inadequate: ‘Because we’ve quite an old building, and quite short on space, we don’t have any changing rooms.’ (M5) Participants were concerned that if a widespread MRSA decolonization programme was completed in nursing homes, it would be difficult to ensure that MRSA remained eradicated from the environment: ‘I am a bit dubious about decolonizing people... because they can pick it up again so easily in the setting [nursing home] like this.’ (LW2) There was conflict in maintaining an environment that was both ‘homely’ and clinical: ‘You want to keep it homely... so you have soft furnishings, carpets in bedrooms... You can’t just have a total sterile environment.’ (LW1) Management The majority of participants felt that their nursing home managers were proactive with infection control measures, while some staff reported that higher level management and owners were not always accommodating, with financial constraints being a major factor: ‘It’s not really the managers, because if they put it forward to the bosses, they just say, “well you know we can’t afford it, this year”. Our manager does try but sometimes she’s let down by the bosses.’ (LW11)
In contrast, most managers felt supported by the owners and higher management: ‘Whatever has to be done, is done. They [the owners] are quite happy to be seen to be leading and getting on with infection control.’ (M3) Culture It was reported that some individuals were not sufficiently interested to ensure that infection control practices were performed properly and complacency was an issue, thus reflecting the culture of the organization (‘the way we do things around here’)9: ‘You’re working with stuff [faeces], and even nowadays, there’s some people don’t wear gloves... you do become complacent with it; that’s what’s wrong, you have to harden yourself.’ (CA7) It was reported that some staff did not have direct contact with residents, and as a result, may not have fully understood their role with regards to infection control: ‘I think because they [domestic, kitchen and maintenance staff] probably think, “well we’re not caring for that person in a personal nature, we do not need to worry so much about it” [infection control].’ (N8) In two homes, the recommendation made during the cRCT of changing uniforms at work was not adopted until after the homes experienced infection outbreaks. In several homes, some of the suggested infection control measures were not implemented during the study, but were implemented later after regulatory inspections: ‘We’re not allowed to wear our uniform out of the home or into the home... that was all brought on to us from the outbreak.’ (CA9) ‘We had chairs with rips in them, they had to go on the skip [following an inspection].’ (LW10)
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There were concerns that the MRSA decolonization process would not be performed properly by some staff members because of their attitude: ‘If we were to try and decolonize a resident, it would have to be certain members of staff, who would be interested in doing that... the next day another member of staff might come in and not care less.’ (CA11)
External factors Hospital Many participants believed that hospitals were a source of infection and resistant bacteria: ‘We have loads of residents that go to hospital... and they come [back to the nursing home] with MRSA and UTIs [urinary tract infections] and C. diff. [Clostridium difficile].’ (CA5) Regulation Some participants expressed frustration with the demands of regulation and enforcing inspectors. Different inspectors’ requirements were reported to be inconsistent, and there were variations between recommendations from the regulatory body and protocols issued by hospitals: ‘What passes with one inspection could be different in another. It depends what inspector you get on what day.’ (LW10) ‘He [the GP] asked us to decolonize him [the resident] but the protocol changes from the last time and then you’re dealing with two different [hospital] trusts so they might say swab this and swab that in one trust and they say in another, swab this and swab that.’ (M6) General practitioners There were conflicting views regarding whether or not GPs adhered to infection control requirements: ‘We still have a lot of older GPs who are casual about the whole affair [infection control].’ (M5) ‘Now they’re [GPs] more prone to cleaning their equipment and washing their hands, where before, they were the worst culprits... I notice in the past year [GPs are more compliant].’ (LW10) However, there was a consensus that GPs did not support MRSA decolonization in nursing homes: ‘The doctors all have said, they don’t think it [decolonization] would be worth it in a nursing home setting.’ (M3)
Residents and families Staff felt that there were issues with practising good infection control with confused residents. The risk of MRSA recolonization from other residents and families was identified as an issue with decolonization: ‘If you’ve a resident that’s up walking about and touching other residents.’ (N3)
‘Maybe it’s just because they’re family and some of them sit on the bed or things like that there, we’ve asked them not to but they still do it.’ (CA4)
Discussion Three overarching themes (organizational factors, external factors, and residents and families) were identified as influencing infection control and MRSA decolonization in nursing homes. One dominant organizational factor was the lack of time available for staff to complete all required tasks in the nursing homes, including infection control. Increased workloads are associated with a greater risk of MRSA for nursing home residents.10 The availability of financial resources was another major contributing factor to infection control practices in the nursing homes, despite minimal expenditure being associated with lower-quality staffing and higher rates of adverse events.11 Conflict existed in maintaining an environment that was both ‘homely’ and clinical. Some nursing homes had not been purpose built, and amenities (e.g. staff changing facilities) were not always available. The uniforms of care home staff are frequently contaminated with high levels of MRSA;12 therefore, it is vital that uniforms are changed regularly. Several participants reported their frustration with management hierarchies in chain nursing homes, which led to difficulties in obtaining approval to purchase necessary equipment. The higher rate of MRSA evident in chain nursing homes compared with independently owned homes13 suggests that chain facilities need to increase their focus on infection control. It was reported that some members of staff were resistant to change. Old ritualistic habits can be difficult to modify and can compromise effective infection control practice.14 The behaviour of hospital staff has been linked to personal priorities, with self-protection reported to be a greater concern than patient safety.14 Domestic, kitchen and maintenance staff do not have direct contact with residents and may not fully understand their role in infection control. ‘Familiarity may have bred contempt’ for some nurses and care assistants, as several stated that they had worked with residents with MRSA for a long time and did not perceive there to be any risk. Culture and practice were more likely to change when the homes experienced infection outbreaks. In some nursing homes, certain recommendations that were made during the cRCT were not implemented until inspectors stated that the changes had to be made. In these homes, practice only improved when management were ‘pushed’ by authoritative figures, rather than ‘pulled’ with recommendations on good practice, indicating that regulation was more influential than a quality improvement approach. Furthermore, several participants felt that there were inconsistencies in requirements and information provided by inspectors and hospital infection control departments, indicating that there is a need for standardized policies to be developed and implemented across acute and long-term care. The majority of staff were sceptical about the benefits of decolonization due to the risk of recolonization, particularly from hospital admissions. Both hospitalization and residing in a nursing home are recognized risk factors for MRSA carriage.7 The risk of transfer of infection between both environments further emphasizes the need for a stream-lined approach when implementing infection control measures.
P. McClean et al. / Journal of Hospital Infection 81 (2012) 264e269 Some GPs, particularly older GPs, were considered to be noncompliant with infection control requirements. In order to implement behavioural changes, a strong institutional commitment is necessary.15 This commitment may be difficult to achieve, as GPs do not visit nursing homes regularly and may not be aware of infection control policies. Patients should be involved in infection control programmes; however, there are obvious difficulties in educating residents who are confused, and visiting families may not be compliant. Perhaps there needs to be an increase in staff awareness of how residents can influence infection control, as one study reported that staff did not routinely assist patients in washing their hands before meals or after visits to the toilet.16 The Department of Health, Social Services and Public Safety has published minimum standards (on all aspects of care including infection control)17 which are used by the regulatory body, the Regulation and Quality Improvement Authority, to assess nursing homes in Northern Ireland. However, a questionnaire study conducted in Northern Ireland found that 75% of care home managers believe that more information should be provided with regards to infection control advice and standardized policies, particularly for MRSA.18 This research has a number of limitations. The sample consisted of individuals who agreed to participate; therefore, it is likely that individuals who were interested in the infection control study were more likely to participate, thus introducing a form of bias. It is also possible that some individuals may have decided to take part due to the payment which was provided. The cRCT was completed in August 2008, but the semistructured interviews and focus group discussions were not conducted until Autumn/Winter 2009/2010. This delay may have led to some recall bias. Although the study was small in terms of the absolute number of homes and individuals who participated, the sample size was large for a qualitative study and data saturation was attained. In conclusion, common factors (organizational, external, and residents and families) were found to influence staff views on infection control and MRSA decolonization in nursing homes. Availability of time and financial resources were major barriers, despite infection control being cost-effective.19 The factors identified in this study must be accounted for, and appropriate measures taken, in order to improve infection control in nursing homes. Only then will it be worth considering the implementation of a widespread MRSA decolonization intervention programme in the nursing home environment.
Acknowledgements The authors wish to thank the nursing home managers and staff who participated in the study. Part of the research was presented as a Poster Presentation at the European Society of Clinical Microbiology and Infectious Diseases conference in Milan, May 2011 (Abstract No. P1333). Conflict of interest statement None declared. Funding sources Pamela McClean is funded by a Department of Employment and Learning studentship, and receives additional funding from the Health and Social Care Research and Development, Public Health Agency. Michael Tunney is funded as a UK
269
National Career Scientist by the Health and Social Care Research and Development, Public Health Agency, Northern Ireland. The authors’ work has been independent of the funders. This study was carried out as part of their routine work.
References 1. Wittenberg R, Comas-Herrera A, Pickard L, et al. Future demand for long-term care in the UK. A summary of projections of long-term care finance for older people to 2051. Health Ageing 2004;11:2e4. 2. Mayon-White R, Grant-Casey J. Infection control in British nursing homes. Infect Control Hosp Epidemiol 2003;24:296e298. 3. Trick W, Weinstein R, DeMarais P, et al. Colonization of skilledcare facility residents with antimicrobial-resistant pathogens. J Am Geriatr Soc 2001;49:270e276. 4. Larssen K, Jacobsen T, Bergh K, et al. Outbreak of methicillinresistant Staphylococcus aureus in two nursing homes in Central Norway. J Hosp Infect 2005;60:312e316. 5. Baldwin N, Gilpin D, Tunney M, et al. Cluster randomised controlled trial of an infection control education and training intervention programme focusing on meticillin-resistant Staphylococcus aureus in nursing homes for older people. J Hosp Infect 2010;76:36e41. 6. Department of Health. MRSA screening e operational guidance 3 [letter]. London: Department of Health; 31 March 2010. Gateway ref: 13482. 7. Department of Health, Social Services and Public Safety. The Northern Ireland regional infection prevention and control manual. Belfast: Department of Health, Social Services and Public Safety; 2008. p. 1e8. 8. Curry L, Nembhard I, Bradley E. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation 2009;119:1442e1452. 9. Hughes C, Donnelly A, Moyes S, et al. ‘The way we do things around here’: an international comparison of treatment culture in nursing homes. J Am Med Direct Assoc 2012;13:360e367. 10. Loeb M, Craven S, McGeer A, et al. Risk factors for resistance to antimicrobial agents among nursing home residents. Am J Epidemiol 2003;157:40e47. 11. Comondore V, Devereaux P, Zhou Q, et al. Quality of care in forprofit and not-for-profit nursing homes: systematic review and meta-analysis. BMJ 2009;339:b2732. 12. Gaspard P, Eschbach E, Gunther D, et al. Meticillin-resistant Staphylococcus aureus contamination of healthcare workers’ uniforms in long-term care facilities. J Hosp Infect 2009;71:170e175. 13. Baldwin N, Gilpin D, Hughes C, et al. Prevalence of methicillin-resistant Staphylococcus aureus colonization in residents and staff in nursing homes in Northern Ireland. J Am Geriatr Soc 2009;57:620e626. 14. East J. Control of infection in nursing homes: a risk-management approach. J Hosp Infect 1999;43:S39eS41. 15. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospitalwide programme to improve compliance with hand hygiene. Lancet 2000;356:1307e1312. 16. Mackenzie L, James I, Smith K, et al. Assessing hand hygiene in older people’s care settings. Nurs Times 2008;32:30e31. 17. Department of Health, Social Services and Public Safety. Nursing home minimum standards. Belfast: Department of Health, Social Services and Public Safety; 2008. p. 1e103. 18. Tunney M, Hughes C, Magee J. Infection control policies and procedures for meticillin-resistant Staphylococcus aureus in care homes for older people in Northern Ireland: a questionnaire study. J Infect Prev 2006;7:20e24. 19. Gould I. Costs of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) and its control. Int J Antimicrob Agents 2006;28:379e384.
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Infection control and meticillin-resistant Staphylococcus aureus decolonization: the perspective of nursing home staff P. McClean a, M. Tunney a, C. Parsons a, D. Gilpin a, N. Baldwin b, C. Hughes a, * a b
School of Pharmacy, Queen’s University Belfast, Belfast, UK Northern Health and Social Care Trust, Antrim, UK
A R T I C L E
I N F O
Article history: Received 14 February 2012 Accepted 8 May 2012 Available online 22 June 2012 Keywords: Care homes Nursing homes MRSA Infection control
S U M M A R Y
Background: Infection control and meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes have started to assume greater importance in practice and policy. Aim: To explore infection control and MRSA decolonization in nursing homes in Northern Ireland from the perspective of nursing home staff. Methods: Semi-structured interviews with nursing home managers and focus group discussions with nursing home staff were conducted, transcribed verbatim and analysed via the framework method. Findings: Six one-to-one interviews and six focus group discussions (N ¼ 7, 6, 6, 5, 5 and 4 participants, respectively) were conducted. Three overarching themes with inter-related subthemes were identified as influencing infection control and MRSA decolonization in the nursing homes: organizational factors (e.g. time, financial resources, environment, management and culture), external factors [e.g. hospitals, regulation and general practitioners (GPs)], and residents and families. It was reported that when the workload was unmanageable, aspects of infection control were not adhered to and more financial resources were necessary. There was conflict in maintaining an environment that was both ‘homely’ and clinical, and it was difficult to achieve good infection control practices with confused residents, some families, GPs and members of staff who were resistant to change. Support for MRSA decolonization in nursing homes was tempered by the risk of recolonization, particularly from hospital admissions. Conclusions: Infection control and MRSA decolonization in the nursing home environment appear to be affected by many factors, some of which may be beyond the direct control of staff. Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Address: School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK. Tel.: þ44 (0) 28 9097 2147; fax: þ44 (0) 28 9024 7794. E-mail address: [email protected] (C. Hughes).
It is estimated that the number of beds in UK nursing and residential homes will have to increase by 150% by 2051 in order to cope with future demands from an ageing population.1 Concerns about infection control in nursing homes in the UK are relatively recent compared with the situation in hospitals,2 and routine hospital infection control practices such as
0195-6701/$ e see front matter Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2012.05.005
P. McClean et al. / Journal of Hospital Infection 81 (2012) 264e269 isolation and confinement are not always applicable to nursing homes. Resources for infection control programmes are limited;3 however, infection outbreaks in nursing homes are costly and labour intensive.4 Previously, the authors conducted a cluster randomized controlled trial (cRCT) in nursing homes for older people in Northern Ireland to determine if an infection control education and training intervention programme impacted on the prevalence of meticillin-resistant Staphylococcus aureus (MRSA).5 At the end of the cRCT, only six out of 16 homes from the intervention group were deemed to be compliant with infection control standards. No change in MRSA prevalence rates from baseline was found, and the reasons for this were unclear. Elective and emergency admissions to English hospitals are screened for MRSA.6 In Northern Ireland, MRSA screening in hospitals is reserved for high-risk patients (e.g. history of MRSA; admission to an intensive care, neonatal or renal unit; admission from another hospital or care home).7 No proposals have been made for widespread MRSA screening and decolonization (which involves the application of an antibacterial nasal cream twice daily, and daily bathing in antiseptic solution and laundering of clothing and bed linen for a minimum of five days) in nursing homes. A qualitative study was undertaken with nursing home staff who were participants in the intervention group of the previous cRCT, to explore staff views on factors that may influence infection control and MRSA decolonization in the nursing home environment.
Methods Recruitment Ethical approval was obtained from the Office for Research Ethics Committees Northern Ireland (09/NIR03/57). Sampling was undertaken on a purposive basis in that only those nursing homes (N ¼ 16) and staff which participated for the full duration of the original cRCT study5 were invited to participate. During the cRCT, the manager at each nursing home had nominated at least one member of staff to become an infection control link worker. The link workers received additional training and were responsible for raising the profile of infection control in the homes. Written informed consent was obtained from staff to participate in a focus group discussion, and from managers to participate in a one-to-one semi-structured interview during Autumn/Winter 2009/2010. The ‘privacy of individual interviews’ was considered to be an important factor for managers, whereas the ‘reassurance of a group shared experience’ was thought to be important for nurses and care assistants.8 The sample size was not determined in advance, but was guided by the research objectives and the achievement of data saturation (when no new themes were identified and relationships between data sets were sufficiently explained and explored).
Organization of semi-structured interviews and focus groups Each focus group consisted of either nurses or care assistants for the purpose of facilitating discussion. The exception was the link workers’ focus groups which consisted of a mix of
265
staff, with the common role being that of link worker rather than primary occupation. In each focus group, there were a maximum of two participants from the same nursing home. It was planned to have approximately eight participants in each focus group; however, the number of participants depended on staff availability to attend at the arranged times. Each participant was given £40 as reimbursement for participating in the research during their free time and for travel expenses.
Data collection and analysis Prior to the actual focus groups and interviews, a pilot focus group was conducted to determine the relevance of the topic guide. Topics included: e how the intervention (infection control education and training programme, appointment of infection control link workers, and regular audit and feedback) was implemented and maintained; e benefits and problems with the intervention; e improving the intervention; and e the feasibility of MRSA decolonization in the nursing home environment (previous experience, acceptability to residents and staff, benefits and problems with the process, and ways in which a large-scale decolonization programme could be implemented). Each interview and focus group discussion (held at various nursing homes) commenced with a brief overview of the previous cRCT. All groups were asked the same core openended questions based on the topic guide (developed from a review of the literature and discussion within the research team). However, additional questions were asked and explored further in subsequent groups when relevant themes were generated. The researcher, who had undergone training in qualitative research methods, had not been involved in the original cRCT and was therefore considered impartial. All interviews and focus group discussions were transcribed verbatim. Coding and analysis of themes in the data was facilitated through the use of NVivo Version 9, Melbourne, Australia (a computerized data storage and analysis package) and framework analysis, a five-step approach involving familiarization of the data, identification of the key themes (codes), making comparisons, organizing the data and explaining the findings. All analyses were performed independently by the researcher and another member of the research team, and final consensus was reached by discussion within the whole team.
Results Fifty-nine individuals provided written consent to participate in the study; 39 (66%) were available at the arranged times and took part in a focus group discussion or interview. The participants were from 12 (75%) eligible nursing homes. Five homes were independently owned, three were owned by small companies consisting of two to four nursing homes, and four were owned by large companies (chains; i.e. consisting of more than 400 homes). Six semi-structured one-to-one interviews were conducted with managers, and six focus groups were convened with staff (i.e. two with care assistants, two with nurses and two with link workers). The interviews and focus groups ranged in duration
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from 50 to 110 min (mean 75 min). The participants’ characteristics are summarized in Table I. Three overarching themes with inter-related subthemes were identified as influencing infection control and MRSA decolonization in the nursing homes: organizational factors (e.g. time, financial resources, environment, management and culture), external factors [e.g. hospitals, regulation and general practitioners (GPs)], and residents and families (Figure 1). The following quotations from managers, nurses, care assistants and link workers are represented by the initials ‘M’, ‘N’, ‘CA’ and ‘LW’, respectively, and a number from 1 to 12 has been used to distinguish between participants with the same occupation. The responses from staff working in care homes deemed to be compliant with infection control standards during the cRCT did not differ from the responses from staff working in care homes deemed to be noncompliant.
Organizational factors Time The majority of participants reported feeling under pressure at work, and it was recognized that when the workload was unmanageable, aspects of infection control were not adhered to:
‘Anything to do with infection control is more time consuming... you’re always working short staffed... that’s where bad practice comes in.’(LW10) Some staff felt that decolonization of MRSA in individuals was time consuming, whereas other staff felt that the workload was manageable: ‘It’s quite intense [MRSA decolonization] and it’s acute care, acute needs... you couldn’t do it on a big scale.’ (N8) ‘It [widespread MRSA decolonization] would be time consuming but it could be done.’ (N5) Financial resources Most participants stated that financial constraints were a barrier to performing infection control practices properly: ‘Expenditure would have been the main thing [barrier].’ (M2) Participants discussed how cost would be a barrier to implementing a widespread MRSA decolonization programme in nursing homes: ‘No [GPs are not supportive of MRSA decolonization in nursing homes]... if there was a cost implication, we can’t even get Hibiscrub from them for their patients.’ (M1)
Table I Characteristics of the interview and focus group participants Interview(I)/focus group(FG)
I1e6
FG1
FG2
FG3
FG4
FG5
FG6
Total
Participant codes (M ¼ manager, M1eM6 CA1eCA6 CA7eCA12 LW1eLW4 LW5eLW11 N1eN5 N6eN10 CA ¼ care assistant, LW ¼ link worker, N ¼ nurse) Number of participants 6 6 6 4 7 5 5 39 Gender Female 6 5 5 4 7 5 5 37 Male 0 1 1 0 0 0 0 2 Occupation Manager and nurse 6 0 0 0 0 0 0 6 Care assistant 0 6 6 0 0 0 0 12 Nurse 0 0 0 0 0 5 5 10 Link worker and care assistant 0 0 0 1 2 0 0 3 Link worker and nurse 0 0 0 3 2 0 0 5 Link worker and domestic 0 0 0 0 3 0 0 3 staff/laundry Mean (range) years working 21 (15e30) 8 (2e12) 8 (2e15) 17 (7e22) 12 (3e25) 17 (3e28) 8 (3e25) 13 (2e30) in a nursing home Mean (range) years working 16 (6e25) 7 (2e12) 6 (2e15) 17 (7e22) 9 (3e22) 12 (3e23) 8 (3e25) 11 (2e25) in the current nursing home Mean (range) years qualified as 35 (28e46) N/A N/A 30 (25e38) 19 (13e25) 23 (4e32) 15 (8e27) 25 (4e46) a nurse for three for two nurses nurses Type of nursing home where staff were employed Independent (owner had 3 2 1 2 2 2 0 12 one home) Small company (owner had two 1 2 4 0 3 1 2 13 to four homes) Large company (owner had >400 2 2 1 2 2 2 3 14 homes) N/A, not applicable.
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Organizational
External
Time
Hospital
Financial resources
Regulation
Environment
General practitioners
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Residents and families
Management Culture
Inter-relationships between subthemes Figure 1. Factors influencing infection control and meticillin-resistant Staphylococcus aureus decolonization in nursing homes.
‘If the Government was prepared [to give] so much money per MRSA patient to go through it [decolonization], I’d say nursing home owners probably would... put the extra staff on.’ (LW10) Environment Participants reported that some of the nursing homes where they worked were not purpose built and that facilities were inadequate: ‘Because we’ve quite an old building, and quite short on space, we don’t have any changing rooms.’ (M5) Participants were concerned that if a widespread MRSA decolonization programme was completed in nursing homes, it would be difficult to ensure that MRSA remained eradicated from the environment: ‘I am a bit dubious about decolonizing people... because they can pick it up again so easily in the setting [nursing home] like this.’ (LW2) There was conflict in maintaining an environment that was both ‘homely’ and clinical: ‘You want to keep it homely... so you have soft furnishings, carpets in bedrooms... You can’t just have a total sterile environment.’ (LW1) Management The majority of participants felt that their nursing home managers were proactive with infection control measures, while some staff reported that higher level management and owners were not always accommodating, with financial constraints being a major factor: ‘It’s not really the managers, because if they put it forward to the bosses, they just say, “well you know we can’t afford it, this year”. Our manager does try but sometimes she’s let down by the bosses.’ (LW11)
In contrast, most managers felt supported by the owners and higher management: ‘Whatever has to be done, is done. They [the owners] are quite happy to be seen to be leading and getting on with infection control.’ (M3) Culture It was reported that some individuals were not sufficiently interested to ensure that infection control practices were performed properly and complacency was an issue, thus reflecting the culture of the organization (‘the way we do things around here’)9: ‘You’re working with stuff [faeces], and even nowadays, there’s some people don’t wear gloves... you do become complacent with it; that’s what’s wrong, you have to harden yourself.’ (CA7) It was reported that some staff did not have direct contact with residents, and as a result, may not have fully understood their role with regards to infection control: ‘I think because they [domestic, kitchen and maintenance staff] probably think, “well we’re not caring for that person in a personal nature, we do not need to worry so much about it” [infection control].’ (N8) In two homes, the recommendation made during the cRCT of changing uniforms at work was not adopted until after the homes experienced infection outbreaks. In several homes, some of the suggested infection control measures were not implemented during the study, but were implemented later after regulatory inspections: ‘We’re not allowed to wear our uniform out of the home or into the home... that was all brought on to us from the outbreak.’ (CA9) ‘We had chairs with rips in them, they had to go on the skip [following an inspection].’ (LW10)
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There were concerns that the MRSA decolonization process would not be performed properly by some staff members because of their attitude: ‘If we were to try and decolonize a resident, it would have to be certain members of staff, who would be interested in doing that... the next day another member of staff might come in and not care less.’ (CA11)
External factors Hospital Many participants believed that hospitals were a source of infection and resistant bacteria: ‘We have loads of residents that go to hospital... and they come [back to the nursing home] with MRSA and UTIs [urinary tract infections] and C. diff. [Clostridium difficile].’ (CA5) Regulation Some participants expressed frustration with the demands of regulation and enforcing inspectors. Different inspectors’ requirements were reported to be inconsistent, and there were variations between recommendations from the regulatory body and protocols issued by hospitals: ‘What passes with one inspection could be different in another. It depends what inspector you get on what day.’ (LW10) ‘He [the GP] asked us to decolonize him [the resident] but the protocol changes from the last time and then you’re dealing with two different [hospital] trusts so they might say swab this and swab that in one trust and they say in another, swab this and swab that.’ (M6) General practitioners There were conflicting views regarding whether or not GPs adhered to infection control requirements: ‘We still have a lot of older GPs who are casual about the whole affair [infection control].’ (M5) ‘Now they’re [GPs] more prone to cleaning their equipment and washing their hands, where before, they were the worst culprits... I notice in the past year [GPs are more compliant].’ (LW10) However, there was a consensus that GPs did not support MRSA decolonization in nursing homes: ‘The doctors all have said, they don’t think it [decolonization] would be worth it in a nursing home setting.’ (M3)
Residents and families Staff felt that there were issues with practising good infection control with confused residents. The risk of MRSA recolonization from other residents and families was identified as an issue with decolonization: ‘If you’ve a resident that’s up walking about and touching other residents.’ (N3)
‘Maybe it’s just because they’re family and some of them sit on the bed or things like that there, we’ve asked them not to but they still do it.’ (CA4)
Discussion Three overarching themes (organizational factors, external factors, and residents and families) were identified as influencing infection control and MRSA decolonization in nursing homes. One dominant organizational factor was the lack of time available for staff to complete all required tasks in the nursing homes, including infection control. Increased workloads are associated with a greater risk of MRSA for nursing home residents.10 The availability of financial resources was another major contributing factor to infection control practices in the nursing homes, despite minimal expenditure being associated with lower-quality staffing and higher rates of adverse events.11 Conflict existed in maintaining an environment that was both ‘homely’ and clinical. Some nursing homes had not been purpose built, and amenities (e.g. staff changing facilities) were not always available. The uniforms of care home staff are frequently contaminated with high levels of MRSA;12 therefore, it is vital that uniforms are changed regularly. Several participants reported their frustration with management hierarchies in chain nursing homes, which led to difficulties in obtaining approval to purchase necessary equipment. The higher rate of MRSA evident in chain nursing homes compared with independently owned homes13 suggests that chain facilities need to increase their focus on infection control. It was reported that some members of staff were resistant to change. Old ritualistic habits can be difficult to modify and can compromise effective infection control practice.14 The behaviour of hospital staff has been linked to personal priorities, with self-protection reported to be a greater concern than patient safety.14 Domestic, kitchen and maintenance staff do not have direct contact with residents and may not fully understand their role in infection control. ‘Familiarity may have bred contempt’ for some nurses and care assistants, as several stated that they had worked with residents with MRSA for a long time and did not perceive there to be any risk. Culture and practice were more likely to change when the homes experienced infection outbreaks. In some nursing homes, certain recommendations that were made during the cRCT were not implemented until inspectors stated that the changes had to be made. In these homes, practice only improved when management were ‘pushed’ by authoritative figures, rather than ‘pulled’ with recommendations on good practice, indicating that regulation was more influential than a quality improvement approach. Furthermore, several participants felt that there were inconsistencies in requirements and information provided by inspectors and hospital infection control departments, indicating that there is a need for standardized policies to be developed and implemented across acute and long-term care. The majority of staff were sceptical about the benefits of decolonization due to the risk of recolonization, particularly from hospital admissions. Both hospitalization and residing in a nursing home are recognized risk factors for MRSA carriage.7 The risk of transfer of infection between both environments further emphasizes the need for a stream-lined approach when implementing infection control measures.
P. McClean et al. / Journal of Hospital Infection 81 (2012) 264e269 Some GPs, particularly older GPs, were considered to be noncompliant with infection control requirements. In order to implement behavioural changes, a strong institutional commitment is necessary.15 This commitment may be difficult to achieve, as GPs do not visit nursing homes regularly and may not be aware of infection control policies. Patients should be involved in infection control programmes; however, there are obvious difficulties in educating residents who are confused, and visiting families may not be compliant. Perhaps there needs to be an increase in staff awareness of how residents can influence infection control, as one study reported that staff did not routinely assist patients in washing their hands before meals or after visits to the toilet.16 The Department of Health, Social Services and Public Safety has published minimum standards (on all aspects of care including infection control)17 which are used by the regulatory body, the Regulation and Quality Improvement Authority, to assess nursing homes in Northern Ireland. However, a questionnaire study conducted in Northern Ireland found that 75% of care home managers believe that more information should be provided with regards to infection control advice and standardized policies, particularly for MRSA.18 This research has a number of limitations. The sample consisted of individuals who agreed to participate; therefore, it is likely that individuals who were interested in the infection control study were more likely to participate, thus introducing a form of bias. It is also possible that some individuals may have decided to take part due to the payment which was provided. The cRCT was completed in August 2008, but the semistructured interviews and focus group discussions were not conducted until Autumn/Winter 2009/2010. This delay may have led to some recall bias. Although the study was small in terms of the absolute number of homes and individuals who participated, the sample size was large for a qualitative study and data saturation was attained. In conclusion, common factors (organizational, external, and residents and families) were found to influence staff views on infection control and MRSA decolonization in nursing homes. Availability of time and financial resources were major barriers, despite infection control being cost-effective.19 The factors identified in this study must be accounted for, and appropriate measures taken, in order to improve infection control in nursing homes. Only then will it be worth considering the implementation of a widespread MRSA decolonization intervention programme in the nursing home environment.
Acknowledgements The authors wish to thank the nursing home managers and staff who participated in the study. Part of the research was presented as a Poster Presentation at the European Society of Clinical Microbiology and Infectious Diseases conference in Milan, May 2011 (Abstract No. P1333). Conflict of interest statement None declared. Funding sources Pamela McClean is funded by a Department of Employment and Learning studentship, and receives additional funding from the Health and Social Care Research and Development, Public Health Agency. Michael Tunney is funded as a UK
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National Career Scientist by the Health and Social Care Research and Development, Public Health Agency, Northern Ireland. The authors’ work has been independent of the funders. This study was carried out as part of their routine work.
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