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Educating the infection control team – past, present and future. A British prespective
Journal of Hospital Infection (2000) 46: 96–105 doi:10.1053/jhin.2000.0822, available online at http://www.idealibrary.com on
INFECTION CONTROL IN PRACTICE
Educating the infection control team – past, present and future. A British perspective E. A. Jenner* and J. A.Wilson† *Faculty of Health and Human Sciences, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB; †Nosocomial Infection Surveillance Unit, Public Health Laboratory Service, Colindale, London NW9 5HT, UK
Summary: This review sets out to explore how education and training provisions for members of the Infection Control Team (ICT) have developed alongside their roles and in response to changes in the British National Health Service. It focuses on the Consultant in Communicable Disease Control, the Infection Control Doctor and the Infection Control Nurse in the United Kingdom, but also briefly considers approaches adopted by other countries. Future developments should include maximizing information technology for delivering teaching materials, shared learning and improvements to pre-registration curricula for both doctors and nurses. © 2000 The Hospital Infection Society
Keywords: Education; training; shared learning; infection control.
Introduction The principles of infection prevention in hospitals have been known for thousands of years, even if they were not grounded in science.1 Introducing practices designed to prevent infection was often difficult, as evidenced by Semmelweis. His work on the epidemiology of puerperal sepsis which showed that infection was spread on unwashed hands after performing postmortem examinations was ignored by the medical establishment for over ten years.2 Meanwhile, Florence Nightingale was taxed by the challenges of nursing cases of smallpox and measles with ‘the best women who are woefully deficient in sanitary knowledge’.3 Being of the view that ‘true nursing ignores infection, except to prevent it’, she went on to teach those same ‘best women’ the principles of infection prevention at the Nightingale School and Home for Nurses at St Thomas’ Hospital, founded in 1860. It was to be nearly 100 years, however, before a nurse specializReceived 30 March 2000; manuscript accepted 22 June 2000. Author for correspondence: Elizabeth A. Jenner, Faculty of Health and Human Sciences, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB. Fax: 01707 284954; E-mail: [email protected]
0195-6701/00/020096;10 $35.00
ing in the prevention and control of infection was appointed. Hospital-acquired infection (HAI) is now recognized as an important problem affecting almost 8% of patients admitted to hospital and costing National Health Service (NHS) hospitals in Britain an estimated £930 million annually.4 Comprehensive arrangements for preventing and controlling HAI are a requirement for all British hospitals, implemented and co-ordinated by an Infection Control Team (ICT).5,6 This paper begins by considering the recent changes in the NHS in the UK and how these changes have affected the service provided by the ICT. It then explores the composition of the ICT and focuses on the historical development and training provision for Consultants in Communicable Disease Control (CCDCs), Infection Control Doctors (ICDs) and Infection Control Nurses (ICNs). Contemporary approaches that may need to change in the light of current developments are examined, with particular regard to those that affect the education of specialist nurses. The ways in which members of the ICT are trained for their respective roles in other countries are then briefly reviewed. Finally, ideas are presented on the future
© 2000 The Hospital Infection Society
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development of education and training provision, with a recommendation that there should be a move towards shared learning, not only for members of the ICT but also for other healthcare professionals. Changes in the NHS Over the last few years, there have been several radical changes in the provision of healthcare in the UK. These began in the late 1980s with the introduction of purchasers and providers of health care and the formation of NHS Trusts.7,8 These changes enabled health authorities and fundholding general practitioners to determine a service provision that matched the needs of the local population more closely. The formalization of healthcare provision also had an important impact on infection control services. For the first time, the provision of such a service was specified in contracts drawn up between purchaser and provider units. The separation of acute and community services also provided opportunities for ICNs to be appointed to community healthcare trusts and to work alongside the CCDC in Public Health Departments, providing advice in a variety of community settings. The new framework for the NHS, announced a decade later in the form of a Government White Paper, ‘The New NHS’, moved the emphasis towards providing a service that is of high quality as well as efficient.9 The primary care groups and health authorities with responsibility for commissioning care now also have a remit to ensure the quality of the services provided. National Health Service Trusts are required to introduce clinical governance, a framework for ensuring that quality improvement processes, for example, clinical audit, risk reduction programmes and systems for detecting adverse events and poor clinical performance, are in place.10 These changes will have important implications for ICTs. They will need to be involved in risk assessment and management, the implementation of evidence-based practice, standard setting and audit in relation to infection control and a planned programme for monitoring HAIs. Clinical governance also requires all healthcare workers to ensure that their own professional development enables them to practice competently and provide a high quality service. New standards for infection control11 need to be implemented and incorporated into the training programme of all practitioners.12 Other changes in the NHS which influence the ICT service include the increased throughput of
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patients in hospital, more patients who are acutely ill and undergo complex medical interventions, reductions in the number of hours worked by junior doctors, the extension of the role of nurses13 and other healthcare workers, and an acute crisis in nurse recruitment and retention resulting in an increased use of temporary staff supplied by employment agencies and in-house staff banks. The Infection Control Team In the UK, the core members of the hospital ICT have traditionally been the ICD and the ICN. The hospital Infection Control Committee includes the CCDC [in Scotland the Consultant in Public Health Medicine (CPHM)] responsible for communicable disease throughout a Health District.5,6 Close collaboration between the ICD, ICN and CCDC/CPHM (hereinafter referred to as CCDC) is essential for co-ordinating infection control activities in hospitals and in non-acute healthcare services within the community. Development of the role of Consultant in Communicable Disease Control Doctors with specific responsibility for the control of communicable disease were first appointed in England and Wales in the latter part of the nineteenth century, following the Public Health Acts of 1872 and 1875. These Acts established a British Public Health Service and the role of the Medical Officer of Health (MOH).14 Chadwick’s report ‘The Sanitary Condition of the Labouring Population of Gt. Britain’, published in 1842 (cited in Essex-Cater14), pointed out the relationship between sanitary conditions and disease. Some local authorities, first Liverpool in 1846 and then London in 1848, appointed an MOH to control sanitary services. The first Public Health Act of 1848 gave district authorities power to appoint MOHs with responsibility for drainage, sewers and street cleaning although their appointment did not become compulsory until the Public Health Act of 1875. This Act extended the role of the MOH to include food inspections, control of housing standards and infectious diseases. It also saw the introduction of fever hospitals. Hospital services and vaccination came under the control of the MOH when the Poor Laws were abolished in the 1929 Local Government Act. Even at this time, adequate training for the role was considered important and
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MOHs were required to hold an appropriate post-graduate diploma.15 The NHS, which was founded in 1948, was reorganized in 1974 along with local government. This resulted in the role of the MOH being replaced by that of the Medical Officer of Environmental Health (MOEH) who had a narrower range of responsibilities but, unlike MOHs, was not required to have any specific postgraduate training or qualification.15 The 1988 report on Public Health in England16 resulted in the replacement of the role of the MOEH by that of the CCDC, the intention being to provide more expertise in, and greater focus on, the control of communicable disease. However, CCDCs, like the MOEHs before them, were vulnerable to professional isolation as they were not recognized as a speciality in their own right but combined elements of public health medicine and medical microbiology. Training provision for the role of Consultant in Communicable Disease Control The 1988 report of Public Health in England16 recognized the need to formalize training arrangements in public health. Galbraith identified the training needs of CCDCs in 198917 and discussions on training for this role15 culminated in a training programme recommended by the Faculty of Public Health Medicine in 1994.18 This was later modified to take account of developments in the role and the new arrangements for specialist training.19 This programme combines academic training with field experience and has been designed to be flexible in meeting the training needs of those taking on the role of CCDC from a background in either public health or clinical microbiology. Training is organized and funded by Regional Health Authorities and a regional training consultant liaises with the trainee and designated trainer. The training is focused on public health medicine, infectious diseases, epidemiology and statistics, medical microbiology, environmental science and the legal framework for the prevention and control of communicable diseases. Details of the programme can be found elsewhere.15 It is noteworthy that it addresses the skills and competencies, as well as knowledge, required to perform the role. Assessment of theoretical knowledge is by faculty examination and whilst completing requirements for the first part of this, trainees may also complete a master’s degree in public health or epidemiology.
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Trainers assess competence using a Regional Interactive Training Assessment. Suc-cessful completion of the training programme leads to the award of Membership of the Faculty of Pub-lic Health Medicine (MFPH) and a certificate of completion of specialist training (CCST).
Development of the role of Infection Control Doctor The early twentieth century saw many publications stipulating practices for the prevention and control of various infections.20–24 However, it was not until the second world war, with the publication of memoranda by the Medical Research Council, that official recommendations were made about the control of cross-infection in hospitals.25,26 ‘Memorandum 11’26 recommended that every hospital should establish a Control of Cross-Infection Committee which ‘should be the basis for standing orders which all hospital personnel would be required to know and obey’. The unique problems associated with HAIs became increasingly apparent in the late 1950s when staphylococcal infections, particularly those caused by virulent strains belonging to phage type 80, began to cause serious problems. In response, the Ministry of Health offered advice on how to control staphylococcal infections in hospitals27 and made a recommendation, first suggested by Colebrook in 1955,28 that every major hospital should appoint a full-time Control of Infection Officer (CIO). The memorandum recognized the key position of the CIO in the prevention and control of outbreaks. Williams et al.29 further emphasized the need for a designated individual responsible for translating the recommendations from the Infection Control Committee (ICC) into practice. Later, the CIO was renamed the ICD. Today every healthcare Trust should have a nominated ICD.5,6 In most hospitals this is a consultant medical microbiologist who spends part of their time in infection control activity. Guidance from the Royal College of Pathologists30 recommends that for a 500-bed hospital this should equate to 0.5 whole time equivalents (WTE), however, the recent report from the National Audit Office12 suggests that true levels are much lower, with an average of one WTE ICD to 2258 beds. Furthermore, there are only 46 hospital Trusts in England where ICDs (WTE) spend at least 50% of their time on infection control activities.
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Training of the Infection Control Doctor The ICD in the UK usually relies on their training for Membership of the Royal College of Pathologists (MRC Path) to provide the necessary knowledge and skills to perform their role. Infection control does not constitute the main focus of this training despite a recent recommendation that 50% of a consultant medical microbiologist’s time should be spent in infection control. However, valuable experience is gained by working alongside the existing ICD and ICN.31 In the past, training was often provided in specialist centres such as the Hospital Infection Research Laboratory (HIRL) in Birmingham and the Central Public Health Laboratory (CPHL) at Colindale for trainees from the UK and from overseas. Later control of infection was also included in the diploma and MSc courses in Medical Microbiology at the London School of Hygiene and Tropical Medicine (LSHTM). Most medical microbiologists join the Hospital Infection Society (HIS) which was founded in 1980.32 Since its inception, the Society has provided informal training in infection control by organizing seminars and conferences and publishes the Journal of Hospital Infection. In 1986 a week-long course was organized by the HIS and Public Health Laboratory Service (PHLS), mainly for trainee and junior consultants in Medical Microbiology. Instruction was provided in matters relevant to infection control. Recently, however, members of the HIS have joined representatives of the PHLS, the Infection Control Nurses’ Association of Great Britain (ICNA) and the LSHTM to produce the Diploma in Hospital Infection Control (DipHIC)33 which addresses the specific educational and training needs of ICDs. This development recognizes the increased complexity of the role and the many new challenges facing ICDs today. These include the changing demographic profile of the population, increased numbers of immunocompromised patients, more widespread use of invasive procedures and the increasing emphasis on evidence-based practice, standard setting and risk management.9 Fifty years of inappropriate use of antimicrobial agents is the likely explanation for significant problems now encountered with antibiotic resistance, including the emergence of methicillin resistant Staphylococcus aureus and vancomycin resistant enterococci as well as outbreaks of Clostridium difficile.34 The DipHIC is a post-graduate diploma intended to ‘provide infection control staff with a systematic
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training in the sciences relevant to infection control’.33 It consists of a combination of self-directed learning and taught courses, the content of which is detailed elsewhere.33 Assessment is based on the compilation of a ‘reflective portfolio’, a written project report, and oral and written examinations. It remains to be seen whether this course can provide training in the ‘arts’ as well as the ‘sciences’ relevant to infection control. At present, the DipHIC is not an essential qualification for ICDs. Consequently, most ICDs still rely on knowledge and skills in infection control gained whilst training for the MRC Path examination. Development of the role of the Infection Control Nurse In a similar way to the ICD, the role of the ICN also emerged as a result of problems with staphylococci. In the late 1950s, the increased incidence of staphylococcal infections in the nursing staff at the Torbay Hospital prompted the appointment of the first ICN.35–37 This made it possible for the CIO ‘to promote active prevention of hospital infection on the lines envisaged by Colebrook’.35 Today, most healthcare Trusts employ ICNs to advise employees and patients/clients on the prevention and control of infection. There are now over 600 ICNs in Britain working in public, private and military healthcare organizations. A questionnaire survey of 326 ICNs showed that 83% were based in acute hospital Trusts. Of these, almost 41% continued to advise the community that had previously formed part of the District Health Authority. Only 17% of respondents worked in the community alone.38 Training provision for the role of Infection Control Nurse The ICNs who pioneered the role of the ICN in England in the late 1950s were taught ‘on the job’ by the ICD, who was usually a medical microbiologist.35–37 Where this was not the case, however, ICNs were sometimes left to their own devices and the late Brendan Moore, encouraged novice ICNs to visit Exeter and Torbay with a view to learning about infection control. In 1966 the first infection control conference was held in Taunton, Somerset and became an annual event until 1970, when the Infection Control Nurses’ Association (ICNA) was formed. The ICNA has continued to organize this annual national conference and also a quadrennial
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international conference. More structured programmes of education were developed initially by the HIRL and later by the Royal College of Nursing (RCN) in Birmingham. Certificate level courses In 1974, acting on advice from the Education Sub-Committee of the ICNA, the Joint Board of Clinical Nursing Studies (JBCNS), an independent body with responsibility for accrediting courses, approved Course 326 (level 1) in infection control nursing.39 Owing to financial constraints, however, it was not until 1977 that a shorter course, Course 910 on The Principles of Infection Control, was accredited.40 It first took place in 1978.41 In 1979 a longer, part-time Foundation Course in Infection Control Nursing, Course 329, was produced. This course was designed to equip suitably qualified nurses with basic skills and knowledge in infection control and it was recommended that it should be taken as soon as possible after entering this field of work.42 The first JBCNS 329 course took place in November 1979.43 When the English National Board (ENB) for Nursing, Midwifery and Health Visiting took over the functions of the JBCNS, these courses were designated ENB 91044 and ENB 329.45 Other institutions have since established similar courses46 including one in Scotland. Neither Wales nor Ireland have produced a syllabus specifically for training ICNs. In 1979 the ICNA established a multidisciplinary short course on infection control in conjunction with the PHLS. Shared learning was an important feature of this course, which was always oversubscribed. However the great amount of time required to organize the programme eventually led to its demise in 1989. The move to higher education The above courses provided training for most of the ICNs in the UK until the changes in nurse education which began in 1989.47 These moved nurse education from Schools of Nursing into universities in order to raise the minimum educational level of pre-registration nurses.48 A consequence of these changes was demand for increased academic rigour in post-registration courses. As a result, post-registration diplomas, first degrees and higher degrees in a range of subjects have been developed for nurses. In 1993, the University of Hertfordshire was the first institution to validate a diploma,
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honours degree and Master’s degree in infection control for nurses. The only other British institution currently offering a diploma course in infection control nursing is the RCN in conjunction with South Bank University. In Scotland, there is a post-graduate diploma in infection control nursing validated by the University of Glasgow Nursing and Midwifery Studies in conjunction with the Scottish Centre for Infection and Environmental Health (SCIEH) and approved by The National Board for Nursing, Midwifery and Health Visiting (Scotland).49 In all the English courses, the professional qualification for ICNs, the ENB 329, is embedded within the programme of study. Progress in professional qualifications for specialist nurses The existence of professional awards at differing academic levels poses problems, and so does the fact that those who have been awarded the ENB 329 may differ considerably in levels of subject specific knowledge and skills. Prospective or current employers may not appreciate this. Another factor influencing the value of the ENB 329 has been the widening of the requirements for entry to the course in order to accommodate the heavy demand from those seeking a post in infection control, but not actually working in it. Such individuals’ experiential learning will clearly be very different from that of a practising ICN. After 1996, changes in the professionally registerable status of courses meant that those such as the ENB 329 could not be recorded on the professional register of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC).50 Since then, the only recordable post-registration qualification for nurses is ‘Specialist Nurse Practitioner’, which requires completion of degree level studies.50–52 In consequence, courses such as the BSc(Hons) Specialist Nursing Practice have been developed. The emergence of specialist nursing roles has led to a proliferation of titles which may cause confusion and do not necessarily reflect the knowledge and expertise of the title holder.53 To address this problem, the UKCC is in the process of developing a standard for a ‘Higher Level of Practice’. The proposed requirement for this qualification is a relevant programme of study at a minimum of degree level and a corresponding level of expertise.54,55 This is clearly intended to fit in with the consultant practitioner role in the new career framework that has been proposed for nurses in Britain.56
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All these developments raise questions about the value of the ENB 329 as the professional qualification for ICNs. There is clearly a need for a debate about the training requirements for ICNs in the future and how these can best be developed to take account of the changing role and career structure.
likely to have an adverse effect on research in infection control, and as yet there are no professorial posts in Infection Control Nursing.
Assessment of clinical competence in the UK
The approach to training members of the ICT differs between countries. As in the UK, many other European countries tend to focus on the ICN, also known as a hospital hygienist. Most countries have courses for hygienists, in some there is formal training as in Germany, but in others there is not, e.g., Sweden, Italy.70 In Belgium, hygienists must have a certificate in Medical Social Sciences and Hospital Policy and then undertake specific hygienist training. Similarly, in the Netherlands, diploma level education in healthcare is a prerequisite for hygienist training, which then involves two years of parttime study. In the USA, three short courses operated by the Association for Practitioners in Infection Control and Epidemiology are available.71 In Canada a two-week training programme is taught by members of the Toronto infection control fraternity (D. Thornley, personal communication). However, in such a large country many are unable to meet the costs of attendance. In response to this, distance learning packages in infection control are now being produced.72 The infection control organizations of both the United States and Canada have produced a single set of practice standards defining infection control competence.73 Professional competence to practice as an ICN/Infection Control Practitioner (ICP) is demonstrated through certification by the Certification Board of Infection Control. Practitioners take an examination, usually by post, every five years, to obtain a ‘certified in infection control’ (CIC) award. This award is a preferred, but not essential requirement to practise in the field.74 In Southern Africa, ICNs can obtain a hospital diploma by undertaking a six-month intensive course. This has an emphasis on practical experience under the guidance of a qualified ICN. Other courses, such as a two-day introductory course and distance learning diploma are also available (J. Pearse, personal communication). In Australia, the first ICN was appointed in 1962 and was largely taught by the ICD.75,76 There is limited information on current education programmes in infection control in Australia. In
The assessment of a range of clinical competencies in practice is a requirement for a post-registration professional award.57,58 However, in the speciality of infection control, the absence of nationally agreed competencies for ICNs and the scarcity of suitably qualified assessors poses problems. An ICNA consensus meeting on competencies for ICNs in 1999, began to address these issues and promoted dialogue between the ICNA, academic institutions and employers about the skills, knowledge and qualifications that ICNs require. Infection control link nurses In order to enhance the provision of the infection control service many hospital Trusts in the UK have established infection control link nurse (ICLN) schemes.59–61 These nurses are usually ward-based staff nurses with an interest in infection control, although some schemes encourage other professionals allied to medicine to take on the role too. Their responsibilities have been described by the DOH/PHLS who emphasize that the role should not substitute that of the ICN.62 Their educational needs are met by either attendance at locally organized courses or by secondment to undertake the ENB course N26.63 Post-graduate research training Much research on various aspects of infection control has been carried out by infection control personnel, including MD and PhD theses. Contributions from British nurses include studies of surveillance,64 handwashing,65 causes of central line infections,66 the psychological problems associated with being nursed in isolation67 and the teaching, learning and use of infection control knowledge in nursing.68,69 These empirical studies highlight the importance of clinically applied research. It is of concern that the number of professorial posts in clinical microbiology in the UK has diminished substantially over the past few years. This is
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Western Australia, a hospital-based, two-week full-time course was first run in 1984 for ICNs and other nurses (D. McGechie, personal communication). Today, the course is affiliated with Curtin University and a graduate diploma and an MSc. course are proposed.77 In Victoria, there is a certificate course in sterilization and infection control which runs over a year (F. Wilson, personal communication). Although most Australian ICPs have only attended certificate-type workshops (M. Wishart, personal communication) there are several levels of education available including graduate certificate, graduate diploma and master’s levels from several tertiary institutions. However, the authors of a recent study claim that there is no consensus as to the most appropriate qualifications and experience for ICPs. They conclude that the variation in ICPs’ perceptions ‘threatens the credibility and viability of the profession’.78 Meanwhile, at least one association in Australia has devised a set of infection control competencies.79 There is no information available on infection control training for medical staff. Around the world there appear to be limited training opportunities for the role of ICD. In France, the ICP is a doctor who must pass an examination in hospital hygiene, although there is no recognized national course. In the USA, there is no system of certification for Hospital Epidemiologists. Most are certified in infectious disease and will have covered some aspects of infection control as part of this training. Some may also have undertaken the course in hospital epidemiology co-sponsored by The Society for Healthcare Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention (CDC).80 The course is also offered in Europe sponsored by the European Study Group of Nosocomial Infections (ESGNI) of the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and SHEA.
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Shared learning The successful course run by the ICNA and PHLS between 1979 and 1981 shows that shared learning for members of the ICT is a practical possibility. Failure to adopt a multi-disciplinary approach to learning has hitherto resulted in doctors and nurses having different perceptions about infection control. For example, nurses have generated procedure manuals which contain advice about the prevention and control of infection, but there are very few similar procedure manuals for medical staff.87 Hence, concepts such as ‘barrier nursing’ are perceived to be the sole domain of the nurse.88 This is supported by studies that show, for example, that doctors are less likely than nurses to wash their hands.89 The development of multi-disciplinary protocols under the present aegis of clinical governance may improve this situation. The need to improve pre-registration curricula One of the frustrations faced by ICTs is clinical staffs’ poor knowledge and understanding of medical microbiology. Several empirical studies have demonstrated nurses’ inadequate knowledge of microbiology and infection control90–93 and so there is an urgent need for these subjects to have greater prominence in pre-registration training programmes for nurses. Similarly, doctors, both in the UK and USA, have expressed their concern about the limited time devoted to microbiology and infection control in medical undergraduate curricula94–97 which has continued to decrease with recent changes in curricula. The problem is further compounded by medical students’ lack of formal practical training in a range of clinical procedures such as handwashing, insertion of intravenous devices and bladder catheters. An important role for the ICD and university teachers is to address these problems.
Information technology Advances in information technology have changed methods of teaching and learning. For example, CD-Roms and computer-assisted learning packages relevant to infection control are now available81–83 and distance learning programmes can be enhanced by the use of electronic communications.72 The Internet is of value in infection control84 and electronic discussion groups provide a forum for discussion of issues in infection control organizations.85,86
Conclusion This review has highlighted that whereas the role of the ICD was established many years before those of the other members of the ICT, formal ICD training has begun only recently whilst specific training for ICNs started 25 years ago and the training needs of the CCDC were recognized early on.17 In the future, there will be a requirement for members of the ICT to take responsibility for their
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own continuing professional development and to demonstrate their competence to practise. Theoretical knowledge will no longer be a sufficient qualification for specialists in infection control; a range of practical skills as well as transferable and communication skills (both verbal and non-verbal) are also required. In this respect, the training programmes for ICNs and CCDCs currently meet these needs, as they incorporate systematic assessment of competencies in practice as well as the acquisition of knowledge necessary to perform the specific role. Consultant medical microbiologists who are ICDs are expected to spend a considerable proportion of their time on infection control activity yet mainly rely on their training in medical microbiology to provide their knowledge of infection control. Although a postgraduate diploma in hospital infection control has recently become available, it is not currently an essential qualification for ICDs. Assessment of proficiency in infection control in practice does not feature in either of these training programmes. Despite these deficiencies, the attachment of the medical microbiology trainee to the ICT for five or more years and acting as ICD on occasion has produced many competent ICDs. For ICNs, there has been a transformation in the educational opportunities and academic level of training with the move from a certificate level to a graduate level professional award; however, the current arrangements are fragmented and poorly understood by both health service managers and others. The nature and delivery of future infection control courses in the UK will no doubt be influenced by further reforms in the NHS and in higher education. A report on the Nurses’, Midwives’ and Health Visitors’ Act of 1997 recommends ‘a new single UK-wide statutory body with functions carried out from bases in all four countries’.98 This may result in less disparity between infection control courses nation-wide. Further developments are likely once the standards required for the recognition of a ‘Higher Level of Practice’ have been defined.55 Educational strategies for all members of the ICT are required to develop expert and competent professionals who will be able to meet the challenges of healthcare in the 21st century. The multi-disciplinary composition of the ICT requires more opportunities for shared learning. Advances in information technology offer new approaches to continuous professional development which should
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help overcome some of the limitations of traditional methods of course delivery, but may be constrained by available resources. Acknowledgements We thank Dr Helen Glenister, Professor Graham Ayliffe, Dr Marian McEvoy and Dr Andrew Pearson. References 01. Selwyn S. Sir James Simpson and hospital cross-infection. Med Hist 1965; 10: 241–246. 02. Newsom SWB. Pioneers in infection control. Ignaz Philipp Semmelweis. J Hosp Infect 1993; 23: 175–187. 03. Nightingale F. Notes on Nursing: What It Is and What It Is Not. Philadelphia: JB Lippincott Co. 1859. 04. Plowman R, Graves N, Griffin M et al. The SocioEconomic Burden of Hospital Acquired Infection. London: PHLS 1999. 05. DOH and PHLS. Hospital Infection Control. Guidance on the Control of Infection in Hospitals. HSG (95)10. BAPS. Health Publication Unit 1995. 06. Scottish Office Department of Health. Advisory Group on Infection. Scottish Infection Manual. Guidance On Core Standards For The Control of Infection In Hospitals, Healthcare Premises And At The Community Interface. St Andrew’s House, Edinburgh: TSO 1998. 07. Department of Health. Working for Patients. London: HMSO 1989. 08. Department of Health. National Health Service and Community Care Act. London: HMSO 1990. 09. Department of Health. The New NHS. Modern. Dependable. London: TSO 1997. 10. Department of Health. A First Class Service. Quality in the News NHS. London: TSO 1998. 11. Corporate governance in the NHS: controls assurance statements. NHS Executive 1995. London, HSG (97)17. (http://tap.ccta.gov.uk/doh/rm5.nsf/ AdminDocs/CAStandards?OpenDocument). 12. Comptroller and Auditor General. National Audit Office. The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. London: TSO 17 February 2000. HC 230 Session 1999–2000. 13. Dowling S, Martin R, Skidmore P, Doyal L, Cameron A, Lloyd S. Nurses taking on junior doctor’s work: a confusion of accountability. Br Med J 1996; 312: 1211–1214. 14. Essex-Cater AJ. A Manual of Public Health and Community Medicine. John Wright and Sons Ltd. 1979. 15. PHLS. Working Group on Training for the Consultant in Communicable Disease Control Rôle. Training of consultants in communicable disease control. CDR Review (PHLS). 1994; 4: R 37–R 49.
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16. Committee of Enquiry Into The Future Development Of The Public Health Function. Public Health in England. London: HMSO 1988 (Cmmd.9772). 17. Galbraith NS. Consultants in communicable disease control: training needs and provision 1989 to 1995/6: a report to the Chief Medical Officer. London 1989. 18. Faculty of Public Health Medicine. Training for the CCDC Rôle. FPHM Handbook on Education and Training 1994. 19. Faculty of Public Health Medicine and the Royal College of Pathologists. Training for the CCDC Rôle. Education and Training in Communicable Disease Control and Environmental Health. February 1998: 1–9. Supplement to the FPHM Handbook on Education and Training – Training for the CCDC Rôle 1994. 20. Keevil NL, Camps FE. Epidemic streptococcal infections in a general hospital. Lancet 1937; ii: 207. 21. Wright HD, Shone HR, Tucker JR. Cross-infection in diphtheria wards. J Path Bact 1941; 52: 111. 22. Medical Officers of Schools Association. A Code of Rules for the Prevention of Communicable Diseases in Schools, 10th edn. London: J and A Churchill 1940. 23. Harries EHR. Infection and its control in children’s wards. Lancet 1935; ii: 173, 233. 24. Peters BA. The elimination of cross-infection in fever hospitals. Publ Hlth 1913–14; 27: 296. 25. Medical Research Council. War Memorandum No.6. The Prevention of ‘Hospital Infection’ of Wounds. London: HMSO 1941. 26. Medical Research Council. War Memorandum No.11. The Control of Cross-Infection in Hospitals. London: HMSO 1944. 1–33. 27. Ministry of Health, Central Health Services Council Standing Medical Advisory Committee. Staphylococcal Infections in Hospitals. Report of the Sub-Committee. London: HMSO 1959. 28. Colebrook L. Infection acquired in hospital. Lancet 1955; ii: 885–891. 29. Williams REO, Blowers R, Garrod LP, Shooter RA. Hospital Infection: Causes and Prevention. London: Lloyd Luke 1960. 30. Royal College of Pathologists. Medical and Scientific Staffing of NHS Pathology Departments. Royal College of Pathologists. London June 1999. 31. Royal College of Pathologists. Training Record for Medical Microbiology. Royal College of Pathologists. London 1998. 32. Editorial. J Hosp Infect 1980; 1: 1–2. 33. Emmerson AM, Spencer RC, Cookson BD, Roberts C, Draser BS. Diploma in hospital infection control (Dip HIC). J Hosp Infect 1997; 37: 175–180. 34. DOH. Standing Medical Advisory Committee: Subgroup on Antimicrobial Resistance. The Path of Least Resistance. London: DOH 1998. 35. Gardner AMN, Stamp M, Bowgen JA, Moore B. The Infection Control Sister. A new member of the control of infection team in general hospitals. Lancet 1962; ii: 710–711. 36. Bradbeer TL, Forman A, Furze RM, Moore B. Duties and status of an infection control sister in the Exeter Hospital Group. Mnthly Bull Min Hlth and PHLS 1966; 25: 269–276.
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37. Moore B. The infection control sister in British hospitals. Int Nur Rev 1969; 17: 84–91. 38. Hateley P. Revealing answers. Nsg Times 1996; 92: 65, 67. Suppl. J Inf Contr Nsg. 39. Joint Board of Clinical Nursing Studies. Outline Curriculum in Infection Control Nursing for State Registered Nurses. Course Number 326. London: JBCNS 1974. 40. Joint Board of Clinical Nursing Studies. Short Course on the Principles of Infection Control. Course Number 910. London: JBCNS 1977. 41. Taylor LJ. 910 – the first sixteen. Nurs Times 1978; 9: 8. 42. Joint Board of Clinical Nursing Studies. Foundation Course in Infection Control Nursing for State Registered Nurses. Course Number 329. London: JBCNS 1979. 43. Stronge J. JBCNS course 329. N Times Suppl. J Inf Contr Nsg 1980; 13: 6–7. 44. English National Board for Nursing, Midwifery and Health Visiting. Short Course on the Principles of Infection Control. Course Number 910. London: ENB 1987. 45. English National Board for Nursing, Midwifery and Health Visiting. Post-Registration Courses. Circular 1995/05/RLV. London: ENB 1995. 46. Infection Control Nurses’ Association. Educational Opportunities in Infection Control for Qualified Nurses, Midwives and Health Visitors, 2nd end. 1998. www.icna.co.uk 47. DOH. NHS Management Executive. Working for Patients. Education and Training. Working Paper 10. Cmnd 555. London: HMSO 1989; 1–47. 48. UKCC. Project 2000. A New Preparation for Practice. London: UKCC 1986. 49. UKCC. Registrar’s Letter 15/1996. Annex 1. London: UKCC. 50. UKCC. The Council’s Standards for Education and Practice Following Registration Programmes of Education Leading to the Qualification of Specialist Practitioner. Annex One to Registrar’s Letter 20/1994. 1994. 51. UKCC. Standards for Specialist Education and Practice. Annex 2 to Registrar’s Letter 20/1994. 1994. 52. The National Board for Nursing, Midwifery and Health Visiting for Scotland and The Scottish Centre for Infection and Environmental Health. A Collaborative Report 2. The Findings of a Review of Current Infection Control Educational Opportunities for Health Care Professionals in Scotland. Edinburgh: NBS 1999. 53. Castledine G. The abuse of specialist nurse titles must stop. Br J Nur 1997; 6: 1137. 54. UKCC. Higher Level Practice (Specialist Practice Project-Phase 11). UKCC CC/98/19. 1998. 55. UKCC. A Higher Level of Practice. Report of the consultation on the UKCC’s proposals for a revised regulatory framework for post-registration clinical practice. UKCC. April 1999. 56. Department of Health. Making a Difference. London: DOH 1999. 57. Phillips T, Schostak J, Bedford H, Robinson J. Assessment of Competencies in Nursing and Midwifery
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Education and Training (The Ace Project). Research Highlights Four. London: ENB 1993. ENB. Changes to regulations and guidelines relating to assessment. ENB. DCL/01/RLV/Jan 1995. Horton R. Linking the chain. N Times 1988; 84: 44–46. Charalambous L. Development of a link nurse rôle in clinical settings. N Times 1995; 81: 24–27. Teare EL and Peacock A. The development of an infection control link-nurse programme in a district general hospital. J Hosp Infect 1996; 34: 267–278. Department of Health/PHLS. Role Specification of Infection Control Link Nurse in Hospital Infection Control: Guidance on the Control of Infection in Hospitals. London: HMSO 1995. English National Board for Nursing, Midwifery and Health Visiting. N26 Developments in Infection Control Nursing for Nurses, Midwives and Health Visitors on all Parts of the Professional Register. 1995. Glenister H. Surveillance Methods for Hospital Infection. (PhD thesis). University of Surrey, 1991. Gould D. Knowledge, Opinions and Clinical Performance of Infection Control Precautions. A Comparison of Nurses Employed in Three Clinical Settings. (PhD thesis). London: Kings College, 1993. Lee KE. Central Venous Catheter Infections. (BL). (PhD thesis). University of Surrey: G6c. 47–1802, 1996. Gammon J. Conceptualisation of coping within a nursing paradigm, for individuals coping with source isolation. An analysis of the effects of the mediating variables preparatory information, nurse support and control. (PhD thesis). University of Wales, Swansea, 1997. Courtenay M. The Teaching, Learning and Use of Infection Control Knowledge in Nursing. (PhD thesis). University of Reading Library (Bulmershe Court Site). 1997. Courtenay M. The teaching, learning and use of infection control knowledge in nursing. NT Res 1998; 3: 118–130. Vereniging voor Hygiëne en Infectiepreventie in de Gezondheidszorg. Proceedings of the Jubilee Congress. 8–10 March 1998. http://www.apic.org/ Birnhaum D. Distance education and technology. Clin Perform Qual Hlth Care 1998; 6: 190–192. Horan-Murphy E, Barnard B, Chenoweth C et al. APIC/CHICA-Canada Professional and Practice Standards Task Force. APIC/CHICA-Canada infection control and epidemiology: professional and practice standards. Am J Infect Contr 1999; 27: 47–51. http://www.cbic.org Davis NC, Fielding G, Garlick F, Rao A. The infection control sister. Her role in a large hospital. Lancet 1962; ii: 1321–1322. Anon. Infection control sister. Annotations. Lancet 1963; ii: 1318–1319. McGechie DB. A hospital-based education programme for infection control in Australia. J Hosp Infect 1991; 18, Suppl A: 490–494. Murphy CL, McLaws ML. Credentialing, diversity and professional recognition – foundations for an
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Australian infection control career path. Am J Infect Contr 1999; 27: 240–246. Cepak P, Winchcombe J, Sakker J. Career Pathway Committee. Competencies for the Infection Control Association, New South Wales Inc. October 1997. http://www.medscape.com/Af filiates/SHEA/ Courses.html British Medical Association. Bloodborne Viruses and Infection Control. CD Rom. Harwood Academic Publishers. 1998. Philpott-Howard J, Casewell MW, Desai N. Infection Control – Training and Policies for Hospitals. CD Rom. Harcourt Brace & Co Ltd. 1999. Desai N, Philpott-Howard J, Wade J, Casewell M. Infection control training: evaluation of a computer-assisted learning package. J Hosp Infect 2000; 44: 193–199. Barrett SP, Jennings S. Infection control and the Internet. Leading article. J Hosp Infect 1997; 36: 3–5. [email protected] [email protected] Glynn A, Ward V, Wilson J et al. Hospital-Acquired Infection: Surveillance, Policies and Practice. London: PHLS 1997. Lynch P, Jackson MM, Cummings MJ et al. Re-thinking the role of isolation practices in the prevention of nosocomial infections. Ann Int Med 1987; 107: 243–246. Bartzokas CA, Williams EE, Slade PD. A psychological approach to hospital-acquired infections. Studies in Health and Human Sciences. London: Edward Mellen 1995. Courtenay M. A study of the teaching and learning of biological sciences in nurse education. J Adv Nur 1991; 16: 1110–1116. Gould D, Chamberlain A. Infection control as a topic for ward based nursing education. J Adv Nur 1994; 20: 275–282. Gould D. Infection control: a survey to determine knowledge of nurses in a clinical setting. N Standard 1995; 9: 35–38. Ho-Yen DO, Crossan MN, Walker E. Nurses’ knowledge of Hepatitis B infection. J Adv Nur 1984; 10: 169–72. Fraser Williams R. Teaching microbiology to medical students. J Biol Educ 1967; 1: 325–335. Fraser Williams R. The place of microbiology teaching in the medical curriculum. Br J Med Educ 1969; 3: 206–214. Neu HC. How is the medical student being trained in microbiology and infections? Ann Int Med 1978; 89: 818–820. Emmerson AM, Ridgway GL. Teaching asepsis to medical students. J Hosp Infect 1980; 1: 289–292. JM Consulting. The Regulation of Nurses, Midwives and Health Visitors: report of a review of the Nurses’, Midwives’ and Health Visitors’ Act 1997. Bristol: JM Consulting 1999.
INFECTION CONTROL IN PRACTICE
Educating the infection control team – past, present and future. A British perspective E. A. Jenner* and J. A.Wilson† *Faculty of Health and Human Sciences, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB; †Nosocomial Infection Surveillance Unit, Public Health Laboratory Service, Colindale, London NW9 5HT, UK
Summary: This review sets out to explore how education and training provisions for members of the Infection Control Team (ICT) have developed alongside their roles and in response to changes in the British National Health Service. It focuses on the Consultant in Communicable Disease Control, the Infection Control Doctor and the Infection Control Nurse in the United Kingdom, but also briefly considers approaches adopted by other countries. Future developments should include maximizing information technology for delivering teaching materials, shared learning and improvements to pre-registration curricula for both doctors and nurses. © 2000 The Hospital Infection Society
Keywords: Education; training; shared learning; infection control.
Introduction The principles of infection prevention in hospitals have been known for thousands of years, even if they were not grounded in science.1 Introducing practices designed to prevent infection was often difficult, as evidenced by Semmelweis. His work on the epidemiology of puerperal sepsis which showed that infection was spread on unwashed hands after performing postmortem examinations was ignored by the medical establishment for over ten years.2 Meanwhile, Florence Nightingale was taxed by the challenges of nursing cases of smallpox and measles with ‘the best women who are woefully deficient in sanitary knowledge’.3 Being of the view that ‘true nursing ignores infection, except to prevent it’, she went on to teach those same ‘best women’ the principles of infection prevention at the Nightingale School and Home for Nurses at St Thomas’ Hospital, founded in 1860. It was to be nearly 100 years, however, before a nurse specializReceived 30 March 2000; manuscript accepted 22 June 2000. Author for correspondence: Elizabeth A. Jenner, Faculty of Health and Human Sciences, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB. Fax: 01707 284954; E-mail: [email protected]
0195-6701/00/020096;10 $35.00
ing in the prevention and control of infection was appointed. Hospital-acquired infection (HAI) is now recognized as an important problem affecting almost 8% of patients admitted to hospital and costing National Health Service (NHS) hospitals in Britain an estimated £930 million annually.4 Comprehensive arrangements for preventing and controlling HAI are a requirement for all British hospitals, implemented and co-ordinated by an Infection Control Team (ICT).5,6 This paper begins by considering the recent changes in the NHS in the UK and how these changes have affected the service provided by the ICT. It then explores the composition of the ICT and focuses on the historical development and training provision for Consultants in Communicable Disease Control (CCDCs), Infection Control Doctors (ICDs) and Infection Control Nurses (ICNs). Contemporary approaches that may need to change in the light of current developments are examined, with particular regard to those that affect the education of specialist nurses. The ways in which members of the ICT are trained for their respective roles in other countries are then briefly reviewed. Finally, ideas are presented on the future
© 2000 The Hospital Infection Society
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development of education and training provision, with a recommendation that there should be a move towards shared learning, not only for members of the ICT but also for other healthcare professionals. Changes in the NHS Over the last few years, there have been several radical changes in the provision of healthcare in the UK. These began in the late 1980s with the introduction of purchasers and providers of health care and the formation of NHS Trusts.7,8 These changes enabled health authorities and fundholding general practitioners to determine a service provision that matched the needs of the local population more closely. The formalization of healthcare provision also had an important impact on infection control services. For the first time, the provision of such a service was specified in contracts drawn up between purchaser and provider units. The separation of acute and community services also provided opportunities for ICNs to be appointed to community healthcare trusts and to work alongside the CCDC in Public Health Departments, providing advice in a variety of community settings. The new framework for the NHS, announced a decade later in the form of a Government White Paper, ‘The New NHS’, moved the emphasis towards providing a service that is of high quality as well as efficient.9 The primary care groups and health authorities with responsibility for commissioning care now also have a remit to ensure the quality of the services provided. National Health Service Trusts are required to introduce clinical governance, a framework for ensuring that quality improvement processes, for example, clinical audit, risk reduction programmes and systems for detecting adverse events and poor clinical performance, are in place.10 These changes will have important implications for ICTs. They will need to be involved in risk assessment and management, the implementation of evidence-based practice, standard setting and audit in relation to infection control and a planned programme for monitoring HAIs. Clinical governance also requires all healthcare workers to ensure that their own professional development enables them to practice competently and provide a high quality service. New standards for infection control11 need to be implemented and incorporated into the training programme of all practitioners.12 Other changes in the NHS which influence the ICT service include the increased throughput of
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patients in hospital, more patients who are acutely ill and undergo complex medical interventions, reductions in the number of hours worked by junior doctors, the extension of the role of nurses13 and other healthcare workers, and an acute crisis in nurse recruitment and retention resulting in an increased use of temporary staff supplied by employment agencies and in-house staff banks. The Infection Control Team In the UK, the core members of the hospital ICT have traditionally been the ICD and the ICN. The hospital Infection Control Committee includes the CCDC [in Scotland the Consultant in Public Health Medicine (CPHM)] responsible for communicable disease throughout a Health District.5,6 Close collaboration between the ICD, ICN and CCDC/CPHM (hereinafter referred to as CCDC) is essential for co-ordinating infection control activities in hospitals and in non-acute healthcare services within the community. Development of the role of Consultant in Communicable Disease Control Doctors with specific responsibility for the control of communicable disease were first appointed in England and Wales in the latter part of the nineteenth century, following the Public Health Acts of 1872 and 1875. These Acts established a British Public Health Service and the role of the Medical Officer of Health (MOH).14 Chadwick’s report ‘The Sanitary Condition of the Labouring Population of Gt. Britain’, published in 1842 (cited in Essex-Cater14), pointed out the relationship between sanitary conditions and disease. Some local authorities, first Liverpool in 1846 and then London in 1848, appointed an MOH to control sanitary services. The first Public Health Act of 1848 gave district authorities power to appoint MOHs with responsibility for drainage, sewers and street cleaning although their appointment did not become compulsory until the Public Health Act of 1875. This Act extended the role of the MOH to include food inspections, control of housing standards and infectious diseases. It also saw the introduction of fever hospitals. Hospital services and vaccination came under the control of the MOH when the Poor Laws were abolished in the 1929 Local Government Act. Even at this time, adequate training for the role was considered important and
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MOHs were required to hold an appropriate post-graduate diploma.15 The NHS, which was founded in 1948, was reorganized in 1974 along with local government. This resulted in the role of the MOH being replaced by that of the Medical Officer of Environmental Health (MOEH) who had a narrower range of responsibilities but, unlike MOHs, was not required to have any specific postgraduate training or qualification.15 The 1988 report on Public Health in England16 resulted in the replacement of the role of the MOEH by that of the CCDC, the intention being to provide more expertise in, and greater focus on, the control of communicable disease. However, CCDCs, like the MOEHs before them, were vulnerable to professional isolation as they were not recognized as a speciality in their own right but combined elements of public health medicine and medical microbiology. Training provision for the role of Consultant in Communicable Disease Control The 1988 report of Public Health in England16 recognized the need to formalize training arrangements in public health. Galbraith identified the training needs of CCDCs in 198917 and discussions on training for this role15 culminated in a training programme recommended by the Faculty of Public Health Medicine in 1994.18 This was later modified to take account of developments in the role and the new arrangements for specialist training.19 This programme combines academic training with field experience and has been designed to be flexible in meeting the training needs of those taking on the role of CCDC from a background in either public health or clinical microbiology. Training is organized and funded by Regional Health Authorities and a regional training consultant liaises with the trainee and designated trainer. The training is focused on public health medicine, infectious diseases, epidemiology and statistics, medical microbiology, environmental science and the legal framework for the prevention and control of communicable diseases. Details of the programme can be found elsewhere.15 It is noteworthy that it addresses the skills and competencies, as well as knowledge, required to perform the role. Assessment of theoretical knowledge is by faculty examination and whilst completing requirements for the first part of this, trainees may also complete a master’s degree in public health or epidemiology.
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Trainers assess competence using a Regional Interactive Training Assessment. Suc-cessful completion of the training programme leads to the award of Membership of the Faculty of Pub-lic Health Medicine (MFPH) and a certificate of completion of specialist training (CCST).
Development of the role of Infection Control Doctor The early twentieth century saw many publications stipulating practices for the prevention and control of various infections.20–24 However, it was not until the second world war, with the publication of memoranda by the Medical Research Council, that official recommendations were made about the control of cross-infection in hospitals.25,26 ‘Memorandum 11’26 recommended that every hospital should establish a Control of Cross-Infection Committee which ‘should be the basis for standing orders which all hospital personnel would be required to know and obey’. The unique problems associated with HAIs became increasingly apparent in the late 1950s when staphylococcal infections, particularly those caused by virulent strains belonging to phage type 80, began to cause serious problems. In response, the Ministry of Health offered advice on how to control staphylococcal infections in hospitals27 and made a recommendation, first suggested by Colebrook in 1955,28 that every major hospital should appoint a full-time Control of Infection Officer (CIO). The memorandum recognized the key position of the CIO in the prevention and control of outbreaks. Williams et al.29 further emphasized the need for a designated individual responsible for translating the recommendations from the Infection Control Committee (ICC) into practice. Later, the CIO was renamed the ICD. Today every healthcare Trust should have a nominated ICD.5,6 In most hospitals this is a consultant medical microbiologist who spends part of their time in infection control activity. Guidance from the Royal College of Pathologists30 recommends that for a 500-bed hospital this should equate to 0.5 whole time equivalents (WTE), however, the recent report from the National Audit Office12 suggests that true levels are much lower, with an average of one WTE ICD to 2258 beds. Furthermore, there are only 46 hospital Trusts in England where ICDs (WTE) spend at least 50% of their time on infection control activities.
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Training of the Infection Control Doctor The ICD in the UK usually relies on their training for Membership of the Royal College of Pathologists (MRC Path) to provide the necessary knowledge and skills to perform their role. Infection control does not constitute the main focus of this training despite a recent recommendation that 50% of a consultant medical microbiologist’s time should be spent in infection control. However, valuable experience is gained by working alongside the existing ICD and ICN.31 In the past, training was often provided in specialist centres such as the Hospital Infection Research Laboratory (HIRL) in Birmingham and the Central Public Health Laboratory (CPHL) at Colindale for trainees from the UK and from overseas. Later control of infection was also included in the diploma and MSc courses in Medical Microbiology at the London School of Hygiene and Tropical Medicine (LSHTM). Most medical microbiologists join the Hospital Infection Society (HIS) which was founded in 1980.32 Since its inception, the Society has provided informal training in infection control by organizing seminars and conferences and publishes the Journal of Hospital Infection. In 1986 a week-long course was organized by the HIS and Public Health Laboratory Service (PHLS), mainly for trainee and junior consultants in Medical Microbiology. Instruction was provided in matters relevant to infection control. Recently, however, members of the HIS have joined representatives of the PHLS, the Infection Control Nurses’ Association of Great Britain (ICNA) and the LSHTM to produce the Diploma in Hospital Infection Control (DipHIC)33 which addresses the specific educational and training needs of ICDs. This development recognizes the increased complexity of the role and the many new challenges facing ICDs today. These include the changing demographic profile of the population, increased numbers of immunocompromised patients, more widespread use of invasive procedures and the increasing emphasis on evidence-based practice, standard setting and risk management.9 Fifty years of inappropriate use of antimicrobial agents is the likely explanation for significant problems now encountered with antibiotic resistance, including the emergence of methicillin resistant Staphylococcus aureus and vancomycin resistant enterococci as well as outbreaks of Clostridium difficile.34 The DipHIC is a post-graduate diploma intended to ‘provide infection control staff with a systematic
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training in the sciences relevant to infection control’.33 It consists of a combination of self-directed learning and taught courses, the content of which is detailed elsewhere.33 Assessment is based on the compilation of a ‘reflective portfolio’, a written project report, and oral and written examinations. It remains to be seen whether this course can provide training in the ‘arts’ as well as the ‘sciences’ relevant to infection control. At present, the DipHIC is not an essential qualification for ICDs. Consequently, most ICDs still rely on knowledge and skills in infection control gained whilst training for the MRC Path examination. Development of the role of the Infection Control Nurse In a similar way to the ICD, the role of the ICN also emerged as a result of problems with staphylococci. In the late 1950s, the increased incidence of staphylococcal infections in the nursing staff at the Torbay Hospital prompted the appointment of the first ICN.35–37 This made it possible for the CIO ‘to promote active prevention of hospital infection on the lines envisaged by Colebrook’.35 Today, most healthcare Trusts employ ICNs to advise employees and patients/clients on the prevention and control of infection. There are now over 600 ICNs in Britain working in public, private and military healthcare organizations. A questionnaire survey of 326 ICNs showed that 83% were based in acute hospital Trusts. Of these, almost 41% continued to advise the community that had previously formed part of the District Health Authority. Only 17% of respondents worked in the community alone.38 Training provision for the role of Infection Control Nurse The ICNs who pioneered the role of the ICN in England in the late 1950s were taught ‘on the job’ by the ICD, who was usually a medical microbiologist.35–37 Where this was not the case, however, ICNs were sometimes left to their own devices and the late Brendan Moore, encouraged novice ICNs to visit Exeter and Torbay with a view to learning about infection control. In 1966 the first infection control conference was held in Taunton, Somerset and became an annual event until 1970, when the Infection Control Nurses’ Association (ICNA) was formed. The ICNA has continued to organize this annual national conference and also a quadrennial
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international conference. More structured programmes of education were developed initially by the HIRL and later by the Royal College of Nursing (RCN) in Birmingham. Certificate level courses In 1974, acting on advice from the Education Sub-Committee of the ICNA, the Joint Board of Clinical Nursing Studies (JBCNS), an independent body with responsibility for accrediting courses, approved Course 326 (level 1) in infection control nursing.39 Owing to financial constraints, however, it was not until 1977 that a shorter course, Course 910 on The Principles of Infection Control, was accredited.40 It first took place in 1978.41 In 1979 a longer, part-time Foundation Course in Infection Control Nursing, Course 329, was produced. This course was designed to equip suitably qualified nurses with basic skills and knowledge in infection control and it was recommended that it should be taken as soon as possible after entering this field of work.42 The first JBCNS 329 course took place in November 1979.43 When the English National Board (ENB) for Nursing, Midwifery and Health Visiting took over the functions of the JBCNS, these courses were designated ENB 91044 and ENB 329.45 Other institutions have since established similar courses46 including one in Scotland. Neither Wales nor Ireland have produced a syllabus specifically for training ICNs. In 1979 the ICNA established a multidisciplinary short course on infection control in conjunction with the PHLS. Shared learning was an important feature of this course, which was always oversubscribed. However the great amount of time required to organize the programme eventually led to its demise in 1989. The move to higher education The above courses provided training for most of the ICNs in the UK until the changes in nurse education which began in 1989.47 These moved nurse education from Schools of Nursing into universities in order to raise the minimum educational level of pre-registration nurses.48 A consequence of these changes was demand for increased academic rigour in post-registration courses. As a result, post-registration diplomas, first degrees and higher degrees in a range of subjects have been developed for nurses. In 1993, the University of Hertfordshire was the first institution to validate a diploma,
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honours degree and Master’s degree in infection control for nurses. The only other British institution currently offering a diploma course in infection control nursing is the RCN in conjunction with South Bank University. In Scotland, there is a post-graduate diploma in infection control nursing validated by the University of Glasgow Nursing and Midwifery Studies in conjunction with the Scottish Centre for Infection and Environmental Health (SCIEH) and approved by The National Board for Nursing, Midwifery and Health Visiting (Scotland).49 In all the English courses, the professional qualification for ICNs, the ENB 329, is embedded within the programme of study. Progress in professional qualifications for specialist nurses The existence of professional awards at differing academic levels poses problems, and so does the fact that those who have been awarded the ENB 329 may differ considerably in levels of subject specific knowledge and skills. Prospective or current employers may not appreciate this. Another factor influencing the value of the ENB 329 has been the widening of the requirements for entry to the course in order to accommodate the heavy demand from those seeking a post in infection control, but not actually working in it. Such individuals’ experiential learning will clearly be very different from that of a practising ICN. After 1996, changes in the professionally registerable status of courses meant that those such as the ENB 329 could not be recorded on the professional register of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC).50 Since then, the only recordable post-registration qualification for nurses is ‘Specialist Nurse Practitioner’, which requires completion of degree level studies.50–52 In consequence, courses such as the BSc(Hons) Specialist Nursing Practice have been developed. The emergence of specialist nursing roles has led to a proliferation of titles which may cause confusion and do not necessarily reflect the knowledge and expertise of the title holder.53 To address this problem, the UKCC is in the process of developing a standard for a ‘Higher Level of Practice’. The proposed requirement for this qualification is a relevant programme of study at a minimum of degree level and a corresponding level of expertise.54,55 This is clearly intended to fit in with the consultant practitioner role in the new career framework that has been proposed for nurses in Britain.56
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All these developments raise questions about the value of the ENB 329 as the professional qualification for ICNs. There is clearly a need for a debate about the training requirements for ICNs in the future and how these can best be developed to take account of the changing role and career structure.
likely to have an adverse effect on research in infection control, and as yet there are no professorial posts in Infection Control Nursing.
Assessment of clinical competence in the UK
The approach to training members of the ICT differs between countries. As in the UK, many other European countries tend to focus on the ICN, also known as a hospital hygienist. Most countries have courses for hygienists, in some there is formal training as in Germany, but in others there is not, e.g., Sweden, Italy.70 In Belgium, hygienists must have a certificate in Medical Social Sciences and Hospital Policy and then undertake specific hygienist training. Similarly, in the Netherlands, diploma level education in healthcare is a prerequisite for hygienist training, which then involves two years of parttime study. In the USA, three short courses operated by the Association for Practitioners in Infection Control and Epidemiology are available.71 In Canada a two-week training programme is taught by members of the Toronto infection control fraternity (D. Thornley, personal communication). However, in such a large country many are unable to meet the costs of attendance. In response to this, distance learning packages in infection control are now being produced.72 The infection control organizations of both the United States and Canada have produced a single set of practice standards defining infection control competence.73 Professional competence to practice as an ICN/Infection Control Practitioner (ICP) is demonstrated through certification by the Certification Board of Infection Control. Practitioners take an examination, usually by post, every five years, to obtain a ‘certified in infection control’ (CIC) award. This award is a preferred, but not essential requirement to practise in the field.74 In Southern Africa, ICNs can obtain a hospital diploma by undertaking a six-month intensive course. This has an emphasis on practical experience under the guidance of a qualified ICN. Other courses, such as a two-day introductory course and distance learning diploma are also available (J. Pearse, personal communication). In Australia, the first ICN was appointed in 1962 and was largely taught by the ICD.75,76 There is limited information on current education programmes in infection control in Australia. In
The assessment of a range of clinical competencies in practice is a requirement for a post-registration professional award.57,58 However, in the speciality of infection control, the absence of nationally agreed competencies for ICNs and the scarcity of suitably qualified assessors poses problems. An ICNA consensus meeting on competencies for ICNs in 1999, began to address these issues and promoted dialogue between the ICNA, academic institutions and employers about the skills, knowledge and qualifications that ICNs require. Infection control link nurses In order to enhance the provision of the infection control service many hospital Trusts in the UK have established infection control link nurse (ICLN) schemes.59–61 These nurses are usually ward-based staff nurses with an interest in infection control, although some schemes encourage other professionals allied to medicine to take on the role too. Their responsibilities have been described by the DOH/PHLS who emphasize that the role should not substitute that of the ICN.62 Their educational needs are met by either attendance at locally organized courses or by secondment to undertake the ENB course N26.63 Post-graduate research training Much research on various aspects of infection control has been carried out by infection control personnel, including MD and PhD theses. Contributions from British nurses include studies of surveillance,64 handwashing,65 causes of central line infections,66 the psychological problems associated with being nursed in isolation67 and the teaching, learning and use of infection control knowledge in nursing.68,69 These empirical studies highlight the importance of clinically applied research. It is of concern that the number of professorial posts in clinical microbiology in the UK has diminished substantially over the past few years. This is
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Western Australia, a hospital-based, two-week full-time course was first run in 1984 for ICNs and other nurses (D. McGechie, personal communication). Today, the course is affiliated with Curtin University and a graduate diploma and an MSc. course are proposed.77 In Victoria, there is a certificate course in sterilization and infection control which runs over a year (F. Wilson, personal communication). Although most Australian ICPs have only attended certificate-type workshops (M. Wishart, personal communication) there are several levels of education available including graduate certificate, graduate diploma and master’s levels from several tertiary institutions. However, the authors of a recent study claim that there is no consensus as to the most appropriate qualifications and experience for ICPs. They conclude that the variation in ICPs’ perceptions ‘threatens the credibility and viability of the profession’.78 Meanwhile, at least one association in Australia has devised a set of infection control competencies.79 There is no information available on infection control training for medical staff. Around the world there appear to be limited training opportunities for the role of ICD. In France, the ICP is a doctor who must pass an examination in hospital hygiene, although there is no recognized national course. In the USA, there is no system of certification for Hospital Epidemiologists. Most are certified in infectious disease and will have covered some aspects of infection control as part of this training. Some may also have undertaken the course in hospital epidemiology co-sponsored by The Society for Healthcare Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention (CDC).80 The course is also offered in Europe sponsored by the European Study Group of Nosocomial Infections (ESGNI) of the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) and SHEA.
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Shared learning The successful course run by the ICNA and PHLS between 1979 and 1981 shows that shared learning for members of the ICT is a practical possibility. Failure to adopt a multi-disciplinary approach to learning has hitherto resulted in doctors and nurses having different perceptions about infection control. For example, nurses have generated procedure manuals which contain advice about the prevention and control of infection, but there are very few similar procedure manuals for medical staff.87 Hence, concepts such as ‘barrier nursing’ are perceived to be the sole domain of the nurse.88 This is supported by studies that show, for example, that doctors are less likely than nurses to wash their hands.89 The development of multi-disciplinary protocols under the present aegis of clinical governance may improve this situation. The need to improve pre-registration curricula One of the frustrations faced by ICTs is clinical staffs’ poor knowledge and understanding of medical microbiology. Several empirical studies have demonstrated nurses’ inadequate knowledge of microbiology and infection control90–93 and so there is an urgent need for these subjects to have greater prominence in pre-registration training programmes for nurses. Similarly, doctors, both in the UK and USA, have expressed their concern about the limited time devoted to microbiology and infection control in medical undergraduate curricula94–97 which has continued to decrease with recent changes in curricula. The problem is further compounded by medical students’ lack of formal practical training in a range of clinical procedures such as handwashing, insertion of intravenous devices and bladder catheters. An important role for the ICD and university teachers is to address these problems.
Information technology Advances in information technology have changed methods of teaching and learning. For example, CD-Roms and computer-assisted learning packages relevant to infection control are now available81–83 and distance learning programmes can be enhanced by the use of electronic communications.72 The Internet is of value in infection control84 and electronic discussion groups provide a forum for discussion of issues in infection control organizations.85,86
Conclusion This review has highlighted that whereas the role of the ICD was established many years before those of the other members of the ICT, formal ICD training has begun only recently whilst specific training for ICNs started 25 years ago and the training needs of the CCDC were recognized early on.17 In the future, there will be a requirement for members of the ICT to take responsibility for their
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own continuing professional development and to demonstrate their competence to practise. Theoretical knowledge will no longer be a sufficient qualification for specialists in infection control; a range of practical skills as well as transferable and communication skills (both verbal and non-verbal) are also required. In this respect, the training programmes for ICNs and CCDCs currently meet these needs, as they incorporate systematic assessment of competencies in practice as well as the acquisition of knowledge necessary to perform the specific role. Consultant medical microbiologists who are ICDs are expected to spend a considerable proportion of their time on infection control activity yet mainly rely on their training in medical microbiology to provide their knowledge of infection control. Although a postgraduate diploma in hospital infection control has recently become available, it is not currently an essential qualification for ICDs. Assessment of proficiency in infection control in practice does not feature in either of these training programmes. Despite these deficiencies, the attachment of the medical microbiology trainee to the ICT for five or more years and acting as ICD on occasion has produced many competent ICDs. For ICNs, there has been a transformation in the educational opportunities and academic level of training with the move from a certificate level to a graduate level professional award; however, the current arrangements are fragmented and poorly understood by both health service managers and others. The nature and delivery of future infection control courses in the UK will no doubt be influenced by further reforms in the NHS and in higher education. A report on the Nurses’, Midwives’ and Health Visitors’ Act of 1997 recommends ‘a new single UK-wide statutory body with functions carried out from bases in all four countries’.98 This may result in less disparity between infection control courses nation-wide. Further developments are likely once the standards required for the recognition of a ‘Higher Level of Practice’ have been defined.55 Educational strategies for all members of the ICT are required to develop expert and competent professionals who will be able to meet the challenges of healthcare in the 21st century. The multi-disciplinary composition of the ICT requires more opportunities for shared learning. Advances in information technology offer new approaches to continuous professional development which should
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