Introduction
Surgical site infections (SSIs) continue to be of major concern for both patients and the healthcare system, and can jeopardise the results of vascular surgery [
1], leading to increased length of hospital stay and costs, and higher rates of readmission, amputation and mortality [
1,
2]. SSIs are among the most common healthcare-associated infections (HAIs) [
3]. Prevention of these infections is complex and requires the integration of a range of preventive actions and measures before, during, and after surgery. To reduce SSIs and maintain low infection rates [
4,
5], bundle of care approaches have proven to be important [
4,
5], such as improved hygiene routines, and perhaps shifts of antibiotic prophylaxis therapy [
6,
7]. WHO has also developed Global guidelines on the prevention of surgical site infection to provide a comprehensive range of evidence-based recommendations for interventions to be applied during the pre-, intra- and postoperative periods for the prevention of SSI [
8]. Open vascular surgery in the lower extremities is associated with a high risk of SSIs, where such measures have been reported to have no retained effect [
6]. Therefore a multi-centre randomized controlled trial investigating the effect of negative pressure wound therapy (NPWT) on closed incisions was warranted [
9]. Many units in the present study centre are engaged in the care vascular surgery patients, some of them follow a checklist but some do not. Therefore, it is important to examine if the ongoing INVIPS-Trial, observations, and such checklist could mediate, i.e., imply a Hawthorne Effect, (HE).
Background
The World Health Organization launched the global hand hygiene programme in 2009 to reduce HAIs and improve patient safety. Evaluation and feedback on hand hygiene performance is not only important elements of this programme but they are one of the consensus recommendations of its guidelines [
10]. Hand hygiene could be improved when healthcare professionals (HCPs) know that they are under observation, however, such observation has some potential bias. These changes in behaviour are often attributed to the well-known HE [
11]. The HE is a type of observer effect, and is often cited as a source of bias in observed behavioural changes among study participants, or due to infection control interventions [
12,
13]. Although the HE is frequently mentioned in the scientific literature, there is considerable inconsistency concerning the description and definition of the phenomenon. The most important and consistent concept of the HE is a change in behaviour due to the participants awareness of being observed [
14]. The change in behaviour occurs after participants become aware of being observed, and the size and direction of the change in behaviour depend on the total time the participant is aware of being observed [
15]. The HE is a non-specific treatment effect; it is a change in behaviour as a motivational response to the interest, care, or attention received through observation and assessment. The HE also has a performance ceiling and the performance impact decreases with continued observation past peak performance [
15]. It is not clear how HE affects human behaviour [
12] or how HCPs think and express in what way their behaviour and ways of working change when being observed. The correlation between improved compliance with hand hygiene routines and a reduction in the rate of HAIs has been well documented [
16]. To obtain a sustainable and constant Hawthorne effect associated with improved compliance with hand hygiene routines, decreased infection and cross-transmission rates could certainly represent an ideal perspective [
17]. Increased adherence to standard precautions, mediated via the HE, would thus probably reduce the rate of SSIs after vascular surgery particularly under ongoing prospective randomized INVIPS-trial at the present study centre.
Local context
The Department for Communicable Disease Control (DCDC) at the Jönköping County Hospital has overall responsibility for hygiene routines and guidelines intended to prevent and reduce the risk of infections within the healthcare system in the county of Jönköping, Sweden. The basic requirements are adherence to standard precautions, protocols, and the use of protective clothing. There are nominated hygiene observers at each healthcare unit where patients are examined, treated, or cared for. The director of each unit appoints a hygiene observer, and the DCDC provides them regular training twice a year. According to local recommendations, each unit is expected to monitor adherence to standard precautions by carrying out direct observations of about 20% of all employees each month. Furthermore, HCPs are encouraged to regularly rate their perceived adherence to these hygiene observers using a simple self-reporting protocol, (see Additional file
1), created for this purpose [
18]. This protocol is based on WHO Hand Hygiene Technical Reference Manual [
19] and SOSFS 2015:10, National Board of Health and Welfare regulations on basic hygiene in health care [
20]. This procedure has been in place since 2006, although compliance measurements have only been mandatory since 2009. The present study centre has a high documented rate of SSI following vascular surgery (> 40%), and to reduce this, it has reverted back to a previous antibiotic prophylaxis regimen [
7]. As it is important to understand why the SSI rate is so high [
7], research collaboration was initiated with Lund University. Surgeons at the University Hospital in Lund/Malmö have a long-standing interest in NPWT, in both open and closed wounds. It has been shown that incisional NPWT has the potential to reduce infection rates [
21‐
23]. The present study centre is one of four centres in an ongoing multi-centre randomized controlled trial (registered at Clinical Trials. gov, identifier: NCT0191313) comparing closed incisional NPWT with standard dressings for the prevention of SSI after vascular surgery (INVIPS Trial) [
24]. It is highly likely that the HCPs involved in this randomized controlled trial will experience a HE [
9,
24]
.
Aims
The aim of this study was to examine how HCPs perceive being observed when following hygiene routines, and how they believe and express how these observations affect their way of working, and thus their adherence to standard precautions.
Discussion
The hospital where this study was conducted, has a well-developed organization for the management of issues related to education and training in hygiene, observation processes, improvements, and the HCPs adherence to standard precautions
. The findings of this study revealed that compliance is affected by many factors, not least a lack of communication between different groups of HCPs. Many HCPs maintained that communication was vital in the care of vascular surgery patients. Most of the HCPs, especially assistant nurses, stressed the importance of verbal reporting on patients specifically about the postoperative care of surgical wounds and the prescription of antibiotics. Inadequate communication and a hierarchical arrangement of healthcare providers foster hostility, frustration and distrust, which hinder collaboration and jeopardize the quality of patient care [
27,
28]. Lack of use of self-assessment by HCPs is an important issue to resolve in the hospital, as self-assessment is one of the most essential factors in preventing HAIs in patients [
29]. The need to improve the observation process and the lack of use of self-assessment reinforce the importance of communication currently available in WHO tools, especially WHO Hand Hygiene Technical Reference Manual [
19].
Constructive and regular feedback is extremely important in ensuring long-term compliance, which in turn will lead to a reduction in nosocomial infections and SSIs. Lewis et al. concluded that an audit and feedback system may be an effective means of improving the quality of care and reducing practice variability within a surgical department [
30]. Furthermore, they showed that the number of SSIs and readmissions were significantly reduced in the high-acuity procedures in head and neck surgery after the feedback period, compared between two assessment periods, the pre- and post-feedback periods [
30]. They also suggested that it was possible that the performance of the surgical staff improved, through the HE, as they were aware that they were being audited [
30]. The communication between HCPs and vascular surgery patients was not clear regarding the perioperative perception of information on the operation. This indicates the need for better communication between HCPs and their patients to increase the patient’s awareness of the need for self-care after surgery and during healing. Such an interaction could strongly influence the patient’s understanding of their condition, and their attitude to self-care [
31], possibly reducing the frequency of SSIs after vascular surgery [
32]. A separate qualitative study on the interaction between HCPs and vascular surgery patients is warranted.
The findings of this study indicate that direct observations are generally effective, but that observation has a smaller effect on the most experienced HCPs and vascular surgeons. The HCPs expressed the importance of direct observation, not only by the observers but also by reminding each other. If the DCDC were to cease hygiene observations, then hygiene-related problems at the units would probably increase, apart from in the operating theatre, in where it was felt that there was already an open climate allowing constructive feedback. The overall interpretation of the findings was that the direct observation method was perceived positively among HCPs. On the other hand, they were dissatisfied with the lack of feedback from management, observers, and from each other. The observers pointed out that they needed the support of management and the DCDC. Management must hold HCPs accountable and give the observers a mandate. A lack of support to observers can reduce the effectiveness of interdisciplinary communication and collaboration [
33], resulting in poor compliance among the most experienced HCPs in vascular surgery patient care. Supporting HCPs generally benefits patient outcomes and may thus also reduce SSIs. Therefore, we suggest that observers be given greater support, including a clear mandate and higher status. The findings of the present study confirm those of Reeves et al., that confused roles, effects of professional socialization, and power and status differentials hinder interprofessional collaboration [
34].
Hierarchy was identified as a major problem, particularly differences in status between assistant nurses and physicians. A hierarchical structure is a major obstacle to cooperation, which may lead to poor compliance and thus jeopardize patient safety. To improve the situation, it is necessary to address the current hierarchical professional structure inherent in the healthcare system [
33]
. Lancaster et al. concluded that,
“A hospital patient care model based on the conductor-less orchestra model would mitigate hierarchy; recognize physician, nurse, and unlicensed assistive personnel’s contributions to care; promote improved communication and collaboration; and enhance patient safety.” [
33].
The differences in compliance between the various categories of HCPs were related to the position they held. Vascular surgeons were not included in hygiene instruction, possibly because it was assumed that this was not necessary. However, they could also benefit from such training. Physicians not only exhibited poor compliance, but they also sometimes expressed erroneous beliefs. This finding is in line with that of a hand hygiene compliance study, in which it was found that nurses’ compliance in hand hygiene was better than that of physicians [
35]. Similarly, Erasmus et al. found that nurses’ compliance was higher than that of doctors and other healthcare workers in 25 of 44 studies on the association between profession and hand hygiene compliance [
36]. Continuous training and the improvement of professional skills among the medical staff regarding hospital hygiene are necessary to reduce HAIs, mainly SSIs.
The HCPs at the operations theatre demonstrated a high level of compliance as a result of their open climate with less hierarchy, better teamwork and the use of checklists. However, they highlighted the poor compliance of the anaesthesiology team. The use of checklists in the operating theatre could have mediated a HE , leading to better compliance. They perceived and experienced that the checklist improved their behaviour and adherence to hygiene precautions, when being observed. Haynes et al. found that the use of a checklist led to changes in both systems and in the behaviour of individual surgical teams. They also found that the implementation of the checklist was associated with concomitant reductions in the rates of death and complications and that the overall rates of SSI and unscheduled reoperation also declined significantly [
37].
The participants in this study voiced their concern regarding contamination by mobile phones. Numerous studies have mentioned possible bacterial contamination from mobile phones, although there is no evidence of a direct association between the environmental pathogens on mobile phones and the rate of HAIs [
38]. Further studies are needed to clarify the question of whether the use of mobile phones by HCPs constitutes a risk to the patient.
The attitude to introducing new HCPs was positive. However, this was negatively affected by external factors such as high workload and lack of time among the staff. In agreement with Knoll et al. [
39], we found that the compliance of HCPs could be significantly negatively affected by external factors such as high workloads (especially in connection with a lack of human resources), which HCPs perceived as disturbing and stressful. Therefore, improving the working environment could lead to better adherence to standard precautions.
The ongoing INVIPS Trial was found to be an external factor that increased awareness among staff and should thus lead to higher compliance with hygiene routines and adherence to standard precautions. The trial has alerted staff to the high postoperative infection frequency at the study centre and made them aware of the importance of hygiene, especially in postoperative wound care. This increased awareness could mediate a HE, but to different degrees among HCPs. The HE would probably have been lower among vascular surgeons and staff with long experience [
40].
We would like to emphasize the importance of including ESS, and their role in the hospital’s environmental high-touch surface cleaning, which is an important component of a multifaceted infection control strategy to prevent HAIs [
41]. The written answers given by the ESS revealed that there was a lack of communication concerning the status of inpatients, particularly those who had recently undergone surgery, which may influence the risk of contamination. Yanke et al. [
42] stated that the ESS may represent an underappreciated resource for hospital infection prevention, and further efforts should be made to engage ESS as members of the health care team. Further efforts should be made to engage these “invisible staff” as part of the healthcare team and culture of infection prevention [
42].
The present study implies that improved basic preventive measures have a central role in reducing bacterial transmission and development of SSI. Indeed, in a recent randomized trial, Loftus et al. [
43] found that improved basic perioperative preventive measures reduced transmission and SSI by
Staphylococcus aureus, perhaps the most common pathogen in the hospital setting. The successful seven-component bundle of care in the perioperative setting included efforts in hand hygiene, vascular access care environmental cleaning, organization of the anaesthesia work area quarterly feedback, targeted ultraviolet C light therapy (Helios) in operating environments that had been exposed to
Staphylococcus aureus and for patient decolonization [
43].
Practical implications
1.
Easy access to hygiene routines, hygiene education for all HCPs regardless of role. Information, feedback, and results. The hospital has now started to use an electronic tablet providing easy access to these routines and information via direct links.
2.
All HCPs shall be required to follow the hospital’s SHPs. This means filling in self-assessment protocols, and not following personal hygiene routines.
3.
Multidisciplinary buy-in is essential to changing the culture of acceptance of feedback from any observer to any HCP.
4.
Anaesthesiologists and ESS should be included in the observation process.
5.
The implementation of checklists for the various tasks involved in patient care.
Conclusions
All the staff participating in this study considered that observations of how well hygiene routines are followed are important. To ensure better adherence to standard precautions, the observers must have better backup from managers and the DCDC. It is necessary to establish systematic professional training and education of HCPs concerning hygiene, and to continuously monitor and evaluate the level of compliance in clinical practice, particularly in vascular surgery. Compliance among HCPs can also be improved by regular training and feedback, improving communication, interprofessional educations, and training opportunities can be a way to break down the hierarchical structures and communication. ESS should be included in the observation process and communication with them should be improved. Good compliance was mediated through the HE in most of the HCPs, nevertheless, physicians and highly experienced staff were less frequently influenced by the HE. High levels of adherence to standard precautions by all HCPs could reduce the SSI rate after open vascular surgery in the lower extremities.
Areas for improvement and limitations of the study
The lack of an open friendly climate that allowed everyone to mention mistakes, occasional insufficient seniority of the observer and lack of support from management were identified areas for improvement in order to legitimate the observers mandate and need for change in cultural behaviour. The researcher, a vascular surgeon, noted that the observers rarely observed surgeons while they washed and sterilized their hands before surgery. Therefore, the surgeon’s behaviour and attitude towards this was not monitored. The ESS does not make observations in the present study centre, and they have therefore not any possibility of expressing their opinions to the DCDC. It is acknowledged that their input in the interviews would have been valuable, but they declined to participate, which is a limitation of the study. Higher external validity of the findings would have been achieved in a multicentre qualitative study.
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