What is needed to sustain improvements in hospital practices post-COVID-19? a qualitative study of interprofessional dissonance in hospital infection prevention and control

The basic principles of hospital infection prevention and control (IPC) – including hand hygiene, sanitation and environmental hygiene, fresh air and appropriate use of personal protective equipment—were established and gradually adopted into practice in the nineteenth century. In the twenty-first century, standard and transmission-based precautions are accepted as routine health care practices, designed to minimise rates of preventable healthcare associated infection (HAI) and transmission of antimicrobial resistance (AMR) [1‐3]. Despite this, HAIs continue to challenge health services and compromise patient outcomes [4]. A recent modelling study estimated that, in 2016/17, HAIs affected ~ 5% of adult inpatients and ~ 2% of frontline healthcare workers (HCWs) in National Health Service (NHS) hospitals in England. They resulted in the deaths of ~ 28,500 patients. The estimated cost to the NHS, of the associated loss of 7.1 million occupied bed days (21% of the total) and 79,700 days’ absenteeism among frontline HCWs, was £2.7 billion [5]. A systematic review and metanalysis, of interventions designed to reduce the rates of selected HAIs, indicated that 35–55% of serious HAIs would be preventable if accepted IPC measures were applied consistently [6]. However, other studies have found that optimal IPC practices often fail because of, inter alia, organisational, systemic and behavioural factors [7, 8].

HAI and AMR transmission rates are poorly monitored in Australia [9] and often underestimated, but exotic or emerging infectious diseases (EIDs) that threaten the health or lives of HCWs are hard to ignore. A series of twenty-first century EIDs, including SARS, MERS, and Ebola virus disease (EVD), [10‐12] focused attention on hospital IPC and changed HCW behaviour, albeit in relatively few countries and/or temporarily [13, 14]. The effects on hospital patients and HCWs, of COVID-19, have been global [15] and will be prolonged; but they vary, even allowing for differences in community transmission and incomplete data [16]. In many countries, inadequate health system preparedness and shortages of personal protective equipment (PPE) have been blamed for the high burden of HCW deaths [14, 17, 18]. In other countries’ nosocomial HCW infections have been largely prevented by pre-emptive escalation and consistent application of IPC measures, despite high levels of exposure to COVID-19 [19‐21].

Now that many countries in the developed world are considering a post-COVID-19 future, protected by widespread immunisation, there is some urgency to ensure that the lessons are consolidated. A comparison of pre-COVID-19 IPC practices—and the professional values and organisational policies that influenced them—with those introduced during the pandemic, will help to inform decisions about which can be relaxed when the immediate danger wanes, and which should become business-as-usual, to ensure that healthcare sector is not caught unawares by the next pandemic.

IPC practices are influenced by, inter alia, historical, professional, and cultural factors that had their origins in the nineteenth century. By mid-century medical science had progressed to a point where doctors could, significantly, improve patient outcomes; but more complex medical and surgical remedies needed skilled nurses, to support them [22]. Initially nurses were trained and supervised by doctors but, as more educated middle-class women became nurses, they demanded more professional independence and recognition. Relations between the powerful medical establishment and the emerging nursing profession, were characterised by conflict over roles and status, complicated by gender, class, religion, politics, and educational differences [23].

The promise of medical and surgical advances was limited by appalling hospital mortality rates due to infection, until improvements in hospital hygiene and design – often driven by nurses—were gradually implemented, and rates began to fall towards the end of the nineteenth century. Vaccines and antibiotics contributed to further improvement in the early twentieth century, but increasing antibiotic resistance and a dwindling supply of new agents, provided the impetus for revival of hospital IPC programmes in the 1960s-70 s [24, 25]. IPC is now established in hospital practice, supported by a growing body of robust evidence, [26, 27] but there are wide variations in resources and effectiveness [28‐30]. Antibiotics are no longer a reliable panacea, [31] and hospitals are still subject to regular outbreaks of viral infection, [32] which now include COVID-19 [15, 33].

As a group, doctors are, generally, less observant of accepted IPC practices than other health professionals [8, 34‐37]. In Australia, this is reflected in rates of compliance with the ‘5 moments of hand hygiene’, the only IPC practice that is systematically monitored in public hospitals. Doctors’ compliance has been consistently 10–15% lower than that of nurses since national reporting began in 2009 [38].

In this paper, we describe the results of a qualitative study, conducted before the start of the COVID-19 pandemic in a large tertiary hospital, in which we sought the views of senior clinicians about the professional and cultural factors that influence doctors’ attitudes to, and practice of IPC, whether they differed from those of nurses and, if so, how this affected interprofessional relationships. We focused on doctors, primarily, because we believe that their status in the hospital means that they disproportionately influence organisational culture, priorities and, indirectly, IPC practices. Based on the results, we propose strategies that may improve interprofessional co-operation and, thereby, sustain COVID-19 driven improvements in IPC.

This was a qualitative case study of a large (~ 950-bed) university teaching hospital in Sydney, Australia, which provides a full range of specialist services to more than 90,000 inpatients, annually. The aim was to provide a detailed understanding of aspects of IPC at a single site, without the potential confounding effects of different policies, patient populations and physical environments.

 Our initial analysis identified four broad-brush themes (Table 3). Theme 1 has been described previously [40]. Within Theme 2, we identified four subthemes, which are subject of this paper. Table 4 shows representative quotes, illustrating subthemes.

Participants’ accounts of doctors’ and nurses’ attitudes to IPC and perceptions of each other, support the view of Irvine et al., that “Interprofessional relationships … are frequently distorted by mutual suspicion, hostility and disparities between the way that a particular profession views itself and how it is viewed by other occupations.” [42]. They reflect the persistent influence of professional stereotypes, on interprofessional interactions. Medical and nursing stereotypes, as depicted by participants of both professions, were highly stylised and unflattering. Doctors are focused on diagnosis and “cure”; they prioritise clinical autonomy and object to rules or advice from other professionals that might challenge their decisions; they are ambitious and competitive in pursuit of career goals; they support each other and ignore or seek to dominate other healthcare professionals. Nurses are driven by rules, which they implement rigidly, without concern for evidence or possible inconvenience to doctors; they are motivated by fear of the nursing hierarchy, as well as being “bossy” and vindictive. Nurses know better than doctors, what is best for patients, because they spend more time with them.

Participants acknowledged wide variation in interprofessional interactions, depending on context, unit/specialty culture and personalities. Nevertheless, repeated references to professional stereotypes suggest that the “doctor-nurse game” is still current, albeit in modified form [41, 43]. According to Stein “…nurses were to make recommendations, but their recommendations had to appear to be initiated by the doctor.” In 1990, he suggested the “game” had all but ceased because of changes in professional education, roles and gender ratios [43]. However, persistence of this “dance of deference” has been recently implicated in communication failures, blame-shifting and mutual mistrust, causing harm to patients [44‐46]. Our findings suggest that the ‘rules of the game’ mean that a nurse, who seeks to remind a doctor about an IPC breach, must balance the likelihood of success (the doctor’s compliance) vs failure (being ignored or humiliated) and act accordingly.

Compared with other threats to patient safety, such as medication error or wrong-site surgery, an IPC breach may seem a low risk, albeit with potentially high consequences. Because of the low risk/high stakes nature of IPC breaches it is sometimes argued that evidence-based “rules”, should be enforced, using the logic applied to aviation safety [47]. Against this, it is argued that medical practice is too varied and unpredictable to be driven by rules, and idiosyncratic IPC practices are excused on the basis that each patient encounter is unique. However, doctors—unlike airline pilots—often discount risks to ‘customers’ and rarely perceive a personal risk of harm or censure if rules are breached [40]. Moreover, many are unwilling to “abandon historical and cultural precedents and beliefs that are linked to performance and autonomy” [48]. However, preventing serious HAIs requires consistent application of standard precautions. This does not imply either mindless compliance with inflexible rules (nurse stereotype) or a ‘doctor knows best’, laissez-faire approach (medical stereotype) to IPC. Rules should be appropriately and safely modified, according to context and with agreement of relevant stakeholders, but doctors – or anyone—flouting them, without explanation, causes confusion and conflict, which inevitably detracts from patient care.

In 2020 – and not for the first time—the low risk/high stakes IPC balance changed. The fact that failure to isolate an infectious patient or use appropriate PPE can initiate a devastating hospital outbreak, affecting HCWs as well as patients, was demonstrated during previous coronavirus outbreaks [49, 50] and has gained even greater salience during the current pandemic [51]. A lack of confidence and consistency in routine and outbreak-level IPC practice [52, 53] among some HCWs exacerbates the fear associated with a novel threat, even if – like EVD in 2015 – it fails to eventuate [54, 55]. During the current pandemic, high rates of HCW infection and deaths, globally, and perceived deficiencies in health authorities’ preparedness and responses, have engendered distrust [56, 57]. HCWs, especially doctors, have demanded greater safeguards than recommended by international and local experts, based on the precautionary principle [58]. Like other aspects of patient safety, IPC is “not simply a technical issue, but a site of organizational and professional politics” [59].

There are still many aspects of COVID-19 and its control that remain uncertain, but it has undoubtedly raised awareness of IPC among frontline HCWs, hospital administrators and the public. This provides an opportunity for long-term improvements based on lessons learnt, if the tendency to revert to old habits, as the risks fade, can be resisted. Aiming for universal consensus in all aspects of IPC, especially during an emergency, may be unrealistic, but the pandemic has highlighted the dangers of confusion, inconsistency, and lack of trust. Nevertheless, different beliefs about risk, what counts as safe practice and who should decide, militated against HCWs speaking up to a colleague about a potential IPC breach, in the past, especially if they feared a hostile or dismissive response [60‐62]. The fact that their fear was justified was reflected in language used by participants to describe what they saw as some doctors’ petty or aggressive behaviour [40]. However, the use of ‘spotters’ to monitor use of PPE and other IPC practices, during the COVID-19 pandemic, has been well-received by HCWs and effective in increasing compliance and reducing HCW infections [63].

Under most circumstances, IPC policies involve simple practices, requiring no special skills or training but with proven effectiveness in reducing rates of preventable HAIs [27]. So, it is unreasonable for doctors (or anyone) to claim ignorance or object to being reminded if they fail to observe them even when they perceive no personal risk of infection. There may be valid reasons for disagreement with how policies are deployed, but the patient’s bedside is not the place, and a ward nurse not the person, to resolve them. Will new-found respect for IPC policies and those who seek to implement them persist beyond COVID-19 or will old interprofessional behaviour patterns return?

This study has identified three major perceived interprofessional influences on doctors’ IPC attitudes and behaviours and potential barriers to change:

Despite different origins, cultures and models of practice, the medical and nursing professions are mutually dependent. Optimal HAI prevention depends on interprofessional collaboration, which is often elusive but critical to patient safety. We argue that it would be enhanced by adherence to basic ethical principles. In the face of ongoing barriers to collaboration, Irvine, et al.proposed a dialogical approach to inter-specialty ethics – an ‘extended collegiality’ [64]. Based on this concept, Clarke et al.proposed a conceptual framework incorporating (i) principles of behaviour; (ii) organisational structures; and (iii) processes to support ethical practices [65]. This framework would provide a suitable ethical basis for interprofessional interactions in the context of hospital IPC: