In recent years, the quality of care of people in institutional settings in the NHS has come under scrutiny following a number of high profile cases. HCAIs, largely preventable adverse events defined as an infection acquired as a consequence of a person’s treatment by a healthcare provider [
1], are a global patient safety problem [
2]. Over the past decade, literature continues to conclude that HCAIs are frequent, catastrophic and costly [
3‐
7].
In recent times, there have been high profile successes in IPC, such as the dramatic reductions in MRSA bloodstream infections (which is viewed as one proxy indicator of overall harm) and
Clostridium difficile in the UK [
8‐
11]. However, HCAIs continue to occur and present a risk to patients and users of healthcare. In September 2013, the UK government published their five year strategy for tackling antimicrobial resistance [
12]. In Wales, the first Welsh Government Delivery Plan specifically relating to antimicrobial resistance was produced in March, 2016 [
13]. The plan included seven delivery themes. The first theme focusses on improving IPC practice. In 2014, the Welsh Government followed up the 2011 framework of actions towards the elimination of HCAIs with a Code of Practice for the prevention and control of HCAIs [
14,
15]. The Code of Practice set out the minimum necessary IPC arrangements for healthcare providers in Wales. Theme one of the new Antimicrobial Resistance Delivery Plan focuses on ensuring the full implementation of this Code of Practice and compliance of other existing policies. Specific priorities address the management of patients with carbapenem resistant infections. HCAIs have thus become a major patient safety issue in the NHS.
Patient safety has been defined as ‘the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare’ [
16], and attention has largely focused on the epidemiology and prevention of adverse events. More recently, thought has been given to understanding the shared attitudes, beliefs, values and assumptions that underlie peoples’ actions in regard to issues of safety; and of the potential importance of these shared characteristics in initiating sustained changes within patient safety [
17‐
19]. Within the literature, these shared characteristics are often referred to as the ‘safety culture’ of an organisation [
20].
Project description
This study will look at the relationship between IPC and patient safety culture within the context of isolation, within surgical, medical and admission hospital settings. For the purposes of this research, we are interested in examining the ways in which health workers engage, or otherwise, with IPC strategies and principles, and in turn, explore what this means for organisational patient safety culture.
Our primary research question is:
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➢ In what ways, if any, does health workers’ levels of engagement, for example, compliance with and adherence to, IPC strategies and principles, shape and inform organisational patient safety culture within isolation in surgical, medical and admission hospital settings; and vice-versa?
In view of the challenges involved in implementing ‘top-down’ IPC initiatives [
21‐
24], contemporary thought has turned to notions that IPC should be the responsibility of all healthcare workers and the concept of frontline staff adopting ‘ownership’ is stressed in international guidelines [
25‐
27]. For Zimmerman [
28], ownership involves health workers’ identifying IPC problems within their own clinical areas, implementing solutions and drawing on the expertise of IPC practitioners, as necessary. Zimmerman studied five Canadian hospitals and identified effective communication between frontline health workers, IPC specialists and managers; encouragement of staff to share ideas and promote good practice; innovative interventions meeting localised needs and a climate of learning from mistakes thus enabling continuously improved performance; as being crucial to ownership. For Zimmerman [
28], the realisation of ownership involved frontline staff receiving and responding to local metrics, while remaining constantly mindful of IPC and engaging in change.
Hospital isolation involves the physical separation of patients with infections (or suspected of infections) to interrupt the transmission of potential pathogens between other patients, staff and visitors; and has historically been used to control and prevent the spread of infectious diseases. In the UK, there has been a move towards isolation in single rooms on general wards, rather than more dedicated isolation wards [
29]. Infections spread by airborne, droplet or contact categories, placing the patient in single room isolation is considered an important element of transmission based precautions (TBPs) [
30‐
33]. TBPs are recommended when infectious agents are present or suspected, and where standard precautions alone would not prevent the spread of infectious diseases and pathogens such as MRSA,
Clostridium difficile and Norovirus. These precautions involve patient placement, the use of personal protective equipment (PPE) (For example: gloves, gowns, masks and eye protection), hand hygiene, the decontamination of equipment and of the environment, and the appropriate management of linen and waste. The barrier of a single room is a further reminder to the healthcare worker of the necessary procedures involved in the practice of isolation [
34,
35]. Even while there is much debate regarding the effectiveness of isolation precautions [
36,
37], the practice is grounded on a sound theoretical rationale and is broadly accepted.
There are a number of challenges involved in implementing isolation practice and broader IPC precautions. Healthcare workers, in addition to patients and visitors, need to conform to strict protocols without compromising patient safety. Isolation or other forms of constraints have serious impact upon a patients’ health, welfare and liberty, and patients’ perspectives of isolation suggest that the imposed environment and isolation procedures, provide barriers to physical, sensory and psychosocial needs that impact adversely on the unseen burden of illness [
38‐
43].
Healthcare can be understood as a complex adaptive system. Drawing on the work of Zimmerman [
28], this qualitative study will explore the ways in which, if at all, the notion of ‘ownership’ is being played out on the ground and the ways in which this shapes and informs patient safety culture. In doing so, we will be mindful of interlinked tensions that may exist, such as: The challenge of coupling together the contributions of evidence based medicine and practice based evidence, as well as the critical role of distributed, problem focused leadership.
Aims and objectives
This study seeks to provide new evidence on the relationship between patient safety culture and health workers’ engagement with IPC principles and strategies within isolation healthcare settings, from the perspective of people working in healthcare and from those placed in isolation.
The objectives of the study are:
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➢ To determine the feasibility of identifying good quality and poor quality IPC strategies and principles within isolation in two DGH settings within Wales.
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➢ To identify and examine organisational factors that promote good quality and poor quality IPC principles and strategies within isolation settings, and relate these to patient safety culture.
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➢ Identify and understand the ways in which IPC principles and strategies shape and inform patient safety culture within isolation healthcare settings, and vice-versa.
Our research questions are:
-
➢ What does organisational patient safety culture look like within isolation healthcare settings at two DGHs, within Wales?
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➢ In what ways does organisational patient safety culture impact on health workers’ engagement with IPC principles and strategies in isolation healthcare settings?
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➢ In what ways do health workers in isolation healthcare settings understand the meaning of IPC ownership?
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➢ In what ways do health workers, patients and relative / informal carers in isolation healthcare settings understand the meaning of patient safety culture?
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➢ What do hospital staff, patients and relative / informal carers in isolation healthcare settings understand by good quality and poor quality patient safety initiatives and practices?