The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians’ perceptions of professional and cultural factors that influence doctors’ attitudes and practices in a large Australian hospital

Abstract

Background Hospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers’ adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors’ behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors’ IPC practices will contribute to development of new strategies to improve IPC, overall. Methods This qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors’ IPC practices, using thematic analysis of data. Results Professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors’ responsibilities for preventing them; and lack of clarity about senior consultants’ obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors’ own assessment of patients’ infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised. Conclusions Failure of healthcare and professional organisations to address doctors’ poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.

Enablers of, and barriers to, optimal glove and mask use for routine care in the emergency department: an ethnographic study of Australian clinicians

“…In an ED where there are numerous 'leaders', different role models and aberrant behaviour can impact negatively on the IPC culture of the department. Participants identified a lack of positive role modelling and leadership which has been shown elsewhere to influence individual behaviour towards PPE [26,47,48]. In contrast to our findings, a recent qualitative study that utilised focus groups with nurses and assistants, reported a positive peer culture for encouraging respirator mask use [49].…”

“…One barrier to optimal mask use demonstrated in our research was the strong personal belief about PPE use of some senior medical staff, which overrode IPC policy. This is reflective of a recent study which found that the clinical autonomy of doctors was a significant factor in their IPC practice [47]. In an ED where there are numerous 'leaders', different role models and aberrant behaviour can impact negatively on the IPC culture of the department.…”

Medical interns’ reflections on their training in use of personal protective equipment.

“…Organisations also have a responsibility to ensure that senior medical staff ful l their accepted professional responsibility to model appropriate clinical practice, including correct PPE use (41). Nevertheless, we suggest that enabling re exivity-in-practice, using methods such as video-re exive ethnography, may not only identify these issues, but also allow clinicians to devise creative and sustainable strategies to address them, as they have previously in similar acute care settings (34,42).…”

Are Australian medical interns adequately prepared for the optimal use of personal protective equipment?

“…For instance, ensuring that appropriate PPE stocks are available, providing physical locations for staff to place items for temporary safekeeping, encouraging use of fob (rather than wrist-) watches for use in clinical assessment. Organisations also have a responsibility to ensure that senior medical staff ful l their accepted professional responsibility to be role models of appropriate clinical practice, including correct PPE use (35).…”