Infection prevention and control (IPC) in hospitals is essential at the best of times, but especially so in a time of Covid. From my previous experience as a Board Director responsible for Infection Control in hospitals, I understand the challenges facing staff in maintaining high IPC standards. In 2003, I was involved in a national initiative to reduce the incidence of hospital acquired Methicillin Resistant Staphylococcus Auereus, (MRSA) bacteraemias, because 9% of hospital inpatients had infections acquired whilst in hospital,[1] equating to100,000 incidents a year, costing the National Health Service (NHS) around £1 billion (N.A.O. 2000)[2]. The term ‘hospital acquired infection’ sits uncomfortably with me, given Florence Nightingales’ founding values that hospitals should ‘do the sick no harm.’ A significant causal factor in their spread cited was the poor hand hygiene of the health professionals when caring for patients. Thankfully, progress has been made in recent years, with the hospital I refer to in this blog meeting their target of zero cases of avoidable MRSA in the last year. But what I have noticed amidst the intense discussions we have been having of late with regard to stopping the spread of Covid, is how similar problems are re-surfacing to those we faced when reducing the spread of MRSA, most notably with regard to compliance with ‘best practice’ as set out in our IPC policies and procedures. I share the following narrative to help think about why implementing corporate values such as ‘patient safety’, or ‘doing no harm’ might not be so easy as people seem to think.
In pursuit of good infection prevention
I recently attended a meeting with hospital staff.[3] We had just one topic on the agenda, giving us a welcome chance to share stories about the ‘challenges’ of ensuring good infection prevention and control in their everyday work. Despite the best efforts of those present, the organisational audits to check that staff were fully compliant with their IPC policies did not meet the target of 100%. The results varied from month to month, but on looking at the data, it felt a bit like a ‘whack-a-mole,’ as they ‘fixed’ non-compliance in one place, or with specific staff, other issues cropped up elsewhere. Discussions started amicably. It was quickly agreed that they all needed to work together across all professional disciplines to ‘change the organisational culture’ to ensure staff complied with our IPC policies.
The conversation moved on to identify specific wards and professional groups that were dragging down their overall audit scores, specifically with regard to their non-compliance with their staff uniform and hand washing policies. The tone of the conversation shifted a little, from the earlier collaborative quality, to one that felt a bit more tetchy. One professional group (who for anonymity I will call the ‘Red’ staff), hesitantly pointed out that although they scored 100%, the ‘Yellow’ staff didn’t always wear their uniform correctly or wash their hands properly, pulling down the audit scores for everyone. I wondered if the apparent hesitancy in the way the Reds raised their concern was a familiar pattern in the way the two groups worked together. Although the Yellows in the meeting were significantly out-numbered by the Reds, a Yellow representative put up a lively defence, questioning the validity of the audit tool and whether the fact the auditors were all Reds might have influenced the results. The Yellows contended that their own audit of fellow Yellows hand-washing compliance had shown they had met the standards.
Discussion then turned to the need to adapt the audit tool and validate the auditing process to ensure intra-observer reliability and give greater confidence in the results. Some Reds said that they felt Yellows sometimes acted with impunity with regards to following IPC policies and procedures, ‘getting away’ with things for which a Red would be ‘shown the door.’ One Red said they’d asked a Yellow to take off their jewellery, but the Yellow refused, with no sanctions seemingly applied. ‘They even won a prize a month later!’ remarked one, with evident frustration.
That remark led to a discussion on how best to change the organisational culture by targeting non-compliant individuals. What about a ‘stick and carrot’ approach? Could the Infection Control Expert (ICE; a ‘Red’), pull together the latest research evidence on hand-washing ‘best practice’ and run education sessions for all staff on what they should do? The ICE was quick to respond. ‘I’ve been all the way back to Semmelweis[4], collected every scrap of evidence, bribed people to come to teaching sessions with free sandwiches, taught hand washing techniques using light-boxes. I even e-mailed round the procedures and protocols to ‘All’ and asked them to get back to me with any queries… and NEVER had a single reply!’ His evident frustration was met with (uncomfortable?) laughter. It was agreed that it didn’t help that the ‘evidence base’ was often open to contestation, depending on which research studies one looked at.
They then turned to the ‘stick’ approach, agreeing strong leadership was essential to uphold the rules. Everyone agreed challenging poor practice was important, that was why it was mentioned in their IPC action plans. Training had even been offered on conflict management. Perhaps the managers weren’t being challenging enough? Someone suggested the Red IPC Expert could maybe help with this task. The ICE reminded them about the incident with the jewellery, speaking movingly about how even he found challenging poor practice difficult sometimes. Staff could be defensive and rude, or question the ‘evidence base’ on things like the ‘bare below the elbow[5]’ policy. When he’d reported such behaviour, he’d not always felt appropriate actions were taken, nor had the individual changed their practice. The problem with feedback was that people didn’t always see it as the ‘gift’ as described in their conflict training. Maybe those being challenged also needed the conflict training to help them respond more appropriately?
We discussed why staff less experienced than the ICE who’d observed such altercations might decide not to take the risk of challenging their colleagues. ‘Especially if they are a Red challenging a Yellow,’ joked one. At which point a Yellow pointed our some Reds were pretty scary too, to more laughter. Someone suggested that maybe the Yellows needed their own ICE, a ’Champion,’ as they would be more likely comply if challenged by a peer, (or even better, a senior Yellow). It was agreed this could be explored. But in the meantime, the Yellow Director (YD) was asked to instruct the errant Yellows to comply. Y. D. confirmed she’d be happy to send an e-mail to ‘All’ to that effect, but noted that a similar instruction she’d sent recently seeking the Yellows compliance with another IPC policy had not yet yielded the desired change in their practice. That prompted suggestions from those present of the need for bigger sticks. What about disciplinary warnings? Or fining the whole department so that their colleagues put pressure on them to achieve compliance? Naming and Shaming?
Those suggestions appealed to some more than others, with the meeting concluding by identifying the need for better communication. Perhaps the Comms’ department could help develop a communications strategy to spread the message? What staff needed were clear instructions, simply stated, clarifying how and when everyone should wash their hands, and the evidence as to why. Like ‘Hands, Face, Space?’ said someone, quoting the slogan used by the UK government control the spread of Covid.
I imagine that those of you reading this post might be experiencing a range of responses when reading the above. From my experience of discussions in a similar vein over four decades,[6] I expect those working in hospitals may have experienced similar conversations, with some rooting for the Reds and others the Yellows, dependent on their own group affiliations. Those less familiar with hospital culture might tend to wonder why we don’t all just get on with it, just ‘do the right thing?’ Or that the leaders should just tell staff to follow the rules.
But that ‘you mean like ‘Hands, Face, and Space?’ remark got me thinking about how our local patterns of conversational themes on how best to keep us safe in a time Covid, mirrored those I saw back on the MRSA initiative, and again now playing out at regional, national and international levels, namely:
A call to follow ‘the science’ along with a belief that people will be persuaded by the rational arguments of what is best and do as they are told.
Seeing the solution to the problem as vested in individuals: both in the leaders and the non compliant.
Questioning the measurement tools. Are they measuring the right things? Are we counting them properly? Are the results biased? Do certain groups quote the statistics which suit their particular point of view?
A belief leaders can/ should identify ‘simple rules’ based on ‘the science’ to tell people what to do.
Educate people, in order to change individual attitudes and cultures, to those consistent with the espoused core values and beliefs.
More ‘policeman’ (be they Czars; Directors or Matrons, or literally the police) to ‘enforce’ the rules.
Developing sanctions, (fines or warnings and public shaming) of those who refuse to comply.
In my experience, all of the above can help serve a useful purpose when tackling infection control and prevention and I felt privileged to be having such a mature discussion on the IPC issue with the hospital staff. I could well appreciate why 97% of their inpatients confirmed in a recent survey that they would recommend the hospital to friends and family. I do the same.
More to do?
But my experience is also that these activities are insufficient for changing and/or sustaining social values and norms. They don't address, for example, why when well-meaning people attempt to collaborate on making things better, it is not always so easy. What patterns of behaviour tend to emerge when we ‘challenge’ each other about what we could and should be doing? Why do we find ourselves making and breaking rules of social conduct? Why is so little attention paid to the role of the ‘bystanders’ to the kind of conflicts described in the narrative, and how what they do (or don’t do) might also contribute to the emerging cultural norms?
Notes
[1] Weaving, P. Cooper, T. Infection Control is everyone’s business Nursing Management. Vol 12 No 10 March 2006.
[2] National Audit Office (2000) The Management and Control of Hospital Acquired Infections in NHS Trusts in England, The Stationary Office, London.
[3] For reasons of anonymity, I have changed some of the identifying details. This is my personal account of the meeting, but those present have seen this narrative and have confirmed they agree it is a fair account. I am grateful for their kind consent for its publication.
[4] Despite evidence that hand washing reduced mortality, Semmelweis’s (1818-1865) observations conflicted with the scientific opinions of the time and his ideas were rejected by the medical community as he could offer no acceptable scientific explanation for his findings. Some colleagues were offended at the suggestion that they should wash their hands and mocked him for it. He is reported to have suffered a breakdown and committed to an asylum. Semmelweis’s practice earned widespread acceptance only years after his death, when Pasteur confirmed the germ theory, and Joseph Lister, acting on the French microbiologist’s research, practised and operated using hygienic methods, with great success.
[6] Norman K. A uniform experience? Reflections on implementing rules into practice. International Journal of Leadership in Public Health Services 2012; 8(4): 191–201.
Suggested further reading
Feffer, Andrew. “Sociability and Social Conflict in George Herbert Mead’s Interactionism, 1900-1919.” Journal of the History of Ideas 51, no. 2 (1990): 233-54.
https://www.jstor.org/stable/2709514 Accessed: 14-11-2020
Note: This blog post was originally posted as "Exploring the complexity of conflict in organising in the time of Covid: washing our hands of a problem?" on complexityandmanagement.com
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