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.
Researchers’ backgrounds and relationship to participants
Both researchers are senior physicians with a special interest in hospital IPC, based on longstanding experience of caring for patients, who have suffered from preventable HAIs and/or the uncertainty and fear associated with becoming colonised by a multidrug-resistant organism. We were employed, before and/or during this study, at the hospital where it was conducted, as staff specialists in infectious diseases/clinical microbiology (GLG) or haematology/bone marrow transplantation (IK) and known to most participants but, with few exceptions, had not worked closely with them.
Participant selection
Participants were senior medical (N=16) and nursing (N=10) clinicians and/or managers or directors, with 10-40 years’ experience (summarised in Table 1). They were purposively selected, as most likely to have a broad perspective of hospital doctors’ attitudes and practices and to be willing to express their views openly to a senior colleague. Our decision was confirmed by the Human Research Ethics Committee (HREC) who expressed concern that junior clinicians may be unwilling to speak frankly to a senior consultant as interviewer. Medical participants were full-time senior staff specialists [SS] or visiting medical officers (VMOs), contracted on a sessional basis, nurses were all full-time hospital employees in leadership positions.
Table 1. Characteristics of participants
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Doctors1 (N=16)
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Nurses (N=10)
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Gender M: F
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10:6
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3:7
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Role
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Senior executive/
divisional director (MDD)
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6
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Divisional director/deputy,
or facility manager (NDD)
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6
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Medical unit/departmental
director (MUD)
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4
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Nursing unit manager (NUM)
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2
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Senior medical consultant (SMC)
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6
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Clinical nurse consultant (CNC)
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2
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Specialty
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Medical 6, surgical 4, other 62
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16
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Medical 5, surgical 3, other 23
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10
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Notes:
- Staff specialists (SS), 11, visiting medical officers (VMO). 5.
- Other doctors’ specialties: intensive care, 2, emergency medicine, 2, anesthetics,1, obstetrics/gynecology, 1.
- Other nurses’ specialties: intensive care, 1, infection prevention and control, 1.
Data collection
Semi-structured interviews were guided by a small number of open-ended questions (Table 2). Participants were not specifically asked for their views of nurses’ IPC practices or how they differed from those of doctors, initially, but many offered opinions, spontaneously. Interviews were recorded and transcribed by a professional transcription service, with participants’ informed consent.
Table 2. Interview topics/questions used to prompt discussion with participants
1 To what extent do doctors, generally, regard healthcare associated infections as a significant problem in this hospital? Could some/most HAIs be prevented? How?
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2 The literature suggests that doctors generally comply less consistently than nurses with infection prevention and control (IPC) measures. Is this consistent with your experience? Why is it so? Does it adversely affect patient care?
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3. What changes, if any, would you make in hospital IPC policies to make them more acceptable to doctors, increase adherence and reduce risks to patients?
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Data analysis
Transcripts were reviewed and coded independently by both authors, using a reflexive thematic analysis approach (37). We chose this approach on the assumption that our experience at the study hospital, knowledge of its culture and history and personal acquaintance with participants would inevitably influence our interpretation of data and therefore require us to continuously review and question our findings.
We identified broad-brush themes, inductively, based on patterns of meaning. As codes were added, subthemes were developed and analysed, iteratively, in relation to research aims and interpreted in the context of our own experiences as senior clinicians. We also noted participants’ rhetorical styles that reflected emotional responses to these issues.
In reporting our findings, we designated participants’ professions and roles broadly, to preserve anonymity, as: nursing divisional director (NDD), nursing unit manager (NUM), clinical nurse consultant (CNC), medical divisional director (MDD), medical unit director (MUD), senior medical consultant (SMC).
FINDINGS
Our initial analysis identified four broad-brush themes (Table 3). Theme 1 has been described previously.(38) Within Theme 2, we identified four subthemes, which are subject of this paper. Table 4 shows representative quotes, illustrating subthemes.
Table 3. Factors affecting attitudes Qto and practices of infection prevention and control (IPC) – themes identified by transcript analysis
1. Characteristics of doctors, medical culture, and medical professionalism1
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2. Interprofessional influences on attitudes to and practices of IPC
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a) Professional characteristics - stereotypes
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b) Unflattering, but varied, interprofessional perceptions
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c) Doctors’ reluctance to accept advice from expert nurse consultants.
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d) The “doctor-nurse game”
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3. Organisational factors affecting IPC practices
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4. Factors relating to IPC policies and/or their implementation
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Note: 1. Previously reported (42)
Professional stereotypes.
Participants’ comments reflected conventional stereotypes of nurses’ and doctors’ professional ‘personalities’. Doctors were characterised (by participants of both professions) as ‘independent thinkers’ (Table 4, Quote 4:1), focused on diagnosis and treatment of individual patients, relying on personal judgment, indifferent to organisational policies and driven by ambition. By contrast, nurses were characterised (mainly by doctors) as driven by rules, rigidly enforced by the nursing hierarchy (Q4:1).
Nurses were said to be more aware of infection risks than doctors because they spend more time with patients and feel obliged to ‘work to policy’ to ensure a safe environment (Q4:2). However, some participants gave examples of inflexible application of rules that they believed could undermine doctors’ respect for policies (Q4:3) and lead to unsafe decisions. Examples included: a) a patient with mild post-chemotherapy fever, being placed in isolation, in the only available single room – according to ward policy - while a patient with acute respiratory infection and cough, remained in the open ward, exposing immunocompromised patients to a risk of infection (MUD1), b) a teenager with lymphoma, identified by routine screening as a carrier of vancomycin resistant enterococci being placed in prolonged isolation, with significant adverse psychological effects, despite posing minimal risk to other patients (CNC1).
Several participants commented that doctors often seemed oblivious to IPC rules during ward rounds. A nurse suggested that this was because they were focused on patients’ test results and treatment plans. However, several doctors believed many of their senior colleagues did not know what the IPC policies were, because they avoided mandatory training with impunity. A MDD believed that VMOs would not undertake training because they were not paid to do so, unlike nurses who regularly receive in-service IPC training, from “supernumerary” clinical nurse educators. This MDD thought that doctors would not accept instruction from nurses and suggested they be paid to attend IPC training, presented by a medical specialist. Several participants believed doctors would only adhere to policies if offered convincing evidence of their effectiveness. (Q4:3)
Doctors’ and nurses’ unflattering perceptions of each other.
Participants’ attitudes towards members of the ‘other’ profession, revealed significant prejudice. MDD2 suggested that hand hygiene audits were biased against doctors because the auditors were nurses (Q4:4), MDD4 felt that “bossy” nurses should be expected to remind doctors when hand hygiene was required to ensure they complied (Q4:5). NDD1 observed that doctors’ poor compliance reflected unfairly on NUMs, who were accountable for their ward’s audit results (Q4:6).
As previously reported, participants recounted instances of doctors’ rudeness or bullying, in response to reminders about IPC precautions.(38) CNC2 reported asking a consultant to put on a gown before entering the room of an ICU patient who was in isolation, to which he retorted “I don’t care about your bloody infection control” and went in without any precautions. Although outright rudeness was not common, doctors were described as often dismissive or grudgingly compliant when reminded about IPC (Q4:7). MDD1 felt criticism of doctors for noncompliance was unfair since many did not know what was required. (Q4:8)
Doctors’ attitudes to IPC may vary even within the same environment. NUM1 described two surgical units that shared the same ward: whereas one unit’s IPC practices were “exemplary”, the other’s consultants rarely visited the ward and its junior doctors consistently ignored nurses’ reminders about standard precautions. After informing these junior doctors of his intention, NUM1 asked the IPC team to audit the team’s hand hygiene compliance during a ward round. He showed the results (zero compliance), to the unit director, whose reaction NUM1 described as “livid” (Q4:9), not at the results, but that the audit had been performed.
Several nurses cited units whose IPC practices they regarded as excellent, their common feature was that the consultants visited the ward regularly, they observed IPC precautions routinely themselves, and made it clear that they expected their teams to do likewise. NDD1 described one surgical unit’s regular ‘structured, interdisciplinary bedside rounds’ in which nurses, allied health professionals, junior doctors, patients and relatives, if present, were included in bedside discussions. Several participants of both professions, implied that senior consultants’ respect for patients and other health professionals correlated with excellent IPC practices. In contrast, some units were identified by several participants as being notorious for their poor IPC practices and (reputedly) high infection rates (based on anecdotes, rather than surveillance data).
Doctors’ disregard for IPC professionals’ experience and expertise.
CNC1 recounted the IPC unit’s prolonged efforts to achieve recognition of their expertise and effectiveness. It was only after the hospital’s poor surveillance results attracted regulatory attention, that the hospital executive began to regularly seek their advice and include them in high level committees. However, they were still often bypassed. CNC1 cited the example of a surgical director seeking advice from a recently appointed medical specialist, rather than an experienced IPC professional, about how to respond to poor results in an international surveillance program (Q4:10). By contrast, IPC unit CNCs were regularly invited to join state and national committees planning responses to infectious disease threats (e.g. SARS, 2003, pandemic influenza H1N1, 2009, EVD, 2014-16), and led the state’s preparations to receive patients with a high consequence infectious disease. MDD2 recalled that, during the EVD threat, some senior doctors sought to overrule the IPC unit’s guidance on PPE use, by demanding excessive, unnecessarily strict precautions. Their demands were rejected, but caused confusion and fear among staff and undermined the IPC team’s authority (Q4:11).
The doctor-nurse game.
We interpreted some participants’ anecdotes as modern examples of the doctor-nurse game, described by Leonard Stein, in 1967,(39) to explain how nurses and doctors were expected to interact, professionally. Participants described doctors’ complying with IPC policies if a nurse reminded them respectfully, but if the reminder implied criticism or was abrupt or inflexible, it was likely to be ignored or met with an angry or abusive response. See Q4:7, Q4:12 and Q4:13 and (Boxes 1 & 2).
Participants’ emotional rhetorical styles.
Participants’ language suggested emotional responses to IPC: e.g. a doctor having “a stand up argument about hand hygiene” (Q4:2), a consultant’s contempt for “your bloody infection control”, a unit director being “livid” about a hand hygiene audit, but indifferent to neglect of hand hygiene (Q4:9), nurses trying “to do the right thing” but “disheartened” by doctors’ behaviour (Q4:2). On the other hand, doctors described how senior nurses “eat their young” (Q4:1) if they broke the rules, and doctors’ poor hand hygiene compliance as nurses’ “payback” for being “kicked around by doctors” (Q4:4).
Table 4. Illustrative participants’ quotes (Q) describing inter-/intra-professional differences in attitudes to and practice of infection prevention and control (IPC).
Professional characteristics - stereotypes
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Q4:1 A medical divisional director’s (MDD1) description of nursing and medical stereotypes.
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Nurses are very process driven. They have very … hierarchical structures that they stick rigidly within. If they drift outside they get jumped upon, they eat their young... Most of the sort of people that go into medicine are more independent thinkers and they don't like to be told what to do by anyone and the further up the tree you go the more like that you become... [they have] a view about themselves that … they're above criticism.
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Q4:2. A nursing divisional director’s (NDD1) different view of stereotypes
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I think the nurses are very keen to do the right thing… to the best of their ability.… it's disheartening when you see others coming in and out of rooms and not doing that and… when you [speak] to them there's a stand-up argument about hand hygiene.
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Q4:3. An IPC nurse clinical consultant (CNC1) blames rigid application of rules for doctors’ lack of respect for IPC.
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I think medical staff are really driven by evidence, the fact that contextually they can see... validity. So if they think something's stupid... and they’re just doing it because it's [the rule] … they lose respect for it. … there's a lot of infection control procedures like that. … Whereas the nurses are more accepting of tradition - that's the way we've done it because... Florence has done it… And they're not looking as much for that evidence.
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Unflattering, but varied interprofessional perceptions
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Q4:4. MDD2 suggests bias on the part of ward auditors
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The audits say that the doctors are terrible, but most of the audits are done by the nurses. So you wonder whether there’s a bit of payback. …it’s Schadenfreude, isn’t it? Maybe they feel they’re kicked around by doctors all the time. It’s nice to point out that the doctors aren’t perfect.
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Q4:5. MDD4 suggests bossy nurses as hand hygiene leaders
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Who is leading? … the nurses would be much better [than doctors] at bossing people around about hand washing, because they’re pretty good at bossing you around about everything else.
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Q4:6. NDD1 speaks of NUMs’ problem with doctors’ poor hand hygiene compliance
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I'd look at my rates across the wards [and ask the NUM] ‘Your rates are sitting below the benchmark, what are you doing about that in your ward?’ I would get back: ‘When I break it down… the medical staff sit quite low and …they’re not my responsibility so I can’t impact them’.
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Q4:7. NDD2 on nurses varied approaches to and responses from medical teams about IPC practices.
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When I was a NUM, I had a very good relationship with the team so I could say to them ‘Hey, you haven’t even washed your hands’ and they would listen. [Other] people don't feel that they can say that, or they’ve got 10 teams coming through and it's very hard to build relationships…. So if you pull someone up they’re going, ‘Oh, don't worry about it, we’ll just move on, let’s get through this and don't worry about her’.
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Q4:8. MDD1 admits doctors are ignorant
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Some feedback clinicians get sounds a bit like they’re deliberately doing people harm - most of it is acts of ignorance.
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Q4:9. A nursing unit manager (NUM1) describes poor IPC attitudes & practice in a surgical unit.
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The infection control team were just flabbergasted. They said ‘They didn't wash their hands at all, not once that whole ward round. They were touching open wounds and then going off and touching the next patient.’ …[the MUD].. was livid, but, not at his team. He was livid at us that we did this audit [and that it was] was out there for everyone to see.
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Doctors reluctance to accept advice from expert nurse consultants.
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Q4:10. CNC1 on surgeons’ response to high surgical site infection rates.
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The only feedback we’ve had was that … [our hospital] was one of the worst-performing globally. …they [surgeons] engaged [infectious diseases physician] to look at their strategies…. [who] came to us for information, [but] there’s a lot …being missed just based on her length of experience.
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Q4:11. MDD2 on senior doctors’ response to Ebola preparations
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I thought the intensivists’ behavior, rather than dampening fears, exaggerated them… nursing staff behaved far better..[although] they were far greater at risk. …there was great debate about the reliability and validity of the [IPC unit’s] advice….Professor Google became problematic.”
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The “doctor-nurse game”
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Q4:12. A medical consultant on nurses’ approaches to doctors
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Junior doctors, don’t mind being told what to do, but only in a way that’s appropriate… So [a nurse] who comes along and says you have to do these things…there’s no flexibility … that’s always going to meet resistance.”
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Q4:13. MDD4 recounts junior doctors’ complaints that nurses interpret policy too literally
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Residents …were saying that some wards will take [peripheral intravenous cannulas] out – ‘oh, it’s 72 hours, we’ll whip it out’ - they haven’t looked at it, they haven’t looked to see when the next [antibiotic] dose is, and they call you, and you have 15 other calls that shift… they’re not equally shouldering the responsibility.”
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