We now undertake a critical realist analysis of the institutionalisation of the
1000 Lives+ programme’s RHAI. Again, our case study considers
sites A, B, C and D. Our analysis focuses on three groups of key actors:
consultant microbiologists, IPAC nurses and pharmacists specialising in
antibiotics medicines management. Each is directly involved in the operation of
RHAI under the auspices of the 1000 Lives+ national programme.
However, as HCAIs are an issue for all to address, we include the perceptions of
a wide range of health-care professionals in our analysis.
As in the two previous chapters, we consider the focal intervention in context
and explore the dominant structural and cultural emergent properties impacting
key actors involved in the operation of the RHAI. Next, to reveal the generative
mechanisms in play, we examine mediation via first- and second-order emergents
and the resultant situational logic. Then, to examine the initiation of change,
we explore the unfolding strategic negotiation of change and the mode of
institutional work enacted. Finally, we reflect on the nature of any sustained
outcome, be that elaborative or reproductive, that occurred following the
implementation of RHAI. This analysis forms the foundation of our refinement of
the I-CMAO configuration spanning the Welsh health-care field in 1000
Lives+
institutionalisation: RHAI – local implementation of the focal
intervention and contribution to I–CMAO configuration spanning the
Welsh health-care field.
Structural conditioning: structural and cultural emergent properties in
the Welsh health-care field
In contrast to the other focal interventions selected from the 1000
Lives+ programme and analysed in Chapters 6 and 7, the discrete interventions selected from
RHAI – standard precautions for hand hygiene to prevent the
transmission of infection and the use of antimicrobial drugs to ensure the
effective prevention and treatment of infection – did not represent
practice innovations. The dominant structural emergent properties impacting
the RHAI were, therefore, the complex array of established alternative
frameworks and the ongoing surveillance of their effectiveness via the WHAIP
(transcription 8:01, below).
The question for me is, how do we untangle 1000 Lives+ from
all of the other elements in play – it’s complicated,
confounded – because what’s happening is happening
between 1000 Lives+, all of the other frameworks and
antimicrobial guidelines that are out there, and mandatory surveillance
reporting and feedback via WHAIP.
So, it’s through one or a combination of all of those things that
the higher echelons, if you like, of hospital management are now faced
with infection control, and its importance, much more so than they were
10 years or so ago, or even less than that. So I think, whether
it’s due to 1000 Lives+, other frameworks, or the
surveillance processes in place, I think it’s achieving
something – because they have to be aware and address HCAI due
to WHAIP reporting to the Welsh Government – my impression is
that they are aware of it and they feel accountability.
Now when you have accountability in the higher levels of management, the
way that they effect that accountability, quite rightly, is through
delegation and spreading the message in terms of what needs doing. The
previous medical director here, who was spectacularly engaged, even
before 1000 Lives+, with the idea of infection control
provided a real sense of leadership, and had an awful lot of insight. I
don’t know why that was, perhaps he just saw it as part of his
role, I don’t know, but he did it very well. But now, now that
we’re a lot bigger, and we have a wider range of – I
don’t want to use that term ‘lower’ –
some of the next tier down levels of management, like director level and
their associates or assistants, that message is dissipated.
Consultant microbiologist, case site C1 (034);
transcription 8:01
Other structural issues also surfaced during discussions with respondents,
notably the compounding impact of the reconfiguration of NHS Wales on
framework alignment, and the need for the co-ordination and consolidation of
different guidelines under a health-board-wide and emergent all-Wales remit
(transcriptions 8:02 and 8:03, below).
The reconfiguration of NHS Wales, the formation of health boards
that’s occurred during the roll-out of the original 1000 Lives
campaign and 1000 Lives+, I think this has created issues
which are problematic. I think that the creation of much larger health
boards has created barriers to the roll-out of 1000 Lives and 1000
Lives+. So, for example, something that’s seen to
be an incredibly high priority within this health board, quite rightly,
is the fact that before we were [number] Trusts, and we all had, I
imagine, a pretty good spread of infection control policies that were
broadly in line, and in their own way ticked the boxes for national
recommendations. But they were not the same. Now a priority, here, is
that we have harmonised consistent policies. So, you know, we all have
workable policies that we could just leave alone to would work on each
site; but no, we are required to have single harmonised policies that we
all agree to. Now the differences that existed were there for a reason.
But now we’ve got to try and overcome those differences, agree
amongst ourselves, and then get wider agreement across the consultants.
And the point being that that’s a job of work that takes time
and is outside the time requirements that might be put into 1000
Lives+.
Consultant microbiologist, case site A1 (035);
transcription 8:02
Working with consultant microbiologists, we produce and review the
antibiotic policies used across the health board. There’re
planning to have all Wales antibiotic policy guidelines. [Have they been
produced and published?] No, no way: it’s still at a very early
stage of discussion, about 6 months in, and I think it will take years
to agree: there’s so much disagreement about what to use, when,
and some doctors simply refuse to follow any guidelines, no matter who
produces them: ‘where’s the evidence; the evidence is
disputed; it’s not that clear cut; it’s my freedom to
prescribe how I see fit for my patient’. We get that same old
argument, from some of them, all the time.
So, we produce the health board’s antibiotic guidelines and
monitor them through audit cycles across each ward or base hospital; we
do the education associated with antibiotic usage for the junior
doctors, nurses, and other staff, including other pharmacists; and we do
antibiotic ward rounds with consultant microbiologists – this is
a small hospital, so consultant microbiologists don’t have
junior doctors attached to them, so, in a way, we act like their juniors
– this involves antibiotic prescribing and follow-up, checking
that the drug and indication are appropriate, that the dose, route, are
all correct, that sort of stuff. I don’t think of the context
outside so much, I suppose; for me, it’s about the people I talk
to and work with each day.
Pharmacist, Antibiotics Medicines Management, case site
B2 (001); transcription 8:03
In addition to the structural constraints arising from various existing
guidelines, a previous patient safety improvement programme, the Safer
Patients Initiative, had a legacy effect which resonated strongly with some
IPAC nurses interviewed as part of this study (transcription 8:04, below,
and transcription 8:05).
If I’m honest with you, when it [1000 Lives] came out originally,
it was a bit of a spin-off from the SPI [Safer Patients Initiative], you
know, the IHI approach, wasn’t it?
It came out at the time when we were reorganising the health service in
Wales. So, I think, a lot of the correspondence went to people whose
positions have changed and so on and so forth. They started off at a
very high level but there was a lot going on in the organisations and it
didn’t really filter down – the leadership was a little
bit fragmented at that time – I think in the last 2 years
we’ve sort of taken hold of it.
We were a little bit at odds with the priorities of the RHAI programme
initially because we had done our own prevalence survey, internally, and
we hadn’t identified problems with catheter-associated UTIs
[urinary tract infections]. We did an incident survey over a period of 1
month in wards in the organisation and there were no issues with
catheter-associated infections at that point in time. However, we
identified problems with peripheral venous cannulas during our point
prevalence survey. But the campaign was mandating a focus on short-term
urinary catheters, whereas our priority at that time was more to do with
peripheral lines. So it was a little bit of, it was a little bit, you
know, sort of didactic I guess: ‘this is a priority, and this is
what you must do’, and I was thinking, well, in our
organisation, this is our priority and we will do that, at the moment we
need to focus on that.
Senior nurse, IPAC, case site A2 (076); transcription
8:04
Such structural constraints were interwoven with the current financial
challenge; as one respondent commented, ‘the biscuits are
gone!’ (transcriptions 8:06 and 8:07).
The cultural emergent properties impacting staff involved with infection
control arose from their different but interlocking roles. It was clear that
there was close liaison between each professional group (transcriptions 8:08
and 8:09, below).
I’m aware that there are different models, if you like, with the
consultant leading, consultant microbiologist, the infection control
doctor leading the service. Here it’s a flat model – a
flat model between the lead infection control nurse and the lead
infection control doctor – and it is something that I feel not
only works well but is appropriate because we bring different skills to
the mix, and I’m not sure that any set of skills is more
important than the other.
Consultant microbiologist, case site C1 (T034);
transcription 8:08
Well, predominantly, in infection control, our role is for support and
advice to staff. That’s our role. But we’re also
involved in conducting audits – particularly things like hand
hygiene audits, commode audits, environmental audits, and those kind of
things – and those are fed back to ward staff, the results and
an required action. But we also carry out things like surveillance, so
we’ll monitor our alert organisms [for WHAIP]. If
there’s any kind of change – an indication that
there’s an increase in health-care-associated infections, or an
increase in any of our WHAIP alert organism, such as MRSA, MSSA
[meticillin-sensitive S. aureus], C.
diff, Group A strep [Group A Streptococcus], E.
coli, any of the alert organisms, we’ll go and find
out, and liaise with the consultant microbiologist.
Senior nurse, IPAC, case site D2 (017); transcription
8:09
Such liaison also gave rise to professional networks which enabled processes
of interprofessional knowledge mobilisation that were perceived to be
operating at a more challenging level than those of 1000 Lives+
(transcription 8:10, below).
If I’m facing something that new, a bit different to what
I’ve handled before, I would first contact other antibiotic
specialist pharmacists – there’s a network across Wales
– so that would be one source of information and advice. The
others, naturally, are the consultant microbiologists and IPAC nurses.
Also, there’s a formal meeting twice a year of the Antibiotic
Stewardship Forum, which consists of medical microbiologists,
pharmacists, and some specialist nurses. They don’t meet that
often but they’re a great source of information, and an
opportunity to share learning and development.
[Are there any other groups that you would contact for advice or
support?] Yes, the UK CPA [UK Clinical Pharmacy Association] is another
source of information. They have an infection management group –
they’re more advanced in England – there’s a
good web site, support materials, that sort of stuff which is very
helpful. In England, they have developed the consultant pharmacists role
– we don’t have those in Wales yet; but I think one is
due to be developed in Renal Pharmacy, which is an incredibly complex
field. So that sort of recognition, legitimacy almost, is absent in
Wales. Another group is the British Society for Antimicrobial
Chemotherapy. They’ve got a useful website, and they run all
Wales study days, which, in terms of the evidence and focus, are pitched
at a far higher level than 1000 Lives+. I feel like
I’m learning something new when I attend these, not just being
told to wash my hands before I go onto a ward, or to make sure that a
course of antibiotics has a defined stop date! Another is the Welsh
Microbiological Association and again, they run study days, really
focused on education, and this is linked into Public Health Wales. So
this is all at a level above 1000 Lives+.
Pharmacist, Antibiotics Medicines Management, case site
B2 (001); transcription 8:10
First-order emergents for key actors central to the institutionalisation
of Reducing Health-care Associated Infection
Such structural and cultural emergent properties shaped the context in which
key actors, central to the institutionalisation of the RHAI now found
themselves and conditioned their ensuing actions. We therefore asked
consultant microbiologists, nurses specialising in IPAC and pharmacists
specialising in the management of antibiotic medicines to reflect on their
placement, their vested interests and the perceived opportunity costs
associated with various courses of action, to determine how this shaped
their activities.
Consultant microbiologists
The vested interests of consultant microbiologists lay in the day-to-day
operational management of IPAC, centred on the provision of their expert
advice, and the ongoing demands which arose from WHAIP surveillance
(transcriptions 8:11 to 8:13). The 1000 Lives+ national
programme and RHAI, though aligned to such tasks, were a secondary
consideration (transcription 8:12, below).
Well, of course, a lot of the mandatory reporting used to be done
manually by microbiologists – that used to take up our time,
particularly statistics for bacteraemia – but that’s
all done centrally now. So all that information is sucked out of the
data store in Wales.
In terms of mandatory requirements, there’s, in theory,
there’s less for us to do. But I strongly suspect that
– I’m not alone here, in fact I guarantee you that
all microbiologists who used to do it, still do it – because
there is an expectation that, a requirement for us, when reports are
generated centrally through WHAIP before those reports come out as
you know the raw data is circulated back to us to check if we think
it’s correct but we would only know that if we were doing
the same data collection that we ever did!
But we would want to do it anyway – not just to check the
accuracy of WHAIP reports, bearing in mind that some of those
reports are somewhat retrospective – because if we relied on
them to find out if we were having an out of the ordinary rise in
numbers of C. diffs in a given area or MRSA bacteraemia associated
with line use in a certain area, we’d miss the boat and
problems would have deteriorated. So we have, we need to do these
things, relatively, real time. So that’s one form of
reporting pressure if you like. I mean we see it as part of our work
– as our normal role – and that’s why
I’m fairly confident that it doesn’t matter who you
ask in Wales they’ll probably give you that exact same
answer. But nonetheless it’s a time pressure that needs, a
role that needs to be fulfilled.
On top of that you’ve then got two other pressures. So, one
is the one I’ve just mentioned, whereby you’re
noticing your own local priorities with these figures that
you’re generating for WHAIP, so that we can focus our
attention and look at the interventions that should be being made,
and audit whether they are being made, and how well they’re
being done and that kind of thing. But at the same time we might be
receiving instructions that we should be looking at other areas
– and it’s not that those areas aren’t
important – but then our time is split because
there’s the thing that we see, that we feel we have an
immediate need, and then there’s the requirement to fit in
with 1000 Lives+ I suppose.
Consultant microbiologist, case site B1 (036);
transcription 8:12
In focusing on the broader remit of IPAC, as opposed to the progressive
institutionalisation of RHAI, consultant microbiologists operated under
a professional (medical) logic co-existent with and complementary to
professional (health-care management) and bureaucratic state logics.
Thus, the RHAI was absorbed and integrated into existing and culturally
entrenched monitoring processes. This aided its adoption and
reproduction across NHS Wales’ health boards.
Infection prevention and control nurses
The vested interests of IPAC nurses at each case site, captured in
transcriptions 8:14 to 8:21, again reflected the impact of their
traditional role jurisdictions. These overshadowed and pre-dated the
1000 Lives+ national programme and RHAI (transcriptions 8:14
and 8:15, below).
We do all the audits – environmental audits, hand hygiene
audits – ward-based teaching, like the session that
you’re going to see this afternoon, and just general support
for the wards, and where we find a problem, we like to go back and
offer a solution and support the staff to eradicate
hospital-acquired infections.
Nurse, IPAC, case site A2 (003); transcription
8:14
We were doing all this before 1000 Lives and 1000 Lives+
– including looking at urinary catheter-associated
infections and peripheral and central line infections – so
the interventions 1000 Lives+ promotes are already
integrated into our monitoring systems, and it would be the same for
all health boards.
Senior nurse, IPAC, case site A2 (002); transcription
8:15
In addition, some aspects of infection control lay far beyond the scope
of RHAI (transcription 8:17, below).
It is unacceptable to have a case of Clostridium
difficile, and if you have two within a 28-day period,
a formal meeting is called. [What do you do if you have a persistent
problem with Clostridium difficle?] If there was a
continuing problem, then we’d look to Bioquel the ward
– bio-bomb it with hydrogen peroxide – they go in,
in their decontamination suits, and close the doors. They do it one
section at a time, they vapour blast it with hydrogen peroxide, they
leave all the equipment in there, all the beds, everything stays in
there, so there’s no risk of us missing something really.
After that the domestic staff will go in and just clean –
soap and water, detergent – and then we put the patients
back in the ward. So far, that seems to be very effective. But
we’ll only do that if we have real hotspots.
Nurse, IPAC, case site B1 (131); transcription
8:17
The newer 1000 Lives+ interventions associated with RHAI,
though beyond the scope of this study, were an extension of established
practice. However, owing to medical resistance, some specified changes
were a source of concern (transcription 8:18, below).
The new 1000 Lives+ intervention was launched nationally
last year, and we’ve been rolling out the PVC bundle but we
have the catheter bundle in place for about 4 years now. The PVC
bundle has proved a little more difficult to implement really, in
that there’s been a change to practice, there’s also
been a lot of medical opposition. [Why?] Because they’ve got
to do stuff! What they’re saying is:
‘where’s the evidence to say that they’re
not doing things properly, and that we’ve got a high rate of
infection? Why should I change my practice without the evidence that
there’s a problem in the first place?’ [They
don’t perceive a problem in their current practice or the
rates of infection?] Because they don’t believe
they’ve got a problem. They don’t believe that by
changing practice, or being forced to evidence that they’re
doing what they should be doing, that that will make any difference.
And, in one respect, you could sort of see their point, in that
there is a low rate of peripheral venous infections. But we do get
catheter-related bloodstream infections and the incidence of MSSAs
[meticillin-sensitive S. aureus] within the health
board has been increasing. But what we asking them to do, due to
1000 Lives+, well, for them, it just takes too long.
Nurse, IPAC, case site C1 (132); transcription
8:18
In regards to 1000 Lives+, I’d say the
introduction of the bundles and the STOP campaign is probably all
the infection control team have been involved with and some of that
just involved minor changes to our practice.
Nurse, IPAC, case site D2 (019); transcription
8:21
In focusing their agential activity on the broader remit of IPAC, in
addition to the institutionalisation of the RHAI, specialist nurses
operated under a professional (nursing) logic that was complementary to
professional (health-care management) and bureaucratic state logics.
Antibiotic medicines management pharmacists
Transcriptions 8:22 to 8:29 suggest that the vested interests of
pharmacists with expertise in antibiotic medicines management were
poorly aligned to RHAI, which they saw as irrelevant given their level
of expertise (transcriptions 8:24 and 8:25, below).
[When you think about the knowledge and information that you use
within you role, do you draw on the 1000 Lives+
resources?] No, I don’t use them. There’s little
information in them that relevant to me; I mean, it’s just
so basic – really bottom-end stuff, basic, mundane –
if you don’t know it, you shouldn’t be working as a
clinical pharmacist.
1000 Lives+ is, it’s too basic, directed at
lower-level nurses. For me, it offers little. [Do you use the driver
diagrams?] No, they’re not relevant: they’re basic.
I do a ward round with a consultant microbiologist each day and
there’s more to that than hand washing! The diagrams
aren’t education. I mean, we are using the key points in our
stickers, developed as part of the antibiotic care bundle, but
it’s our system. [Do you use the PDSA cycle?] No, we have
ongoing audit cycles, which, I guess, serve the same function but
they’re part of the health board’s audit regimen and
not informed by the 1000 Lives+ programme.
Pharmacist, Antibiotics Medicines Management, case site
B2 (001); transcription 8:24
[When you think of 1000 Lives+, what does it mean to you?]
That’s a good question. What does it mean to me? I’d
say it’s pretty much invisible. I guess it’s one of
a number of elements that we take into account on a day-to-day
basis. It’s tricky because you’re undertaking CPD
[continuous professional development] all the time. It’s
probably not recorded as CPD but every article you read in the PJ
[Pharmaceutical Journal] is all CPD. For
example, I’m going to have a lunchtime teaching session, and
there could be two or three things in that that I will take away,
and then use in my day-to-day practice. But as a consequence there
are things that I will probably drop out by day-to-day practice
because they’re become superseded by something else more
important. 1000 Lives+ is just one element. There are
lots of other things you’re taking in and trying to maintain
as current all the time.
Pharmacy manager, case site B2 (016); transcription
8:25
Such disregard was augmented by the notion that, for pharmacists, aspects
of 1000 Lives+ have not been ‘translated to
pharmacy-speak’ (transcription 8.26). Hence, for this
professional group, the resources offered by RHAI were not considered to
be a worthwhile innovation in practice (transcription 8:28, below).
If you look the 1000 Lives+, although I think this might
have existed with 1000 Lives as well, but I mean, with 1000
Lives+ – I forget what the terminology is but
the project theme or something for health-care-associated infection
– you have the key intervention areas, if I remember
correctly, you’ve got things like standard precautions, hand
hygiene and decontamination; isolation precautions, that would be
another, and antimicrobial stewardship and so on and so on. But all
of these are in the strategies we’ve had in Wales for years!
So they, they’re not new and they’re not separate
are they?
Pharmacist, Antibiotics Medicines Management, case site
D2 (020); transcription 8:28
Sociocultural interaction: agency and strategic negotiation
As discussed in Chapter
6, a situational logic of protection is typically
associated with a defensive negotiating stance. However, for RHAI, prior
systems of HCAI surveillance and developed IPAC practices overshadowed the
intervention. The progressive institutionalisation of the 1000
Lives+ national programme and RHAI, therefore, unfolded in a
terrain marred by a degree of disdain. We highlight this complex interplay
in both a discrete case site and across multiple case sites, again drawing
out different degrees of bureaucratisation and normalisation to help enrich
our understanding of the institutional work complementary to the interplay
of the focal intervention, context and mechanism.
Power-induced compliance and political sanction
To examine the issues of power-induced compliance and political sanction,
we considered individual actors’ strategic negotiating stances
across different case sites and professional roles.
It was clear that the IPAC team, in the broader sense, were connected to
the managerial core (transcription 8:30). However, they were also
intermittently connected to ward-based functional health-care teams,
though IPAC nurses and pharmacists undertook regular ward visits as part
of their practice. This created a context in which such roles, while
offering advice and expertise, also functioned as part of the ward-based
governance of IPAC.
However, this oversight role was compromised. Poor practice was adapted
in the presence of IPAC nurses, changing so that it demonstrated, while
observed, close adherence to the hand washing guidelines of RHAI
(transcriptions 8:31 and 8:32, below). This finding was corroborated by
our observation of practice at each case site.
There’s some wards you go to and, you know, 1000
Lives+ is just an aside, an extra element of work.
For example, you ask them about commode cleaning and they say:
‘well, we don’t have to clean it after every
patient’, and then we say: ‘but you’ve got
to, that is part of the task, it’s part of the commode
bundle’, and they roll their eyes and argue: ‘well,
we haven’t got the time’.
I think, wow, if you haven’t got time to just clean a
commode, what else have you not got time for? It’s almost as
if everything on some wards is seen as on top of what
they’re trying to do, you know, because they’re so
run ragged, which is understandable, but that’s when
it’s harder, then, to implement something new: when they
can’t even be doing the things that they should be, you
know?
[Can you mandate adherence to these guidelines?] Yes, we tell them,
and we audit them, but because we are all known to staff, the minute
we walk onto a ward their practice changes. [So they adopt the
expected behaviour when you are present?] Yes.
Nurse, IPAC, case site D2 (019); transcription
8:31
About 90% of the staff in ITU [intensive therapy unit] are familiar
with me. So, they all know me, and they all know what my job is.
When I walk in twice a year, even if they don’t know my
name, they know who I am – that sounds really
self-important, and that not the issue, but they know me and
it’s a problem – and people often will come up, and
they’ll stand and chat to me and wash their hands, and I
know perfectly well that they’ve done absolutely nothing
– they haven’t been near a patient –
it’s just that conscious effort to demonstrate hand washing.
They’ll walk into ITU, they’ll have a squirt of
alcohol gel, and they’ll be watching me, looking at me, to
check I’m watching them. So now I sent up [namea]
and [nameb], both IPAC as most of the staff don’t
know them. So, they went up, on the pretext of looking through
patients’ notes, and the hand hygiene practice was not
acceptable. But, as soon as they realised that they were being
audited, their practice changed immediately. They were like washing
their hands, alcohol gel, everything changed.
Nurse, IPAC, case site B1 (137); transcription
8:32
The IPAC staff demonstrated the professional role-positional power to
challenge poor practice within extant bureaucratic governance processes.
However, confronted by normalised malpractice and decoupling from
pre-existing and repacked RHAI standards, their institutional work was
predominantly corrective.
Similar corrective institutional work was also demonstrated in the
ward-based actions of pharmacists with expertise in antibiotic medicines
management (transcriptions 8:34 and 8:35, below).
We don’t get all doctors following the antibiotic prescribing
guidelines. Some do, some don’t. So it’s a core part
of the role for pharmacists to challenge and change that when they
do their ward rounds.
Pharmacy manager, case site D1 (021); transcription
8:34
[What happens if a doctor prescribes off guidelines within the health
board?] We challenge them. I had one, a few days ago, who I
challenged because he had prescribed two drugs, and only one was
needed for the patient’s indication; but all he said was:
‘so what’s the problem, it’s not illegal is
it?’ But it’s a waste of money, medicine, and more
of a risk and inconvenience for the patient. I think that a lot of
my role is really about education and changing the culture in the
health board. [But is that refusal to follow the guidelines reported
to anyone?] Yes, all the audits go to the medical director. But
it’s anonymised data: ward level, not prescriber level. One
of my colleagues in [name, health board] has done this per
consultant team, and they’ve had good results in changing
prescribing because the data is ranked. Everyone knows who’s
playing ball, and more importantly, who’s not, so to
speak.
Pharmacist, Antibiotics Medicines Management, case site
B2 (001); transcription 8:35
In this example, though such staff demonstrated the professional
role-positional power to challenge poor practice and enacted corrective
institutional work, the lack of transparency and feedback at this site,
compared with the respondent’s example of another site, where
’everyone knows who’s playing ball, and more
importantly, who’s not, so to speak’, only served to
erode the goals of RHAI.
Reciprocal exchange and harmonisation of desires
Gaining widespread support and agreement for a harmonised approach to
IPAC, and thus RHAI, proved difficult due, in part, to individual
prescribing preferences and ensuing practices. Indeed, this issue was a
consistent theme at each case site and across professional groups
(transcriptions 8:36 and 8:37, below).
Getting agreement between the all of the consultant microbiologists
in the health board is quite demanding but that pales into
insignificance when we have to start telling other medical
consultants or surgeons what they are supposed to prescribed for a
given indication. You know this as much as me! They’re all
got their preferred drugs, ones that they have used for years, new
ones that offer more, and cost more, it’s that debate that
difficult, and it’s one we are having to address due to the
formation of the health board.
Consultant microbiologist, case site B1 (036);
transcription 8:36
I don’t know if they’ll all agree to a health
board-wide antibiotic policy. I mean, we’ll get agreement on
the overarching health-care-associated issues – say C. diff
management because that’s changing, and it’s our
area per se: they don’t want to claim that for themselves
– but it’s harder to negotiate with respiratory
physicians, orthopaedics, all the rest, as they’ve got their
preferred drugs. So changing their prescribing practice is
difficult. Our policy is monitored by pharmacists, and IPAC nurses,
as they work at ward level, so they are at the sharp end.
Consultant microbiologist, case site C1 (034);
transcription 8:37
The comment from a respondent that ‘To change something –
whether you’re talking about the 1000 Lives+ work,
adherence to current policy guidelines, or the development of new
guidelines across the health board, you’ve got to know the
people involved in the system’ (transcription 8:38) highlights
the critical role of contextual relational structure and social
interaction in the brokerage of such contested change. Leadership and
the use of co-opted medical power were also seen as central to the
negotiating stance employed (transcriptions 8:39 and 8:40, below).
On the wards, well, you’ve got issues, other things, you
know, if you’ve got high sickness rates on a ward as well,
motivation is often low, so when you’re trying to introduce
1000 Lives+ guided change that’s going to impact
more on their workload, often that’s seen as a negative. The
key issues then is, how do you really sell that to them because
it’s no good us saying: ‘this is all the new
paperwork, go on, use this’, the wards have got to see the
benefits of that, and own it, and want it, for it to work. I think
that’s where good leadership comes in because it’s
sort of, you know, if they sell it, if the ward manager sells it as
this is a positive thing: ‘if we do this we can reduce our
rates’, the staff will be on board.
Lead nurse, IPAC, case site A1 (037); transcription
8:39
We’re having problems with the PVC insertion bundles because
we went on the sticker route for the insertion bundles, whereby you
put the sticker on the prescription chart, on the PRN [as required
medication] side of the prescription chart. Well, every time they
went to change a cannula they would just need to sign the
prescription chart to say that they’d changed it, and the
sticker will have things like hand hygiene, personal protective
equipment, and the right dressing on it, you know. But doctors
insert venflons and doctors don’t like to document that
they’ve inserted something! So when we spoke with the
associate medical director at the time, he suggested that we
approached clinical champions to try and embed that a little bit
further. So with the audit work and the regular feedback, and
identifying clinical champions, we’ll begin to see an
improvement in compliance, you know, if we don’t,
we’ll feed it back to them.
Nurse, IPAC, case site B1 (131); transcription 8:40
Although these IPAC nursing staff demonstrated the professional
role-positional power to challenge poor practice, their corrective
institutional work, buttressed by the power of others, was directed
towards the maintenance of best practice and its evolution through
RHAI.
Structural elaboration or reproduction in the Welsh health-care
field
In examining the progressive institutionalisation of the 1000
Lives+ national programme’s RHAI we sought to gauge
key actors’ perceptions of the structural elaboration or
reproduction that had manifested under a situational logic of protection.
For consultant microbiologists, attributing improved outcomes in HCAIs to
1000 Lives+ or RHAIs was considered to be very challenging, owing
to the interplay and collective impact of multiple IPAC policies on
WHAIP’s robust epidemiological modelling (transcription 8:41,
below).
If you’re looking at say, catheter care policy, now, looking for
it to reduce catheter-associated UTIs [urinary tract infections] then
that’s going to be a small subset. So, it’s very, very
difficult to be able to draw and demonstrate a reduction. It’s
technically possible, if you have a big enough study population.
However, practices in hospital are not static, things change, for the
better, for the worse, for a whole host of reasons, and controlling any
one aspect through 1000 Lives+ policy, or something of that
nature, that may have one impact but there may be contrary aspects that
the main path is working on. So, it can be, I think, very challenging,
and very difficult to really show a reduction and improvement in
outcomes.
Consultant microbiologist, case site A1 (035);
transcription 8:41
Structural change was apportioned to the ward-based functional health-care
team. In enacting RHAI and other IPAC guidelines, such staff not only
delivered change (transcription 8:42, below), but were continually motivated
to do so through fear of exposure of failings (transcriptions 8:43 and
8:44).
Our C. difficile rates have actually gone down, a
reduction again on last year. So it’s good. But, you know,
that’s where our support and advice has come in. But at the end
of the day, in infection control, we’re not there on the
coalface, if you like, it’s the staff who put that into
practice, into place, you know, they carry on with what we advise. So,
you know, a lot of the hard work is down to them.
Nurse, IPAC, case site D2 (019); transcription
8:42
Cultural change, by contrast, was perceived to be far more marked, with a
professional logic of zero tolerance of HCAIs emerging across NHS Wales,
although it remained far removed from the reality of day-to-day health-care
practice (transcription 8:45, below).
I think the culture is changing, I mean, I’ve seen it in the
short time I’ve been in infection control, the ownership at ward
level for infection control has shifted. Whereas, you know, if there was
a problem on the ward, often the wards wouldn’t call us, so we
would find out by our surveillance!
But now wards are contacting us to say: ‘I think we’ve
got a problem’, so there’s the acceptance of their role
in infection prevention and control. Before, for Clostridium
difficile, it was accepted that it’s just a
consequence of being in hospital – the attitude was:
‘what do you expect, you’re going to have antibiotics,
you’re elderly, you’re bound to get it’
– but that is changing now. Now people are saying: ‘no,
they shouldn’t be getting a health-care-associated infection,
it’s just not good enough’. There should be zero
tolerance on infection, health-care-associated infection. [But they
still happen, don’t they? And patients still die as a
consequence, don’t they?] Yes. [Long pause] But I think at ward
level staff now are not accepting that patients should acquire an
infection as a result of being in hospital.
Nurse, IPAC, case site B1 (131); transcription
8:45
In addition, though tangential to RHAI, the normalisation of the 1000
Lives+ MI-PDSA approach was evident (transcriptions 8:46 and
8:47). However, the crux of such cultural change lay in the education of
staff (transcription 8:48, below, and transcriptions 8:49 and 8:50).
Education is key, too, not just education for the sake of antibiotic
education but to change the culture. But, again, we face a huge problem
here as the attitude is: ‘well, what’s the problem; why
do we need to change how we do things; the evidence is weak’,
it’s always the same.
I don’t want to sound cynical, I don’t. I love my job.
But getting people to change is difficult, especially doctors, though
they do know that I know what I’m on about. But we go through
the same issues with each junior doctor rotation – I feel that I
have to re-prove myself to them because they prescribe, wrongly
– I know what they should be prescribing better than they do.
So, a large part of what I do is education, and not just about
drugs.
[Do you think that the junior doctors respect the work you do?] If
they’re arrogant, and think they know it all, probably not; but
they’re the most dangerous. Once you’re stopped them
from killing a patient, once or twice; once they’ve realised how
fallible they’re, and how, within the NHS, you’re lucky
if you got a good team around you, who all know their own profession and
offer different expertise, they start to listen. They’re not all
like it, thankfully. Some are really good, and with more joint training
early on in health-care professional careers, I think the issue of
professional respect is getting better. But the best doctors are those
that listen, and, more importantly, they ask for information and advice,
they’re keen to learn, and you know they’re going to be
good because they work constructively within the team. But with some
with doctors, we often just get point blank refusal to co-operate.
[What are the consequences of this? How does the audit cycle, and
associated governance processes intervene to feedback in such
circumstances?] Well, the pharmacy audit will be sent to the medical
director but, with the lack of prescriber identification, and data
aggregation, it gets blunted.
Pharmacist, Antibiotics Medicines Management, case site
C1 (013); transcription 8:48
