Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: experiences from the safe hands study

Annette Erichsen Andersson, Maria Frödin, Lisen Dellenborg, Lars Wallin, Jesper Hök, Brigid M Gillespie, Ewa Wikström, Annette Erichsen Andersson, Maria Frödin, Lisen Dellenborg, Lars Wallin, Jesper Hök, Brigid M Gillespie, Ewa Wikström

Abstract

Background: Hand hygiene and aseptic techniques are essential preventives in combating hospital-acquired infections. However, implementation of these strategies in the operating room remains suboptimal. There is a paucity of intervention studies providing detailed information on effective methods for change. This study aimed to evaluate the process of implementing a theory-driven knowledge translation program for improved use of hand hygiene and aseptic techniques in the operating room.

Methods: The study was set in an operating department of a university hospital. The intervention was underpinned by theories on organizational learning, culture and person centeredness. Qualitative process data were collected via participant observations and analyzed using a thematic approach.

Results: Doubts that hand-hygiene practices are effective in preventing hospital acquired infections, strong boundaries and distrust between professional groups and a lack of psychological safety were identified as barriers towards change. Facilitated interprofessional dialogue and learning in "safe spaces" worked as mechanisms for motivation and engagement. Allowing for the free expression of different opinions, doubts and viewing resistance as a natural part of any change was effective in engaging all professional categories in co-creation of clinical relevant solutions to improve hand hygiene.

Conclusion: Enabling nurses and physicians to think and talk differently about hospital acquired infections and hand hygiene requires a shift from the concept of one-way directed compliance towards change and learning as the result of a participatory and meaning-making process. The present study is a part of the Safe Hands project, and is registered with ClinicalTrials.gov (ID: NCT02983136 ). Date of registration 2016/11/28, retrospectively registered.

Keywords: Aseptic technique; Co-creation; Hand hygiene; Implementation; Interprofessional learning; Knowledge translation; Operating room.

Conflict of interest statement

Ethics approval and consent to participate

The study was approved by the Gothenburg Regional Ethics Review Board, (Gothenburg, Sweden, reference number:166–15). This ethics approval stipulated that we could only collect data on the profession of the participants and no other identifying information. The study was conducted according to the Swedish Ethical Review Act SFS number: 2003:460. Based on this Act, which stipulates that healthcare workers are not required to provide written consent, only verbal consent was obtained, as approved by the Gothenburg Regional Ethics Review Board. They were informed in writing that they could choose not to participate in the study, however none did. Participants were given written and oral information in line with the four principal requirements of the Helsinki Declaration: autonomy, non-malfeasance, beneficence, and justice. The study was approved by the hospital Chief Executive Officer and the department managers.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
An overview of the three phases of the Knowledge Translation program

References

    1. Sjödahl R, Ahlberg J, Rutberg H, Nylén U, Montgomery A, Borgstedt-Risberg M. Skador i vården – skadepanorama och kostnader för kirurgi. 2014.
    1. World Health Organization. Report on the burden of endemic health care-associated infection worldwide. Geneva: World Health Organization; 2011.
    1. Eriksson N, Mullern T, Andersson T, Gadolin C, Tengblad S, Ujvari S. Involvement drivers: a study of nurses and physicians in improvement work. Quality Management in Health Care. 2016;25(2):85–91. doi: 10.1097/QMH.0000000000000092.
    1. Casewell M, Phillips I. Hands as route of transmission for Klebsiella species. Br Med J. 1977;2(6098):1315–1317. doi: 10.1136/bmj.2.6098.1315.
    1. Doebbeling BN, Stanley GL, Sheetz CT, Pfaller MA, Houston AK, Annis L, Li N, Wenzel RP. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med. 1992;327(2):88–93. doi: 10.1056/NEJM199207093270205.
    1. Grayson ML, Jarvie LJ, Martin R, Johnson PD, Jodoin ME, McMullan C, Gregory RH, Bellis K, Cunnington K, Wilson FL, et al. Significant reductions in methicillin-resistant Staphylococcus Aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out. Med J Aust. 2008;188(11):633–640.
    1. Zafar AB, Butler RC, Reese DJ, Gaydos LA, Mennonna PA. Use of 0.3% triclosan (Bacti-stat) to eradicate an outbreak of methicillin-resistant Staphylococcus Aureus in a neonatal nursery. Am J Infect Control. 1995;23(3):200–208. doi: 10.1016/0196-6553(95)90042-X.
    1. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, Perneger TV. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control Programme. Lancet (London, England) 2000;356(9238):1307–1312. doi: 10.1016/S0140-6736(00)02814-2.
    1. World Helath Organization. Clean Care is safe Care. . Accessed Apr 2017.
    1. World Health Organization guidelines on hand hygiene in health care. . Accessed Apr 2017.
    1. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, van Beeck EF. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283–294. doi: 10.1086/650451.
    1. Krediet AC, Kalkman CJ, Bonten MJ, Gigengack AC, Barach P. Hand-hygiene practices in the operating theatre: an observational study. Br J Anaesth. 2011;107(4):553–558. doi: 10.1093/bja/aer162.
    1. Biddle C. Semmelweis revisited: hand hygiene and nosocomial disease transmission in the anesthesia workstation. AANA Journal. 2009;77(3):229–237.
    1. Megeus V, Nilsson K, Eriksson B, Karlsson J, Andersson Erichsen A. Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating room. Antimicrobial Resistance and Infection Control. 2015;4(5)
    1. Megeus V, Nilsson K, Karlsson J, Eriksson BI, Andersson AE. Hand contamination, cross-transmission, and risk-associated behaviors: an observational study of team members in ORs. AORN J. 2015;102(6):645.e641–645.e612. doi: 10.1016/j.aorn.2015.06.018.
    1. Loftus RW, Brown JR, Koff MD, Reddy S. Heard SO, Patel HM, Fernandez PG, beach ML, Corwin HL, Jensen JT et al: multiple reservoirs contribute to intraoperative bacterial transmission. Anesth Analg. 2012;114(6):1236–1248. doi: 10.1213/ANE.0b013e31824970a2.
    1. Loftus RW, Koff MD, Birnbach DJ. The dynamics and implications of bacterial transmission events arising from the anesthesia work area. Anesth Analg. 2015;120(4):853–860. doi: 10.1213/ANE.0000000000000505.
    1. Loftus RW, Koff MD, Brown JR, Patel HM, Jensen JT, Reddy S, Ruoff KL, Heard SO, Yeager MP, Dodds TM. The dynamics of Enterococcus transmission from bacterial reservoirs commonly encountered by anesthesia providers. Anesth Analg. 2014;120(4):827–36.
    1. Kingston L, O'Connell NH, Dunne CP. Hand hygiene-related clinical trials reported since 2010: a systematic review. The Journal of hospital infection. 2016;92(4):309–320. doi: 10.1016/j.jhin.2015.11.012.
    1. Gould DJ, Moralejo D, Drey N, Chudleigh JH. Interventions to improve hand hygiene compliance in patient care. The Cochrane database of systematic reviews. 2010;(9):Cd005186.
    1. Luangasanatip N, Hongsuwan M, Limmathurotsakul D, Lubell Y, Lee AS, Harbarth S, Day NP, Graves N, Cooper BS. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. BMJ. 2015;351:h3728. doi: 10.1136/bmj.h3728.
    1. Schweizer ML, Reisinger HS, Ohl M, Formanek MB, Blevins A, Ward MA, Perencevich EN. Searching for an optimal hand hygiene bundle: a meta-analysis. Clin Infect Dis. 2014;58(2):248–259. doi: 10.1093/cid/cit670.
    1. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, Moore L, O'Cathain A, Tinati T, Wight D, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258. doi: 10.1136/bmj.h1258.
    1. Steckler A, Linnan L. Process evaluation for public health interventions. First. San Francisco: Jossey-Bass; 2002.
    1. Taylor SL, Dy S, Foy R, Hempel S, McDonald KM, Ovretveit J, Pronovost PJ, Rubenstein LV, Wachter RM, Shekelle PG. What context features might be important determinants of the effectiveness of patient safety practice interventions? BMJ quality & safety. 2011;20(7):611–617. doi: 10.1136/bmjqs.2010.049379.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science : IS. 2009;4:50. doi: 10.1186/1748-5908-4-50.
    1. Rycroft-Malone J, Seers K, Chandler J, Hawkes CA, Crichton N, Allen C, Bullock I, Strunin L. The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework. Implementation science : IS. 2013;8:28. doi: 10.1186/1748-5908-8-28.
    1. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7:50. doi: 10.1186/1748-5908-7-50.
    1. Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. The Journal of hospital infection. 2001;48 Suppl A:S40–S46. doi: 10.1016/S0195-6701(01)90012-X.
    1. Fuller C, Besser S, Savage J, McAteer J, Stone S, Michie S. Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines. Am J Infect Control. 2014;42(2):106–110. doi: 10.1016/j.ajic.2013.07.019.
    1. Fernandez PG, Loftus RW, Dodds TM, Koff MD, Reddy S, Heard SO, Beach ML, Yeager MP, Brown JR. Hand hygiene knowledge and perceptions among anesthesia providers. Anesth Analg. 2014;
    1. Coe R, Gould D. Disagreement and aggression in the operating theatre. J Adv Nurs. 2008;61(6):609–618. doi: 10.1111/j.1365-2648.2007.04544.x.
    1. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330–334. doi: 10.1136/qshc.2003.008425.
    1. Rosenstein AH, O'Daniel M: A survey of the impact of disruptive behaviors and communication defects on patient safety. (1553-7250 (Print)).
    1. Undre S, Sevdalis N, Healey AN, Darzi S, Vincent CA. Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract. 2006;12(2):182–189. doi: 10.1111/j.1365-2753.2006.00614.x.
    1. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204(4):533–540. doi: 10.1016/j.jamcollsurg.2007.01.010.
    1. Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg. 2007;246(5):705–711. doi: 10.1097/SLA.0b013e31815865f8.
    1. Catchpole K, Mishra A, Handa A, McCulloch P. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699–706. doi: 10.1097/SLA.0b013e3181642ec8.
    1. Nembhard IM, Edmondson AC. Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27(7):941–966. doi: 10.1002/job.413.
    1. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126(1):66–75. doi: 10.1067/msy.1999.98664.
    1. Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Dorman T, Dickman F, Fahey M, Steinwachs DM, Engineer L, Sexton JB, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305–315. doi: 10.1016/j.jcrc.2006.07.001.
    1. Reason J. Safety in the operating theatre - part 2: human error and organisational failure. Qual Saf Health Care. 2005;14(1):56–60. doi: 10.1097/00019514-200501000-00007.
    1. Gillespie BM, Gwinner K, Chaboyer W, Fairweather N. Team communications in surgery - creating a culture of safety. J Interprof Care. 2013;27(5):387–393. doi: 10.3109/13561820.2013.784243.
    1. Leslie M, Paradis E, Gropper MA, Reeves S, Kitto S. Applying ethnography to the study of context in healthcare quality and safety. BMJ quality & safety. 2014;23(2):99–105. doi: 10.1136/bmjqs-2013-002335.
    1. Isaacs WN. Creating a shared field of meaning: an action theory of dialogue. In: Roberts NC, editor. The transformative power of dialogue. Research in Public Policy Analysis and Management: Emerald Group Publishing Limited; 2002. pp. 203–241.
    1. Schein E. Organizational culture and leadership: Wiley. 2010.
    1. Ekman I, Swedberg K, Taft C, Lindseth A, Norberg A, Brink E, Carlsson J, Dahlin-Ivanoff S, Johansson IL, Kjellgren K, et al. Person-centered care - ready for prime time. Eur J Cardiovasc Nurs. 2011;10(4):248–251. doi: 10.1016/j.ejcnurse.2011.06.008.
    1. Savage J. Participative observation: standing in the shoes of others? Qual Health Res. 2000;3(10):324–339. doi: 10.1177/104973200129118471.
    1. Carroll C, Patterson M, Wood S, Booth A, Rick J, Balain S: A conceptual framework for implementation fidelity. (1748-5908 (Electronic)).
    1. Miles M, Huberman A, Saldana J. Qualitative data analysis, a methods sourcebook. Thousand Oaks: SAGE Publications; 2014.
    1. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–112. doi: 10.1016/j.nedt.2003.10.001.
    1. Smiddy MP, OC R, Creedon SA. Systematic qualitative literature review of health care workers' compliance with hand hygiene guidelines. Am J Infect Control. 2015;43(3):269–274. doi: 10.1016/j.ajic.2014.11.007.
    1. Havens DS, Vasey J, Gittell JH, Lin WT. Relational coordination among nurses and other providers: impact on the quality of patient care. J Nurs Manag. 2010;18(8):926–937. doi: 10.1111/j.1365-2834.2010.01138.x.
    1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet (London, England) 2003;362(9391):1225–1230. doi: 10.1016/S0140-6736(03)14546-1.
    1. Bodenheimer T. The American health care system--the movement for improved quality in health care. N Engl J Med. 1999;340(6):488–492. doi: 10.1056/NEJM199902113400621.
    1. Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? The Milbank quarterly. 1998;76(4):517–563. doi: 10.1111/1468-0009.00105.
    1. Rogers E. Diffusion of preventive innovations. Addict Behav. 2002;27:989–993. doi: 10.1016/S0306-4603(02)00300-3.
    1. Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis. 2003;9(2):196–203. doi: 10.3201/eid0902.020232.
    1. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev. 2007;85(1):96–103.
    1. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. The Cochrane database of systematic reviews. 2012;6:Cd000259.
    1. O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis DA, et al. Educational outreach visits: effects on professional practice and health care outcomes. The Cochrane database of systematic reviews. 2007;4:Cd000409.
    1. Loup R. The road to commitment: capturing the head, heats and hands of people to effect change. Organ Dev J. 2005;23(3):73–81.
    1. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–383. doi: 10.2307/2666999.
    1. Schein EH. On dialogue, culture, and organizational learning. IEEE Eng Manag Rev. 1995;23(1):23–29.
    1. van Kerkhoff LE, Lebel L. Coproductive capacities: rethinking science-governance relations in a diverse world. Ecol Soc. 2015;20(1)
    1. The Definition and Principles of Interprofessional Education []. Accessed Apr 2017.
    1. Knowles M. The adult learner : a neglected species. 4. Huston: Gulf; 1996.
    1. Lave J, Wenger E. Situated learning: legitimate peripheral participation., vol. 1. Cambridge: Cambridge University Press; 1991.
    1. Wenger E. Community of Practice: learning, meaning and identity. Cambridge: Cambrige University and Identity; 1998.
    1. Metz A, Albers B. What does it take? How federal initiatives can support the implementation of evidence-based programs to improve outcomes for adolescents. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2014;54(3 Suppl):S92–S96. doi: 10.1016/j.jadohealth.2013.11.025.
    1. Bason C. Leading public sector innovation: co-creating for a better society. Bristol: The Policy Press; 2010.
    1. Brown T, Wyatt J. Design thinking for social innovation. Stanf Soc Innov Rev. 2010;8(1):30–35.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj