qualitative analysis of learning needs in infection ... · this study used qualitative research...

Qualitative Analysis of Learning Needs in Infection Prevention and

Control (IPC) Staff

Michelle Clark | Health Psychology Team, Psychology Directorate, NES | 17th January 2017

Study Rationale

Effective infection prevention and control (IPC) within the NHS is essential for patient safety; an

issue which was highlighted by the public inquiry into the clostridium difficile infection (CDI)

outbreak in the Vale of Leven Hospital (VOLH) which occurred between 2007 and 2008 and

claimed the lives of 34 people. The report, published in 20141, found that failures in infection

prevention and control at a systems and individual level had a ‘profound effect’ on the care of

patients. These included failures in inspection systems and implementation of healthcare

associated infection (HAI) policies and guidance. Clinical governance, leadership, management,

record keeping, reporting, staff training, staffing levels and skills mix and antibiotic prescribing,

amongst others, did not reach standards required to prevent and detect infection outbreaks1.

Of the 75 recommendations made in response to the investigation, 26 directly related to IPC.

This highlights the importance of the IPC team and how it functions, from staff training,

implementation of policies, and use of audit and surveillance systems.

Development is underway of the new NHS Education for Scotland (NES) Scottish Infection

Prevention and Control Education Pathway (SIPCEP) which will allow a personalised IPC learning

and progression pathway to be created for all health and social care staff. Using a flexible

delivery model (see Fig 1), the pathway will provide equality of access in response to learning

needs of stakeholders, from novice to expert. The learning needs of IPC team members are

likely to be positioned at the intermediate and improvement levels of the model, and as such,

the NES HAI team wanted to investigate these needs in more detail to ensure that they will be

met by the new pathway.

NEED FOR BEHAVIOUR CHANGE

Providing information is an important element in any adult learning programme. However,

these programmes can be made more effective by using a behavioural approach based on

psychology theory. This allows the identification of evidence based behavioural indicators3

which can be targeted via education programmes with the aim of supporting health

professionals to make changes in behaviour which improve the quality and safety of care

provided.

Previous studies carried out by health psychologists and elsewhere, have identified an ‘intention

– behaviour gap’; most people intend to ‘do the right thing’ in relation to promoting health and

providing good healthcare, but individual or environmental factors sometimes intervene and the

intended behaviour is not performed4. As the IPC team rely on other staff members ‘doing the

right thing’ in order to reduce HAIs, one important role of the IPC team is to support NHS staff

from all departments, to carry out their job roles in a way that is consistent with those

guidelines. This requires IPC staff to deliver education programmes at a local level which are

aimed at changing staff behaviour.

Figure 1 Scottish Infection Prevention and Control Education Pathway

In the event of an outbreak, the role of the IPC team is to contain and manage the outbreak, to

investigate the causes and to spread learning from these events. In order to proactively manage

the risk of HAIs, IPC teams carry out monitoring and auditing of rates of infection, occurrences of

specific organisms and of behavioural adherence to IPC guidelines. This information is used to

provide continuing education and support for staff as well as to guide patient care and as a

warning system for any potential increase in the risk of an outbreak.

If IPC staff are to perform their role effectively, it is useful to know the areas which they find

challenging and for what reason. This information can then be used to inform educational

packages developed by NES which will enable and support IPC staff meet these challenges.

Current Study

In health psychology, the COM-B5 and Theoretical Domains Framework (TDF)6 have been used as

a framework in patient safety research to identify a wide range of barriers and levers influencing

the practice of different patient safety behaviours.7, 8 A summary of the COM-B and the TDF is

provided in Appendix 1. The 14 domains identified in the TDF are defined in Table 1. These

domains create a framework which can be used to investigate a wide range of barriers and

facilitators of change, thus providing a wider range of intervention targets.

This study used qualitative research methods to assess the learning and educational needs of

IPC staff in relation to HAI and patient safety across a number of health boards in Scotland.

Focus groups were carried out with IPC nurses, and one to one interviews carried out with IPC

managers and doctors. Behaviour change models, the COM-B5 and TDF6 were used to guide

both data collection and data analysis to ensure the relevance and utility of the project outputs,

thus improving the sustainability of future educational programmes and interventions

developed from them.

Table 1. TDF domains and constructs6

TDF Domain Definition Constructs within the domain

Knowledge (an awareness of the existence of something)

Knowledge; Procedural knowledge; Knowledge of task environment.

Skills (an ability or proficiency acquired through practice)

Skills; Skill development; Competence; Ability; Interpersonal skills; Practice; Skill assessment.

Social/Professional Role and Identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting)

Professional identity; Professional role; Social identity; Identity; Professional boundaries; Professional confidence; Group identity; Leadership; Organisational commitment.

Beliefs about Capabilities (Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use)

Self-confidence; Perceived competence; Self-efficacy; Perceived behavioural control; Beliefs; Self-esteem; Empowerment; Professional confidence.

Optimism (The confidence that things will happen for the best or that desired goals will be attained)

Optimism; Pessimism; Unrealistic optimism; Identity.

Beliefs about Consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation)

Beliefs; Outcome expectancies; Characteristics of outcome expectancies; Anticipated regret; Consequents.

Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus)

Rewards (proximal / distal, valued / not valued, probable / improbable); Incentives; Punishment; Consequents; Reinforcement; Contingencies; Sanctions.

Intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way)

Stability of intentions; Stages of change model; Trans theoretical model and stages of change.

Goals (Mental representations of outcomes or end states that an individual wants to achieve)

Goals (distal / proximal); Goal priority; Goal / target setting; Goals (autonomous / controlled); Action planning; Implementation intention.

Memory, Attention and Decision Processes (The ability to retain information, focus selectively on aspects

Memory; Attention; Attention control; Decision making; Cognitive overload / tiredness

of the environment and choose between two or more alternatives)

Environmental Context and Resources (Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour)

Environmental stressors; Resources / material resources; Organisational culture /climate; Salient events / critical incidents; Person x Environment interaction; Barriers and facilitators

Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours)

Social pressure; Social norms; Group conformity; Social comparisons; Group norms; Social support; Power; Intergroup conflict; Alienation; Group identity; Modelling

Emotion (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event)

Fear; Anxiety; Affect Stress; Depression; Positive / negative affect; Burn-out

Behavioural Regulation (Anything aimed at managing or changing objectively observed or measured actions)

Self-monitoring; Breaking habit; Action planning

AIMS AND OBJECTIVES

Aims:

1. To understand the specific patient safety and quality improvement learning needs of IPC

staff required for the delivery of safer healthcare, using a behaviour change model as a

framework

2. To provide recommendations which will inform the development of the Scottish

Infection Prevention and Control Education Pathway

Objectives: 1. Devise a semi-structured interview guide based on a behaviour change model which will

elicit relevant patient safety and quality improvement learning needs (Appendix 3a&b)

2. Carry out a series of semi-structured interviews /focus groups with 3 different groups of

IPC staff (IPC nurses, IPC managers and IPC doctors), from a variety of different health

boards

3. Analyse data for themes relating to training needs

4. Map the themes identified in the analysis to evidence based behaviour change

techniques

5. Use the outcomes of the analysis and mapping exercise to highlight current gaps in IPC

staff training and to suggest specific learning/behaviour change interventions to address

these learning needs.

METHOD

Participant recruitment:

A recruitment email (Appendix 2a) was sent via the NES HAI team to all IPC managers and

doctors (n=49) and IPC nursing leads (n=18), in Scotland inviting them to take part in either a

focus group (choice of five groups held in Glasgow, Edinburgh and Dundee) or a one to one

interview. As we did not have contact details for all IPC nurses currently in post, email recipients

were asked to cascade the recruitment email to their teams so that all grades of IPC nurses were

included. Participants were offered the choice to attend in person or virtually via the use of

video or audio conferencing to increase participation in the project. If interested, they were

asked to contact the researcher directly to arrange an interview or to confirm they were

attending a focus group, and in return they were sent a participant information sheet (Appendix

2b & c) and a consent form (Appendix 2d & e) to complete and return.

Development of the focus group and semi-structured interviews:

Semi-structured interview guides were created for both the focus groups and one to one

interviews using the COM-B5 model as a structure. In order to understand what

training/education is required for IPC staff at different levels, the COM-B and TDF6 frameworks

were used to investigate the barriers and levers to effectively carrying out the role of IPC

nurse/manager/doctor. By knowing what the main issues are in the field, education

programmes can then be developed to address these issues and to provide IPC staff with the

knowledge, skills and confidence required to carry out their roles. As the TDF has been mapped

onto the behaviour change taxonomy, this can be used to identify specific behaviour change

techniques, teaching methods or activities which could be included in the programme to achieve

the learning outcomes. Participants were also asked for a ‘training wish list’ so that any specific

topics and methods identified by staff could be included in the report.

When using the COM-B and the TDF to investigate barriers and levers to a behaviour, it is

necessary to define the behaviour.9 In this case, the behaviour has been defined as ‘performing

the role of IPC nurse/manager/doctor’. Although this is a broad definition, it is important to

establish the barriers and levers to performing the job as a whole. This can then be used to

develop supporting generic educational programmes ensuring all aspects of the IPC role are

included.

First, exploratory questions were asked relating to the job role, the main issues experienced in

carrying out that role and views on the existing education programmes available from NES in

relation to HAI. Participants were then asked if they had a training ‘wish list’ and to describe

what training would make it easier to carry out their role. Finally, if not already addressed,

questions relating to the COM-B domains of ‘capability’, ‘opportunity’ and ‘motivation’ were

asked to investigate the impact of these factors on participants’ ability to perform their role.

Focus groups and interviews:

Focus groups were carried out with the largest staff group i.e. IPC nurses, in order to optimise

resources and capacity. Similarly, to increase access to the groups, participants were able to

take part in the groups face to face or virtually, using video or audio conferencing. Although five

focus groups were arranged, only three could be classed as focus groups due to low

participation numbers on two of the planned group days. In addition, one video conference

which was initially considered to be a focus group, was reclassified as an IPC manager interview

(only two participants), as although the IPC nurse for that board was present, most of the

feedback came from the IPC manager. In total, four sets of IPC nursing data were obtained for

analysis (n=17).

Individual interviews, carried out face to face or via video or audio conferencing, were

completed with IPC managers and doctors. In total, five interviews were carried out with IPC

managers (n=5) and five with IPC doctors (n=5).

Across the whole study 27 staff participated and 10 out of the 14 NHS boards were represented,

including a mix of remote, rural and urban areas. A response rate was not calculated as it is not

possible to know the final number of IPC nurses who received the recruitment email.

All interviews were voice recorded and transcribed by an external transcription company, with

the exception of one manager interview, where the voice recording failed. In this case, hand

written notes were taken and verified with the participant for accuracy.

Audio files and electronic documents will remain stored on a database held on a secure NHS

Education for Scotland (NES) server.

Ethics

Participants were supplied with a project information sheet and asked to complete a consent

form prior to taking part in a group or interview (see Appendix 2d&e). Participants were also

verbally reminded about the details of the study and what they had consented to prior to the

interview beginning. NHS Ethical approval was not required as this project is considered to be

service improvement. The project was registered with NES Psychology Directorate Research

Governance as per the Psychology Directorate policy.

Data Analysis

Transcripts were analysed for themes using the COM-B5 and TDF6 as a framework. As the COM-

B model can be broken down further into the domains from the TDF, data were coded for items

relating to the TDF domains. An excel database was created containing data items from each

transcript, categorised according to the TDF domain it related to. Data items could relate to

more than one domain at a time.

Once all transcripts were coded, the number of data items in each domain category was

counted to establish the most common domains highlighted in the interviews (Figure 2). Those

domains with an average of 9 or more data items (median split) were analysed further for the

additional context surrounding the involvement of each domain.

Results

Analysis of focus group and interview data provided a wide range of issues relating to the

practice of IPC across NHS boards. Not all of these issues can be addressed through education

programmes and as such, not all are within the remit of NES to resolve. However, in order to

represent the voices of the staff who took part in the project, both educational and non-

educational issues have been reported in order to highlight the nature and complexity of IPC

staff experiences.

TDF DOMAINS MOST COMMONLY HIGHLIGHTED IN ALL 3 GROUPS (AVERAGE ≥ 9

OCCURRENCES; FIGURE 3)

In response to the questions asked during the interviews/focus groups, participants discussed

issues which could be categorised according to the TDF6 domains. The most common domains

highlighted were:

1. Environmental context & resources

2. Social & professional role & identity

3. Knowledge & skills

This suggested these are areas where staff believe there are the most barriers to performing

their job.

1. Environmental context and resources

Comments relating to the practice of IPC could most frequently be categorised into the

environmental context & resources domain of the TDF and most often as barriers to the

performance of the IPC role across all three groups.

1a. Resources

The most common barrier to effective IPC practice was related to a perceived lack of resources,

which had a range of impacts on both IPC team members’ perceived ability to do their job, and

also on the rest of NHS staffs’ ability to operationalise IPC guidance.

For all IPC staff, this included a reported lack of specific training for new IPC doctors and

managers, especially in small rural and island boards where often the context (geographical

location, population needs etc.) can create variation in job roles, and where there are few

existing staff for new starts to shadow

certainly for all of us it’s learning on the job because there is no sort of

toolbox of things, there is no little handover booklet, (IPCM)

Figure 2.Frequency of TDF domains highlighted per staff group

For IPC nurses and managers, a reported increased workload and difficulties in recruiting and

retaining staff have added significant pressures, reducing their ability to meet the IPC role

requirements.

it’s managing the expectations and the variability of the demand because we

can have high instances of outbreaks where our workload …can be sky high

and then the problem being is we’re constantly having to rob Peter to pay

Paul to keep on top of the workload. But resource wise you have a finite

resource and to deliver the expectations within that finite resource, when

you’re trying to manage multiple incidents, is a massive, massive challenge

(IPCM)

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IPC Doctors

IPC Managers

IPC Nurses

they (IPCNs) are desperately, desperately trying to protect their patients and

keep their patients safe. But that becomes very, very hard when you’re

competing six priorities. (IPCM)

Figure 3. Average frequency of data items per domain category for all groups of IPC staff

IPC managers spoke about a desire to work proactively to prevent IPC incidences but that this

was sometimes not possible due to pressures on the service.

It’s tipping a balance of the proactive and reactive, trying to do it more

proactive and less reactive. But you do seem to be putting fires out all over

the place (IPCN)

we have an educational component, we have a surveillance component, we

have policy development and guidance development component. We have

obviously the patient management aspect, so it’s a massive role. And

balancing the proactive parts of the job like policy development, and for me

things like strategy development, against the reactive service delivery

component is enormously challenging (IPCN)

It was reported that lack of resources within the NHS as a whole can also impact on the

outcomes of the IPC teams’ interventions to improve IPC adherent behaviour and to reduce

infection rates. Time and perceived staffing pressures mean that some staff do not get released

to attend the education sessions run by the IPC teams. Staff also reported there is a general lack

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TDF Domains

of access to computer systems to complete online training and staff may have several other

training commitments. Similarly, high work load and high cognitive load can interfere with IPC

adherence as staff prioritise other tasks in order to get through the work.

getting anybody freed from the ward to do training is very, very difficult

these days. So, people, you know, the core people sign up to courses and

they don't get released from the ward to do it and I guess in theory although,

you know, people could do these things in their own time at home, I think

that's very, you know, realistically that's not what people do (IPCD)

Funding for training or attendance at conferences to keep up to date with recent developments

was also reported to be a problem, again especially for the rural and island boards. Therefore,

despite being viewed as a less than optimal way to deliver education, the availability of

eLearning and distance learning was seen as a lever for staff in remote and island boards as they

were often unable to travel to attend training courses.

1b. Culture

Another relevant aspect of the environmental context and resources which could be a barrier or

a lever to performing their role as an IPC nurse, manager or doctor, is the culture in which the

patient care is carried out. Environments where patient safety is explicitly stated as a high

priority for the board and where departments take ownership of the care they provide, often

help IPC teams feel more supported.

right from the top Chief Exec level, HAI leads, it filters down through your

infection control manager, the structures and unless these structures are in

place and you yourself have support from the management it is very very

difficult with regards to education (IPCN

For example, one manager highlighted that ownership of IPC and patient safety issues within

departments has improved due to Executive level support,

we feed (the data) back to the stakeholders, and it’s, I think…it’s always

perceived that that’s Infection Control’s responsibility… You tell us what’s

wrong and we’ll sort it. But now…(the) Chief Executive… who’s been saying

‘actually it’s not x’s responsibility, it’s your responsibility’, so I think that was

the biggest challenge that we had within this Board. Now it’s getting easier

(IPCM)

However, sometimes the patient safety culture within a board was reported to be reactive and

driven by government inspections as opposed to being embedded in patient care from the

outset.

because our Board focus is very much on “Let’s get it right before the

inspectors come in”, rather than, “This is the full agenda and this is where

your resources are”, so that it…it’s not this sort of quick fix type thing (IPCN)

If a supportive culture is not in place, it can be more difficult to prioritise and manage the

competing demands and to change attitudes of staff who perceive that IPC is an additional task

which interferes with patient centred care, as opposed to being the basis of providing patient

centred care

we're sort of putting in barriers to efficient patient flow and they (staff) might

see efficient, speedy patient flow as being as more important from a patient

safety point of view than cleaning your hands every time or cleaning the bed

properly every time or something like that. (IPCD)

one of the real issues now is I think is being able to direct some of our efforts

and resource to our local risks, because there is such a strong drive from the

centre to achieve certain targets, or collect data from a surveillance point of

view. So we are driven very much by mandatory requirements, which takes

up a huge part of our time, and then having to fit in the other aspects which

we would see at a local level as having a bigger impact on patient care (IPCN)

still people see infection control as add on extras they don’t see it should be

imbedded into every day practice. (IPCN)

1.c Context

Of the three groups of staff participating in the project, IPC nurses had the clearest job

description and career pathway. In most cases, nurses were required to achieve a qualification

in IPC although there was some debate over the level of this qualification i.e. certificate,

diploma or master’s level, in different boards. In relation to their job description and the duties

they carried out, they were similar across the boards. However, there was less standardisation

for IPC managers and doctors with variation in the roles and duties performed, as well as the

level of experience and training required. Some managers and doctors reported it was difficult

to be sure of their responsibilities and that they were meeting the objectives of the role, as a

result

I think there's quite a lot of variability in the way different boards, I don't

think boards themselves think about infection control doctors, they just

assume someone's there and they'll do the job. But they don't necessarily

think about what the resource is required to provide that service or even

exactly what that service is (IPCD)

the infection control doctor, it’s much less certain how you actually arrive at

that point. And historically, the infection control doctor and their role of

looking after infection control is always linked to, often, the last in the door,

really; from a consultant point of view it’s often gone to one of the more

junior microbiology consultants, (IPCD)

Some boards found it difficult to recruit to IPC posts, especially IPC doctor posts due to the

challenging nature of the role. Recent IPC incidents and subsequent inquiries, such as at the

VOL, may also have made the IPC doctor role less attractive.

it isn't always a popular job, so I think if you look around here there's plenty

of people who do it because they find it interesting, but there are some

aspects of it that aren't particularly fun (IPCD)

my worry is that, you know…people…the next generation of doctors realise it

is a big role and are kind of shying away from it, unless they particularly want

to do it. (IPCD)

2. Social, Professional Role & Identity

From the interviews with IPC doctors and managers, there was a sense of a lack of clarity in the

job role across health boards, which left some individuals covering a variety of responsibilities

not always relevant to the IPC role. Newer members of staff joining IPC teams expressed

uncertainty regarding their responsibilities and a lack of confidence in achieving the outcomes

expected.

so there’s probably something about really understanding what the role is.

I’ve had a look and I don’t think there’s much around what the actual

expectations are and what the experience and what the skills that an ICD

should have. (IPCD)

if you’re a microbiologist, then what are the other things you need to be an

ICD, around outbreaks and things like that. (IPCD)

This was especially the case in small island boards, where often staff have multiple job titles.

It is the same for a lot of the stuff we do here, because everybody here has to

wear so many hats that it’s quite often we’re doing the bare minimum, but

proportionate to the size of our Board though obviously. (IPCD)

Another barrier to carrying out the role of IPC doctor, manager or nurse, was the perceived

negative, authoritarian identity and reputation that IPC staff have. This identity may have been

developed through the actions in the past of IPC teams who used hierarchy and threat to

encourage adherence to guidelines.

they see us being a bit more just ‘sigh, it’s a jobsworth thing’. (IPCM)

I think what I’ve learned is…from being a nurse in the ward and knowing

when the infection control nurse would come in, you would always run a

mile. (IPCN)

Participants expressed that this has resulted in some staff members in other departments not

being willing to take responsibility for their own behaviour and for IPC events that occur,

assuming that the IPC team will resolve the issues. However, current IPC teams are more aware

that building positive relationships with all staff through being a visible and supportive resource,

can be a lever to effectively performing as a member of the IPC team.

our team have moved away from what we would refer to as the wagging

finger of infection control… Where the ICN rolls up and tells you off for what a

rubbish job you are doing, and you have caused the case of X or Y through

your very poor practice, and it’s very punitive and very negative, and doesn’t

really engage people. So it is about using a different skill set to go in and

listen to people, and understand from their perspective (IPCN)

There was an acknowledgement from IPC nurses that IPC is not something that they ‘do’ to the

rest of the staff. Instead, it is recognised that the IPC role is to support staff through the use of

communication, negotiation and behaviour change skills to change their attitudes and behaviour

to be consistent with IPC guidelines as part of providing patient centred care.

But anyone can learn about Microbiology, and learn about organisms, blah

de blah, but it’s the getting people to change behaviours, and influencing

that change that is key to the proactive aspect of the role, and it is difficult

(IPCN)

we are not that far away from the coalface ourselves, we can empathise with

them, appreciate what they are going through. And we are part of their

team to try and make things better, or to try and untangle a situation, and

we appreciate if there is an outbreak or there is some sort of incident, the

level of anxiety that can be caused can be immense. (IPCN)

3. Knowledge & Skills

Knowledge was seen as both a barrier and a lever for all staff group members. Indeed,

knowledge and skills were seen as a prerequisite for the job but there was a sense that

participants did not feel they always had the required knowledge and skills when they first took

on the role and that it took a long time to develop without the necessary support.

I think it takes years to cook a fully functioning effective infection control

nurse because of the breadth of the topics and the subject (IPCN)

In all groups, it was agreed that, in comparison to other specialist areas in the NHS where one

may become expert in a specific area, IPC teams need to know a lot about all aspects of the NHS

suggesting it can take a long time to gain all the knowledge and experience required to be

competent and confident in the role. Indeed, participants often talked about learning on the job

You certainly learn about all the various issues to do with infection and all the

rest of it, but a lot of the tools and skills that are required of an infection

control doctor are probably picked up once you become the infection control

doctor, rather than anyone gets training for it. (IPCD)

Each group highlighted a lack of standardised job specification and person specification for each

role. In particular, both IPC doctors and IPC managers appeared to be unclear about what their

role entails and what qualifications and training were required to do the job.

rather uncertain training, and uncertain... not revalidation but an update in

training for infection control doctors, because unlike being a consultant in

microbiology, the infection control doctor role is more of an appointment

rather than a fixed training programme (IPCD)

Despite there being a more formal education pathway in place for IPC nurses, there was still a

sense that it was hard to find all the information that you needed in order to be able to do the

job and also to be ready for completing further qualifications such as the master’s degree.

we always insisted that the nurses had a diploma and certainly at previous

boards I have worked in that has been the cut off point for us because we felt

that they needed that academic background in terms of the microbiology and

all the rest of it. (IPCN)

I did my SVQ in infection control and it didn’t enhance my learning for coming

out in infection control, a lot of learning is on the floor and it very much

depends on what is coming through the door. (IPCN)

There seemed to be an assumption that all that is required is a knowledge of infection control,

but in reality there are many other requirements.

it’s not knowledge of the infection that’s the issue. They know about the

knowledge of the infection and they know how transmissible the infection is,

it’s the knowledge of the experience that goes with managing the politics and

pitfalls, and maybe some other stuff that’s not purely microbiology (IPCD)

a lot of the risk assessments and the rest of it fall very much into science,

but... and actually outbreak control, there can also be a lot of grey in there

and it’s very much an art form in controlling and managing outbreaks and

working out, because the whole situation is changing continually, even during

the outbreak. It’s a lot of judgement calls at the appropriate time based on

experience, and it’s how to convey that type of experience to people who

have maybe not been exposed to it before. (IPCD)

Knowledge & skills were also seen at times to be levers to performing the role well at times. For

example, despite appearing to have less knowledge than more experienced IPC nurses, newly

qualified IPC nurses highlighted that they are more aware of current practices on the ward

which helps them to relate to the issues the staff face in adhering to IPC guidelines. It was

acknowledged that as a team, it was important to ensure a good knowledge and skills mix due

to the broad range of issues covered in the speciality.

Other relevant TDF domains

Apart from those detailed above, there were other TDF domains which were relevant to

individual groups.

For example, IPC nurses also discussed issues that related to: the ‘memory, attention and

decision processes’ domain; the ‘social influence’ and the ‘reinforcement’ domains. IPC

managers discussed issues that related to ‘belief about capabilities’ and ‘social influence’

domains.

Memory, attention & decision processes

IPC nurses highlighted concerns about other NHS staff repeatedly not performing in an IPC

consistent manner. They acknowledged that workloads can be high and resources are limited so

they may feel that IPC is not a priority, despite the interventions delivered by the IPC team.

I know that’s not an excuse, but I think they’ve got so much going on in the

clinical area that sometimes infection control is pushed aside (IPCN)

I don’t know what’s going on. Why they’re not getting it. Because we do, do

the education sessions and…there’s the learn pro modules that everybody

does as well (IPCN)

Reinforcement

The reinforcement domain was also highlighted by staff as a barrier to effective IPC. Some

things, such as HAI inspections, have provided NHS staff with reinforcement of the IPC message,

but it was felt that the goal of having IPC embedded in patient centred practice and not just

when inspections are due, has yet to be achieved in some boards.

everything’s focussed on…what do the inspectors want? What’s their

agenda, rather than, this is what our agenda is and that’s the benefit of

trying to improve the standards (IPCN)

It’s true unless the inspectorate or the HSE become involved in something

sometimes you just don’t feel the interest is up there. We are not in it for the

glory are we? it is a real thing preventing infection, people die of infection

and that is one of the frustrations (IPCN)

As mentioned previously in relation to social and professional role & identity, many IPC nurses

acknowledge that reinforcing staffs’ positive behaviour and strengths is a more effective way to

encourage adherence to guidelines than the negative use of punishment and hierarchy that was

often used in the past.

Social influences

It was recognised that perceived social influences can either help or hinder IPC teams’ ability to

influence adherence to IPC guidelines. These include the influence of senior management, the

culture within the board or department, the Scottish Government and the media. The social

influences that can act as barriers to effective IPC for nurses are related to hierarchy within an

organisation and a perceived culture of limited support for IPC from senior management.

the band fives I have are absolutely fantastic as well and their clinical

knowledge is exemplary but they are less confident about dealing with senior

people in the organisation and their lack of confidence is due to the fact that

they have never had to handle these people or if they have it has been very

much “I am in charge; you are the junior do as you are told.” (IPCN)

IPC managers also mentioned the impact of social influence on their ability to do their job. In a

similar way to IPC nurses, managers were negatively influenced by hierarchical structures and

perceived negative responses from others which had a demotivating effect on them.

your confidence can be undermined because if you’re trying to engage with

senior management and saying, “What you’re suggesting just will not work.”

And they just don’t listen; it does knock your confidence. When you’re sitting

at a meeting presenting your data and basically people keep arguing with

your data, that can knock your confidence, or just because you didn’t do it as

a chart that they liked… this is where the managers are very sure about this

isn’t going to work in practice but we don’t get listened to. You then think

well why bother because they’re not going to listen anyway. So that can be

de-motivating (IPCM)

Belief in capability

IPC managers expressed more often than other groups that they felt unable to achieve the

desired outcomes of the role due to perceived unrealistic workload and expectations. The

environmental context and resources factor came into this, with managers expressing that they

physically didn’t have the time or staffing to keep with the work demand. However, there was a

sense that they were being “pulled in different directions” between the needs of their patients

and the expectations of the government.

we’re doing things like mandatory surveillance where the infection rates are

one percent. And you’re thinking, where is the added value to improve things

for patients when we’re counting beans and very low beans when I’ve got

something over here that’s much higher and much more a risk to the patient,

much more a risk to the organisation, much more a risk to the reputation of

the organisation. But I can’t focus on it because I’ve got to count those, and

you want me to count them. You’re not telling me I’ve to do anything about

them, you’re just telling me I’ve to count them (IPCM)

Wish list

As well as enquiring about the COM-B5 and TDF6 domains, a question was asked to elicit

participant’s ideas about what they need from an IPC education pathway. They were asked, in

an ideal world with no restriction on cost or resources what would be on their ‘education wish

list’. The responses from this question were mapped onto the three most common TDF

domains as suggestions which could be employed in addressing the issues raised. Matrices were

created to present this information and for the areas which are within NES’s remit, possible

training suggestions, including specific behaviour change techniques which could be

incorporated into the programme to increase effectiveness, were collated in Table 2.

Learning needs and recommendations

The aim of this project was to establish the learning needs specific to the members of IPC teams

in view of the development of the new Scottish Infection Prevention and Control Education

Pathway. As this was a very broad area, behaviour change models the COM-B5 and TDF6 were

used to structure the collection and analysis of the data. The TDF allows the barriers and levers

to carrying out behaviour to be investigated according to 14 domains, which have been created

from the key constructs from 33 behaviour change theories (Table 1 and Appendix 1).

According to the COM-B model, behaviour is based on the presence of 3 factors: capability,

opportunity and motivation. If staff are to behave in a certain way, in this case, being an

effective IPC nurse, manager or doctor, it is important to ensure that staff members are well

equipped in all three of these areas. By asking how staff feel about each of these areas in

relation to their ability to do their job effectively, we can detect areas in which there are barriers

and develop education programmes which will strengthen IPC staffs’ capability, opportunity and

motivation to perform their role. Table 2 contains suggestions for training which would address

the most common TDF barriers and the specific issues around this as identified in the data. The

suggestions are a combination of items from the participants’ wish list, and other educational

interventions that incorporate behaviour change techniques which have evidence supporting

their effectiveness in addressing these domains.

TRAINING RECOMMENDATIONS

Specific induction courses for IPC teams

Participants suggested that as there is no specific training indicated for ICDs and ICMs, that an

induction course containing topics such as epidemiology, microbiology, risk management and

chairing outbreak meetings would be helpful. Participants also suggested regular update

training to maintain skills and knowledge. This would ensure that everyone had the required

knowledge base regardless of their previous IPC experience and would provide the relevant

specific training.

Facilitating Adult Education course

This course could be specifically aimed at ICNs who deliver both planned and ad hoc training in

IPC to staff from all areas of the NHS. It would support them in understanding the best ways to

engage adult learners and also ways to approach learning in informal situations such as when on

the ward. By using an adult learning approach, ICNs would be more equipped to tackle the issue

of high cognitive load often seen in NHS staff which often makes IPC adherence less of a priority

for them.

Facilitate coaching network

In order to ensure ongoing fidelity of knowledge and skills gained through the induction course

and the education pathway as a whole, a system of coaching is essential to enable IPC teams to

reflect on their own skills and development, to seek support and practice skills in a safe

environment.

Table 2 Training suggestions based on TDF domains and participants' wish list.

NES Remit Training Suggestions

Training suggestions TDF domains Staff group

IPC issues addressed

Specific induction courses for IPC team -

including: epidemiology,

microbiology, host defense, risk

management in IPC, managing/chairing

outbreak investigation

Knowledge & Skills;

Environmental Context & Resources

All Knowledge base of new IPC staff not standardised as come from all different backgrounds

lack of specific training for IPC staff to provide sound knowledge and practice in skills based techniques

Lack of training for new staff especially in small/remote/island boards where few staff to shadow/support new starts

Mentoring/ coaching network

Knowledge & Skills;


All Knowledge base of new IPC staff not standardised as come from all different backgrounds

Lack of specific training for IPC staff to provide sound knowledge and practice in skills based techniques

Lack of training for new staff especially in small/remote/island boards where few staff to shadow/support new starts

Facilitating Adult Education course

Knowledge & Skills;


ICN Not trained in delivering adult education

High workload/cognitive load interferes with IPC as a priority behaviour for most NHS staff - ICNs can use adult education methods to increase awareness of this barrier

Human factors training Knowledge & Skills;


ICM Vast range of topics they need to know about - different from many other specialties in the NHS

IPC team's actions have an impact on many other NHS depts.: need to have wide range of Non-Technical Skills in negotiating/managing/communicating etc.

Organisational culture: respond only to current govt agenda, not addressing local IPC needs

Reactionary culture - IPC prompted by inspections; not embedded in patient care

Non-technical skills training (inc.

communication skills, negotiation skills,

conflict management, decision making,

leadership)

Knowledge & Skills;

Environmental Context & Resources;

Social & Professional

Role & Identity

All Staff report knowledge of guidelines yet have low levels of adherence

Reactionary culture - IPC focused on when being inspected, not part of how care is performed

Staff see IPC role as enforcer/authoritarian/ policing behaviour/ 'jobsworth' - building better relationships which demonstrate support and respect in order to change the old image of IPC

Perception that IPC is IPC teams' responsibility - don't take ownership for behaviour

IPC identified as an additional task staff need to carry out, not embedded in patient focused care

Behaviour change training (including how

to use audit & QI for behaviour change)

Knowledge & Skills;

Environmental Context & Resources;

Social & Professional

Role & Identity

All Staff report knowledge of guidelines yet have low levels of adherence

High workload/cognitive load interferes with IPC as a priority behaviour - behaviour change techniques can be used to support adherence

IPC identified as an additional task staff need to carry out, not embedded in patient focused care

Increased monitoring/audit expectations reduces ability to perform proactive IPC duties and interventions

Use interactive/engaging

software (gaming principles) and blended learning approach (e.g. roadshows) to deliver

education


All On line & remote learning programmes are a lever for remote/island boards

Funding for training/travel to conferences etc. (especially island/remote boards)

Behaviour change training

It was appreciated that IPC teams cannot do their jobs without relying on other people to

adhere to guidelines and as such changing peoples’ behaviour is an important aspect of the IPC

role. However, in reality there often exists an ‘intention-behaviour gap’ whereby people may

intend to perform a behaviour, but they don’t carry out their intentions. Specific evidence

based behaviour change techniques (BCTs) can be used by IPC staff, in conjunction with soft

skills (or ‘non-technical skills’ see below), which increase the likelihood of IPC adherent

behaviours being adopted and maintained by clinical and non-clinical staff. Similarly, as

guidelines and policies are continuously changing, these techniques could also be useful in

changing the behaviour of IPC team members. For example, demonstrating how behaviour

change approaches could enhance the delivery and effectiveness of quality improvement

methodology and audit/monitoring processes.

Human Factors training

Several participants highlighted the role of human factors in the field of IPC. It was clear when

they were discussing issues relating to doing their job that the role is very varied and has wide

reaching implications for the NHS as a whole. Having an awareness of how all of the systems

interact with each other and with the individuals operating and using the systems would help to

reduce unintended consequences. Similarly, as patient safety can only occur when there is a

suitable culture operating in the organisation, human factors tools can be used to assess and

address the culture and other essential requirements of a safe and proactive organisation. The

‘Non-technical skills’ training highlighted below would form part of the overall approach to

address human factors issues in the field of IPC.

Non-Technical Skills (NTS) training

Non-technical skills have been defined as ‘the cognitive, social and personal resource skills that

complement technical skills and contribute to safe and effective task performance.10 This

includes communication, decision making, leadership, teamwork and managing stress and

fatigue. It was recognised by participants that IPC staff have to develop and maintain effective

working relationships with a wide variety of staff and departments and that conflicts of priorities

and resources can often challenge these relationships. Therefore, a course which supports staff

in managing these complex interactions and skills would be beneficial.

Use of technology and blended learning methods

Although many participants reflected that eLearning modules are often not the best way to

deliver training, there was an acknowledgement that with current resources, they are often the

first choice when rolling out education programmes. Indeed, eLearning packages can be the

only way for staff in remote or island boards to access training. However, this does not mean

that they have to be unengaging and de-motivating, delivering only surface knowledge which is

not context based. Technology can be used to produce blended learning packages which allow a

more realistic and contextual learning experience incorporating evidence based behaviour

change techniques and these should be explored in relation to education resources developed

specifically for IPC teams.

Discussion and Conclusions

This qualitative study aimed to gain insight to the main issues which act as barriers to IPC staff

performing their role effectively. From this broad list of barriers, created using a behaviour

change model as a framework, as well as participants’ own learning ‘wish list’, a variety of

educational resource suggestions have been made, which aim to address the barriers which are

within NES’s remit.

There are limitations to this study and as a result, findings and recommendations should be

interpreted with caution. Using qualitative methodology has the potential to produce data that

is biased, both by the researcher and by participants who have agreed to take part. Similarly, as

participants volunteer to take part, it is possible that the sample was unrepresentative and

therefore it is not possible to generalise the results to the whole IPC population. However, steps

were taken to mitigate these influences, such as sending reminder recruitment emails and

providing an additional fifth focus group to ensure everyone who wished to take part had the

opportunity to do so. An effort was made to ensure that there was a wide spread of

professionals within and across the groups, and that Boards with a range of contexts were

represented. It was hoped as the researcher was from an unrelated field and with no

professional influence in relation to IPC, that this would limit issues relating to anonymity and

confidentiality and of the researcher’s presence during data collection, which also often limits

the reliability of qualitative data.

As previously acknowledged, many of the barriers highlighted by the study are driven by other

factors and do not fall within NES’s remit. The National Implementation Research Network

(NIRN)11, 12 suggest however, that providing strong support for staff training, coaching and in the

selection of healthcare staff (which is within NES’s remit), can produce a compensatory effect

which can lessen the impact of the other organisational and leadership factors which have been

highlighted as challenges by IPC staff.

This implementation framework has been adopted by the NES Psychology Directorate to inform

the development and delivery of psychological based educational interventions across the NHS.

It could be used in conjunction with the results of the current study in order to provide a

comprehensive approach to supporting IPC teams and the NHS as a whole in achieving effective

IPC and the highest levels of patient safety and care.

References 1. MacLean. The Vale of Leven hospital enquiry report. APS Group Scotland. Report

number: DPPAS10898 (11/14), 2014.

2. NHS Education for Scotland. Healthcare Associated Infection (HAI): Education resources

to support health and social care staff in the prevention and control of HAI [leaflet]. NHS

Education for Scotland: Edinburgh; 2016.

3. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological

theory useful for implementing evidence based practice: a consensus approach. Quality

and Safety in Health Care. 2005; 14:26-33.

4. Sniehotta FF, Schwarzer R, Scholz U, Schuz B. action planning and coping planning for

long-term lifestyle change: theory and assessment. European Journal of Social

Psychology. 2005; 35: 565-576.

5. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for

characterising and designing behaviour change interventions. Implementation Science.

2011; 6:42. Available from: http://www.implementationscience.com/content/6/1/42

6. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use

in behaviour change and implementation research. Implementation Science. 2012; 7:37.

Available from: http://www.implementationscience.com/content/7/1/37

7. Taylor N, Lawton R, Slater B, Foy R. The demonstration of a theory-based approach to

the design of localized patient safety interventions. Implementation Science. 2013;

8:123. Available from: http://www.implementationscience.com/content/8/1/123

8. Atkins L, Hunkeler EM, Jensen CD, Michie S, Lee JK, Doubeni CA, Zauber AG, Levin TR,

Quinn VP, Corley DA. Factors influencing variation in physician ademona detection rates:

a theory-based approach for performance improvement. Gastrointestinal Endoscopy.

2016; 83:617-26.

9. Michie S, Atkins L, West R. The behaviour change wheel: a guide to designing

interventions. Great Britain: Silverback Publishing; 2014.

10. Flin R, O’Connor P, Crichton M. Safety at the Sharp End: A Guide to Non-Technical Skills.

Hampshire: CRC Press; 2008.

11. Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace. Implementation Research: A

Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte

Florida Mental Health Institute, The National Implementation Research Network (FMHI

Publication #231), 2005.

12. Fixsen DL, Blase KA, Naoom SF, Van Dyke M, Wallace F. Implementation: the missing link

between research and practice. Tampa, FL: University of South Florida, Louis de la Parte

Florida Mental Health Institute, The National Implementation Research Network, 2008.

http://www.implementationscience.com/content/6/1/42



Appendix 1

COM-B & TDF

The COM-B is a model of behaviour change which proposes that for a behaviour to occur, the

person has to have capability (physical and/or psychological), opportunity (physical and/or

social) and motivation (automatic and/or reflective) to carry out that behaviour. In addition, the

motivation for the behaviour must be stronger than the motivation to carry out competing

behaviours.

Figure 1. The COM-B model of behaviour change. Michie et al 20111.

In designing an intervention, the first step is to define the behaviour(s) that is to change. The

next step is to identify which of the three components need to change to result in the desired

behaviour change. Physical capability can include skills or strength, psychological capability

includes knowledge and understanding. Opportunity includes all factors that prompt or allow

the behaviour to be carried out, which can be physical or environmental opportunities, or social

opportunities as a result of the cultural environment. Finally, motivation (cognitive processes

which direct behaviour) can include reflective processes, such as making plans and evaluating

outcomes; or automatic processes, such as habits or emotional responses.

These three components can be further broken down into the 14 domains of the Theoretical

Domains Framework (TDF)2, 3, 4 which provides key constructs from 33 behaviour change

theories, arranged into 14 domains and can be used to identify barriers and levers to behaviour

change and areas in which an intervention may target (see Fig.2). The TDF has previously been

used to assess HH performance amongst physicians using qualitative interviews5, and healthcare

workers using real-time explanations6, and quantitative questionnaires.7 In all three studies, the

‘memory, attention and decision processes’ domain has been associated with HH performance,

where HH is higher if it was easier to recall. Amongst physicians, ‘knowledge,’ ‘skills,’ ‘beliefs

about capabilities,’ ‘beliefs about consequences,’ ‘goals,’ ‘environmental context and resources,’

social professional role and identity,’ and ‘social influences’ domains were also identified as

relevant within HH5. Where various professionals were assessed, results varied across

professionals, with doctors reporting ‘social influences’ as the most important predictor of HH,

however the sample was small7.

Figure 2. TDF domains linked to the COM-B components4

When considering health professional’s behaviour, such as the implementation of HH guidelines,

different processes require consideration. When assessing (self-reported) diabetes related

behaviours amongst health professionals, Presseau and colleagues found intentional, post-

intentional (planning), self-efficacious, and non-intentional (habit) processes were all likely

determinants of health professional’s behaviours.8

Another advantage of using the TDF as a framework, is that these domains have been mapped

onto the Behaviour Change Technique Taxonomy (v1) (BCTTv1).9 Thus, once barriers and levers

to behaviour change have been identified via the TDF, it is then possible to devise interventions

grounded in theory by selecting the most appropriate evidence based behaviour change

techniques to influence the desired change.

Although this project focuses on the initial learning needs analysis only, it is hoped that by

grounding this initial work in theory will make the development of future staff training and

evidence based interventions easier.

Appendix 2A

RECRUITMENT EMAIL SENT TO IPC NURSES

Dear Colleague,

The HAI team at NES are currently developing a new Scottish Infection Prevention and Control

Education Pathway to restructure the provision of national education in infection prevention

and control and to phase out the current Cleanliness Champions Programme (CCP). This is a

major work package for NES which will be undertaken over three years and completed by 2018.

This programme of work will consolidate the current HAI induction programmes and Cleanliness

Champions Programme to one Scottish Infection Prevention and Control Education Pathway.

As part of this work and in response to the Vale of Leven Hospital Inquiry report and subsequent

potential work plan for SARHAI, the HAI Policy Unit have requested NES undertake a gap

analysis relating to education and training for NHS health board Infection Control Doctors,

Managers and Nurses with a view to determining the areas where education provision can be

enhanced, adapted or generated.

We would very much appreciate your support either through direct participation, where

relevant, or through dissemination of information and encouraging participation within your

Health Board area. We are conscious of the demands on staff time and will schedule focus

groups at a time and location to suit, endeavoring to ensure these activities are conducted as

close to practice as possible to minimise disruption to day-to-day work. The results of the

evaluation will support NES in identifying and addressing gaps in provision and areas for

development which will help ensure NHSScotland staff are well informed and knowledgeable,

with appropriate training and skills development.

We hope that you will be able to support NES undertake this scoping study across your

NHS Board and thank you in advance for your co-operation.

Should you have any queries or wish to discuss further, please do not hesitate to contact

us.

There are 4 groups taking place and each will last approximately 1 hour:

Wednesday 20th July – Ninewells Hospital & Medical School, Dundee – 11.00-

12.00

Friday 22nd July – NES Central Office, 2 Central Quay, Glasgow – 11.00-12.00

Tuesday 26th July – NES Office, 102 Westport, Edinburgh – 11.00-12.00

Thursday 28th July – NES Central Office, 2 Central Quay, Glasgow – 11.00-12.00

Tea & coffee will be provided.

We hope you will join the discussion and help shape the new IPC training package.

If you are interested, please reply to this email by close of business on Friday 8th July

2016.

If you have any questions about the focus group process, please contact

[email protected] for more information.

RECRUITMENT EMAIL SENT TO IPC MANAGERS AND DOCTORS

Dear Colleague,

The HAI team at NES are currently developing a new Scottish Infection Prevention and Control

Education Pathway to restructure the provision of national education in infection prevention

and control and to phase out the current Cleanliness Champions Programme (CCP). This is a

major work package for NES which will be undertaken over three years and completed by 2018.

This programme of work will consolidate the current HAI induction programmes and Cleanliness

Champions Programme to one Scottish Infection Prevention and Control Education Pathway.

As part of this work and in response to the Vale of Leven Hospital Inquiry report and subsequent

potential work plan for SARHAI, the HAI Policy Unit have requested NES undertake a gap

analysis relating to education and training for NHS health board Infection Control Doctors,

Managers and Nurses with a view to determining the areas where education provision can be

enhanced, adapted or generated.

We would very much appreciate your support either through direct participation, where

relevant, or through dissemination of information and encouraging participation within your

Health Board area. We are conscious of the demands on staff time and will schedule interviews

at a time and location to suit, endeavouring to ensure these activities are conducted as close to

practice as possible to minimise disruption to day-to-day work. The results of the evaluation will

support NES in identifying and addressing gaps in provision and areas for development which

will help ensure NHSScotland staff are well informed and knowledgeable, with appropriate

training and skills development.

We hope that you will be able to support NES undertake this scoping study across your NHS

Board and thank you in advance for your co-operation.

We would like to invite you to participate in an interview and would appreciate if you could

contact Michelle Clark (details below) to notify your intent to participate, and Michelle will

contact you to arrange a suitable date. The interviews can be conducted as either a face-to-face

meeting, teleconference or videoconference.

We hope you will join the discussion and help shape the new IPC training package.

If you are interested, please reply by close of business on Friday 8th July 2016.

mailto:[email protected]

Should you have any queries or wish to discuss further, please do not hesitate to contact us.

Contact Details:

Dr Michelle Clark

Chartered Health Psychologist/Specialist Research & Training Lead

NES Psychology Directorate

2 Central Quay, Glasgow.

Tel: 0141 223 1637

Email: [email protected]


Appendix 2B – Information leaflet for nurses

Participant Information Leaflet:

Project Title: IPC Education and Training Gap Analysis. An invitation to take part in a project The HAI team at NES invite you to take part in a study that will inform the restructuring of the provision of national education in infection prevention and control through the development of a new Scottish Infection Prevention and Control Education Pathway. Before you decide, we would like you to understand why the project is being carried out and what it would involve for you. What is this project about? As part of this work and in response to the Vale of Leven Hospital Inquiry report and subsequent potential work plan for SARHAI, the HAI Policy Unit have requested NES undertake a gap analysis relating to education and training for NHS health board Infection Control Doctors, Managers and Nurses with a view to determining the areas where education provision can be enhanced, adapted or generated. Who can take part in this study? Any NHS health board Infection Control Nurses. Do I have to take part? No. Please be assured you are under absolutely no obligation to take part. If you choose not to take part, you will not be disadvantaged in any way. Risks There are no known risks for you in this project. What happens if I decide to take part in the study? We would like you to take part in a focus group. If you want to take part, please respond to the email in which you received this information sheet and advise which session you wish to attend. During the session we would like you to discuss your views in relation to your learning needs as an Infection Prevention and Control Nurse. There are no right or wrong answers and all of your views are important to us regardless of how different they may be from others The sessions will be audio recorded and then sent to an independent company who will transcribe what has been said during the session to allow the data to be analysed.

Time commitment The sessions will take approximately 1 hour to complete and will take place in the following venues on the following dates: Date Venue Time

Wednesday 20th July 2016 Ninewells Hospital and Medical School, Dundee, DD1 9SY (room to be confirmed)

11.00 -12.00

Friday 22nd July 2016 NES Central Office, 2 Central Quay, Glasgow G3 8BW (Room 6)

11.00-12.00

Tuesday 26th July 2016 NES Office, 102 Westport, Edinburgh, EH3 9DN (Room 1)

11.00-12.00

Thursday 28th July 2016 NES Central Office, 2 Central Quay, Glasgow G3 8BW (Room 5)

11.00-12.00

Confidentiality and anonymity Everyone attending the focus group will be asked to keep everything that was said during the discussion confidential and that we all show respect and empathy for each other throughout. You can say as little or as much as you wish. In the transcriptions, names will be changed so you will not be identifiable and at no point will your name appear in the final report or any publications. We will ensure you are not identifiable from any quotes used in reports or publications. Transcripts and audio files will be downloaded to a secure NHS server and the printed transcription documents will be stored in a locked cupboard within the NHS Education for Scotland offices These files will be held for 5 years. The audio recordings will be kept until the final report is completed, after which time they will be destroyed. What will happen if I don't want to carry on with the study? If you decide to take part in the study you can withdraw your participation at any time and without explanation. You can also refuse to answer any questions. If you agree to take part in the study, but then decide to withdraw, please contact Michelle Clark (see contact details). Once the focus group has been completed, data cannot be withdrawn but you will be reminded about this before the start of the focus group. What if there is a problem? If you have a concern about any aspect of this project, you should ask to speak to the researchers who will do their best to answer your questions (Contact details at the end of this information sheet). If you are still unhappy, you can make a formal complaint to Gill Walker, Programme Director, HAI, NHS Education for Scotland, 102 Westport, Edinburgh EH3 9DN; Email [email protected]; Tel 0131 656 3375.


What do I do next? If you wish to take part, please read all the information about the study and make sure you understand it before making a decision. If you decide to participate, please email [email protected] with your preferred focus group session. You will be given a copy of this information sheet and asked to sign a consent form before the focus group begins. Research Team Contact Details Dr Michelle Clark Chartered Health Psychologist/Specialist Research & Training Lead NES Psychology Directorate 2 Central Quay, Glasgow. Tel: 0141 223 1637 Email: [email protected] Mrs Catherine Murray CPsychol Chartered Health Psychologist/Specialist Research and Training Lead NES Psychology Directorate 2 Central Quay, Glasgow Tel: 0131 656 3476 Email: [email protected] Dr Julie Ferguson Research and Education Coordinator/Research and Training Officer NHS Education for Scotland 2 Central Quay, Glasgow Tel: 0141 223 1466 E-mail: [email protected] Elaine Boyd Practice Education Coordinator – HAI NHS Education for Scotland 2 Central Quay, Glasgow Tel: 0141 223 1471 Mobile: 07775 035533 E-mail: [email protected]






Appendix 2c –Information leaflet for managers and doctors

Participant Information Leaflet:

Project Title: IPC Education and Training Gap Analysis. An invitation to take part in a project The HAI team at NES invite you to take part in a study that will inform the restructuring of the provision of national education in infection prevention and control through the development of a new Scottish Infection Prevention and Control Education Pathway. Before you decide, we would like you to understand why the project is being carried out and what it would involve for you. What is this project about? As part of this work and in response to the Vale of Leven Hospital Inquiry report and subsequent potential work plan for SARHAI, the HAI Policy Unit have requested NES undertake a gap analysis relating to education and training for NHS health board Infection Control Doctors, Managers and Nurses with a view to determining the areas where education provision can be enhanced, adapted or generated. Who can take part in this study? Any NHS health board Infection Control Doctors or Managers. Do I have to take part? No. Please be assured you are under absolutely no obligation to take part. If you choose not to take part, you will not be disadvantaged in any way. Risks There are no known risks for you in this project. What happens if I decide to take part in the study? We would like you to take part in a one-to-one interview. This interview could be conducted face to face, or via video or teleconference. If you want to take part, please contact Michelle Clark (see contact details) to arrange a suitable date and time. During the session we would like you to discuss your views in relation to your learning needs as an Infection Prevention Doctors/Manager. There are no right or wrong answers and all of your views are important to us regardless of how different they may be from others The sessions will be audio recorded and then sent to an independent company who will transcribe what has been said during the session to allow the data to be analysed.

Time commitment Interviews will take approximately 20 minutes to complete and can be conducted at a time to suit you. Confidentiality and anonymity In the transcriptions, names will be changed so you will not be identifiable and at no point will your name appear in the final report or any publications. We will ensure you are not identifiable from any quotes used in reports or publications. Transcripts and audio files will be downloaded to a secure NHS server and the printed transcription documents will be stored in a locked cupboard within the NHS Education for Scotland offices. These files will be held for 5 years. The audio recordings will be kept until the final report is completed, after which time they will be destroyed. What will happen if I don't want to carry on with the study? If you decide to take part in the study you can withdraw your participation at any time and without explanation. You can also refuse to answer any questions. If you agree to take part in the study, but then decide to withdraw, please contact Michelle Clark (see contact details). Once the interview has been completed, data cannot be withdrawn. What if there is a problem? If you have a concern about any aspect of this project, you should ask to speak to the researchers who will do their best to answer your questions (Contact details at the end of this information sheet). If you are still unhappy, you can make a formal complaint to Gill Walker, Programme Director, HAI, NHS Education for Scotland, 102 Westport, Edinburgh EH3 9DN; Email [email protected]; Tel 0131 656 3375. What do I do next? If you wish to take part, please read all the information about the study and make sure you understand it before making a decision. If you decide to participate, please email [email protected] to arrange an interview. For face to face interviews, you will be given a copy of this information sheet and asked to sign a consent form before the interview begins. For interviews conducted remotely, you will be sent this information sheet again and a consent form to sign and return. Research Team Contact Details Dr Michelle Clark Chartered Health Psychologist/Specialist Research & Training Lead NES Psychology Directorate 2 Central Quay, Glasgow. Tel: 0141 223 1637 Email: [email protected] Mrs Catherine Murray CPsychol Chartered Health Psychologist/Specialist Research and Training Lead NES Psychology Directorate 2 Central Quay, Glasgow Tel: 0131 656 3476 Email: [email protected] Dr Julie Ferguson





Research and Education Coordinator/Research and Training Officer NHS Education for Scotland 2 Central Quay, Glasgow Tel: 0141 223 1466 E-mail: [email protected] Elaine Boyd Practice Education Coordinator – HAI NHS Education for Scotland 2 Central Quay, Glasgow Tel: 0141 223 1471 Mobile: 07775 035533

E-mail: [email protected]



Appendix 2d – Consent Form (Nurses)

For office use only

Centre no:____________________

Participant ID no:_______________

Date:_________________________

Consent Form – Focus Group Title of project: IPC Education and Training Gap Analysis.

Name of researcher: Michelle Clark Please initial below

I confirm that I have read and understand the participation information sheet for the above project.

I have had the opportunity to consider the information provided and had my questions answered satisfactorily.

I am aware that the data from this project may be used in conjunction with future research.

I understand that my participation is voluntary and I can withdraw from the project at any time without giving and notification or reasons.

I understand that if I withdraw from the project, I will not be disadvantaged in any way

I understand that any personal information recorded for this project will be stored in a secure database for 5 years. I give permission for this to be retained for 5 years.

I consent to the focus group being audio recorded

I agree to participate as a volunteer in this project

Name of Participant

Signature of participant Date

Name of Researcher

Signature of Researcher Date

Appendix 2e – Consent Form (Managers and Doctors)

For office use only

Centre no:____________________

Participant ID no:_______________

Date:_________________________

Consent Form - Interview Title of project: IPC Education and Training Gap Analysis.

Name of researcher: Michelle Clark Please initial below

I confirm that I have read and understand the participation information sheet for the above project.

I have had the opportunity to consider the information provided and had my questions answered satisfactorily.

I am aware that the data from this project may be used in conjunction with future research.

I understand that my participation is voluntary and I can withdraw from the project at any time without giving and notification or reasons.

I understand that if I withdraw from the project, I will not be disadvantaged in any way

I understand that any personal information recorded for this project will be stored in a secure database for 5 years. I give permission for this to be retained for 5 years.

I consent to the interview being audio recorded

I agree to participate as a volunteer in this project

Name of Participant

Signature of participant Date

Name of Researcher

Signature of Researcher Date

Appendix 3a Interview Guide Managers/Doctors

IPCT Learning Needs Analysis – Interview Guide – IPC Managers/Doctors

Behaviour = carry out role of IPC manager or doctor (according to your job description)

1. Introduction Introduce myself & C/J – what we do and role in the group today

Invite M/D to briefly introduce themselves, what they do, where they work and how long they

have been in the job

1.1 Introduce the session – purpose of research Research topic – after Vale of Leven report, NES required to address several points by providing

education programmes and support. (showing leaflet) HAI team have produced a range of

modules on learnPro – some generic for all staff, some specialised – However, the HAI team are

keen to understand the specific patient safety and quality improvement training needs of IPC

staff required and if there are any other educational needs specifically for IPC staff which aren’t

currently covered by the courses already provided.

The information from this consultation will provide recommendations which will inform the new

National Infection Prevention and Control Education Pathway

You have a copy of the information sheet attached to the email to keep for your reference.

1.2 Practical issues

This interview is to allow you to share your views in relation to your learning needs – what do

you need from NES in order to be able to perform your job role according to your job

description. I want to take part in this as little as possible because it’s your viewpoint that’s

important, there are no right or wrong answers – I have a list of questions to help me make sure

I cover everything but other than that, I’d like you to speak freely.

If it is ok with you, I’d like to voice record this discussion and have it transcribed word for word

onto a word doc to assist us with the analysis process – is that ok?

In the transcriptions, names will be changed in order to anonymise the data. In the write-up of

this report quotations may be used but you will be identifiable from these quotes. Does anyone

have any questions about this?

I’m aware of time – we’re hoping to have 45 minutes but I’m aware if required you may be

called away and that’s fine obviously – if you have more time we can chat on a bit longer – we

are flexible.

2. Main Discussion

A) First of all, could you give me a brief description of your role, if that’s possible?

B) For you, what are the main issues in infection prevention and control? (what helps &

hinders you in your job)

C) Here’s the NES HAI team’s catalogue of HAI education programmes – which of these have

you completed?

D) Thinking about the difficult aspects of your role (the hinders) - Are the NES HAI courses

adequate for your needs?

i) If so, why?

ii) If not, and you had a training needs wish list, what would be on the list that would

make it easier to carry out your role and achieve high levels of infection control?

(see how the conversation goes – map topics onto COM-B & or TDF domains – if any not

covered probe further using questions)

COM-B & TDF prompts

E) Capability

What stops IPC nurses from being able to perform their role:

Lack of knowledge – do IPC M/Ds know what to do in an outbreak? Do they know how

to train and motivate others in IPC?

Physical inability – personal physical barrier to performing the role

Memory – are there any processes or tasks which are difficult to remember or that

don’t make sense

Lack of procedures to promote action – action on the part of IPC Ms/Ds (eg outbreak

management procedures, risk management, use of audits,)? Action on the part of other

staff to follow IPC manual guidelines (eg staff not released for training/ don’t follow

protocols)

F) Motivation

How do beliefs or intentions influence how IPC nurses from performing their roles?

Lack confidence in their ability

Not in job description – are there any tasks that you do which you do not this are part of

your job?

Cannot be done – good IPC cannot be achieved

Not important – what are the benefits/harms of doing/not doing job well

Deciding not to do it – is there any part of the job you just decide not to do?

Conflicting priorities? – are there other roles which interfere with the IPC role?

Lack of reward/penalty – any reinforcements for positive/negative behaviours?

Uncomfortable feelings – does taking action (eg addressing poor compliance in staff,

quarantining patients, announcing outbreak) provoke strong emotional response

G) Opportunity

How does the physical and/or social environment influence the way you perform your role?

Lack of management support, equipment, time and staff

Contrary views opinions of others – cultural norms, hierarchy

Wrapping Up

H) Have you noticed any training needs which apply to other staff in the IPC team?

I) Anything else you think is relevant?

Summary of main points

Contact details on the info sheet if have any further comments /questions

We can email out a summary of the results if you are interested – please leave your email

address on the sheet if you wish us to contact you.

Appendix 3b – Interview Guide Focus Groups (Nurses)

IPCT Learning Needs Analysis – Interview Guide – Nurses Focus Groups

Behaviour = carry out role of IPC nurse, manager or doctor (according to your job description)

3. Introduction Introduce myself & C/J – what we do and role in the group today

Invite members to briefly introduce themselves, where they work and how long they have been

in the job

1.1 Introduce the session – purpose of research Research topic – after Vale of Leven report, NES required to address several points by providing

education programmes and support. (showing leaflet) HAI team have produced a range of

modules on learnPro – some generic for all staff, some specialised – However, the HAI team are

keen to understand the specific patient safety and quality improvement training needs of IPC

staff required and if there are any other educational needs specifically for IPC staff which aren’t

currently covered by the courses already provided.

The information from this consultation will provide recommendations which will inform the new

National Infection Prevention and Control Education Pathway.

You have a copy of the information sheet attached to the email to keep for your reference.

1.2 Practical issues

This is a focus group and ideally we would just like you to talk to each other about what your

views are in relation to your learning needs – what do you need from NES in order to be able to

perform your job role according to your job description. We want to take part in this as little as

possible it’s your viewpoint that’s important, not ours - all of your views are valuable to us

regardless of how different they may be from others – there are no right or wrong answers – we

might come in with some questions to get started or to steer back on course if we get off track

but it’s up to you how much you speak.

I’m aware of time – we’re hoping to have 45 minutes but I’m aware if required you may be

called away and that’s fine obviously – if you have more time we can chat on a bit longer – we

are flexible.

In order to allow everyone to talk freely, I would be grateful if we could all agree that what is

said in the room stays in the room and that we all show respect and empathy for each other

throughout.

We would like to voice record this discussion and have it transcribed word for word onto a word

doc to assist us with the analysis process – does anyone not agree/consent to this? Does anyone

have any questions about this?

In the transcriptions, names will be changed in order to anonymise the data. In the write-up of

this report It may still be possible to be identified from what you say but every effort will be

made to try and avoid this. Does anyone have any questions about this?

4. Main Discussion Identifying the most difficult aspects of the IPC nursing role

A) First of all, could you give me a brief description of your role, if that’s possible?

B) For you, what are the main issues in infection prevention and control? (what helps &

hinders you in your job)

C) Here’s the NES HAI team’s catalogue of HAI education programmes – which of these have

you completed?

D) Thinking about the difficult aspects of your role (the hinders) - Are the NES HAI courses

adequate for your needs?

i) If so, why?

ii) If not, and you had a training needs wish list, what would be on the list that would

make it easier to carry out your role and achieve high levels of infection control?

(see how the conversation goes – map topics onto COM-B & or TDF domains – if any not

covered probe further using questions)

COM-B & TDF prompts

E) Capability

What stops IPC nurses from being able to perform their role:

Lack of knowledge – do IPC nurses know what to do in an outbreak? Do they know how

to train and motivate others in IPC?

Physical inability – personal physical barrier to performing the role

Memory – are there any processes or tasks which are difficult to remember or that

don’t make sense

Lack of procedures to promote action – action on the part of IPC nurses (eg tracking

staff training plans, outbreak recording procedures, use of audits, different

interventions delivered by the team to increase compliance)? Action on the part of

other staff to follow IPC manual guidelines (eg don’t use prompts/don’t complete

training/ don’t follow protocols)

F) Motivation

How do beliefs or intentions influence how IPC nurses from performing their roles?

Lack confidence in their ability

Not in job description – are there any tasks that you do which you do not this are part of

your job?

Cannot be done – good IPC cannot be achieved

Not important – what are the benefits/harms of doing/not doing job well

Deciding not to do it – is there any part of the job you just decide not to do?

Conflicting priorities? – are there other roles which interfere with the IPC role?

Lack of reward/penalty – any reinforcements for positive/negative behaviours?

Uncomfortable feelings – does taking action (e.g. addressing poor compliance in staff,

quarantining patients, announcing outbreak) provoke strong emotional response

G) Opportunity

How does the physical and/or social environment influence the way you perform your role?

Lack of management support, equipment, time and staff

Contrary views opinions of others – cultural norms, hierarchy

Wrapping Up

H) Have you noticed any training needs which apply to IPC managers or doctors?

I) Anything else you think is relevant?

Summary of main points

Contact details on the info sheet if have any further comments /questions

We can email out a summary of the results if you are interested – please leave your email

address on the sheet if you wish us to contact you.

qualitative analysis of learning needs in infection ... · this study used qualitative research...

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