Healthcare-associated infections (HAIs), particularly in patients post-surgery or after an acute care episode, are considered a ‘preventable’ harm and a patient safety issue. HAIs are secondary infections patients may acquire while receiving treatment from health providers. Studies have shown that respiratory infections, wound infections and urinary tract infections are significant contributors to complications post-surgery or after a myocardial infarction, often leading to hospital readmission (Ali and Gibbons 2017; Awolaran et al, 2017; Kwok et al, 2017). Community-acquired infections (CAIs) include the transmission of viruses, bacteria, and parasites outside of the healthcare system. Community nurses frequently care for patients on discharge from hospital, as well as managing the care of an increasingly older and frail population residing in the community, who are also at increased risk of infection (McComiskey, 2017; Higginson, 2018). With the advent of the coronavirus outbreak, there has been an increased focus on infection risk and infection prevention strategies across all facility-based and community-based health care sectors worldwide (Centers for Medicare and Medicaid Services, 2020; Public Health England and NHS, 2020).
In the UK, there are clinical guidelines to guide infection control practices in community settings (National Insitute for Health and Care Excellence (NICE), 2012). These guidelines highlight the importance of universal infection control and prevention strategies, including hand hygiene, the use of personal protective equipment (PPE) and the safe disposal of sharps (NICE, 2012; Public Health England and NHS, 2020). However, what is not recognised in the guidelines are some of the unique challenges faced by nurses who care for patients in their own homes, particularly in relation to the ability to control the home environment (Higginson, 2018).
Despite a large number of studies exploring adherence by clinicians to infection control and prevention guidance in acute care settings, particularly in relation to hand hygiene (Erasmus et al, 2010), there has been very little focus on infection control and prevention behaviours and adherence to guidelines in community nursing settings. Prior to the work described in this article, the authors identified one study conducted in a community setting in Australia, which observed hand hygiene compliance among eight nurses during 40 patient visits. They found an average adherence rate of 59.2% (individual variation between nurses ranged from 36.4% to 86.4%), which is considered to be poor (Felembam et al, 2012).
In this paper, the authors describe some of the key findings from a programme of work conducted in a home care agency (community care organisation) in an urban setting in the US. Although the authors recognise that there will be differences in the organisation and context of care compared with that of the UK, there are lessons that can be learned from the findings that are of relevance to community nurses in the UK. The studies outlined here addressed the following aims:
- To describe home care nurses' levels of infection prevention and control knowledge, attitudes and practices
- To identify levels of hand hygiene adherence in a sample of home care nurses and factors associated with adherence
- To explore home care nurses' management of patients they identify as being at high risk of infection.
Methods
The full methods for each component of the programme of work have been described elsewhere (Russell et al, 2018; Dowding et al, 2020; McDonald et al, 2020). Mixed methods, comprising of a survey of nurses' infection control and prevention-related knowledge, attitudes and behaviours; observation of hand hygiene practices during home visits; and interviews with home care nurses were used to address the research aims.
Setting
The study was conducted in a large not-for-profit home care agency located in an urban area in the US. The agency provides community nursing care, occupational and physiotherapy and social worker support (known as home care) to patients who are deemed eligible for their services. Although the majority of patients receive care funded via either Medicare (the US government program for individuals older than 65 years) or Medicaid (state-funded care for individuals who are on minimum income), it also provides care for patients who receive private health insurance. In the US, to be eligible for home care, an individual is deemed to be homebound and require skilled nursing or rehabilitation care. Care is provided in 30-day payment periods with full reassessment and recertification of need every 60 days. The agency that was the focus of this study employs over 1500 nurses and makes 1.2 million clinical visits a year.
Participants
For the survey, home care nurses (registered nurses (RNs) and licensed practice nurses (LPNs)) working in this agency and another large not-for-profit agency in a neighbouring state were approached to participate. Email invitations were sent to 1134 nurses, with three weekly reminders. A total of 415 responses were received (a 36.6% response rate), of which 359 were valid and complete and subject to analysis. For the observation and interviews, a total of 50 nurses (RNs and LPNs) purposively sampled to ensure variation in geographic location and experience were recruited to the study. A total of 400 observations were conducted (eight patient visits per nurse), and all 50 nurses were subsequently interviewed.
Data collection
An online survey questionnaire was used to explore home care nurses' infection prevention and control knowledge, attitudes and self-reported practices. Questionnaire items were developed from existing instruments and home care agency infection control policies. They were assessed for content and face validity by experts in the field of infection control in the home care setting. The survey was piloted with 47 home care nurses in two agencies who did not participate in the main study, with feedback used to modify the final questionnaire (Russell et al, 2018).
To examine nurses' actual infection control practices and explore their strategies for implementing infection control in a home care setting, home care nurses were observed and interviewed. For the observation data collection, an observation checklist was used, with items taken directly from the World Health Organization's (WHO) five moments of hand hygiene checklist (Sax et al, 2009), which is a validated tool implemented globally, together with specific elements relevant to the home care setting (e.g. hand hygiene performed on arrival in the home). Trained observers accompanied home care nurses to patient visits and observed the number of opportunities (times during the visit when hand hygiene should be performed) and actual behaviour (whether hand hygiene was performed) and recorded it on the checklist (McDonald et al, 2020). Each nurse who participated in the observation was also interviewed, with questions developed to explore various issues related to infection prevention and control, including the practices they used based on a patient's risk of infection. Interviews were audio-taped and transcribed before analysis (Dowding et al, 2020).
Data analysis
Survey data were analysed using descriptive statistics, chi-square and t-tests to compare across the two agencies, and multivariate mixed regression was used to explore variation in compliance with infection control practices. Adherence to hand hygiene practices from the observation data was estimated using intercept-only regression models, to control for multiple observations conducted by the same nurse. Interview data were analysed with the support of qualitative analysis software (NVivo 11) by three researchers from the study team. An iterative approach to coding was used, with themes generated both inductively from the interview guide, and deductively from the data.
Ethics
All elements of the programme of work were approved by both the home care agency's institutional review board (IRB) and the IRB of the collaborator's institution. All nurses who participated in the study were provided with written information about the different study elements (the survey was separate from the observation/interviews) and provided consent to participate. Patients provided verbal consent in the observation study for an observer to be present during the home care visit.
Results
The characteristics of the nurses who participated in the survey and observation/interview studies (there were two separate samples, so nurses who participated in the observation/interview study may not have provided survey responses) are summarised in Table 1.
Table 1. Participant characteristics
| Characteristic | Survey (n=359) % (n) or mean (SD) | Observation/interviews (n=50) % (n) or mean (SD) |
|---|---|---|
| Age | 50.0 (10.5) | 47.4 (10.6) |
| Gender | ||
| Male | 8.4% (30) | 10% (5) |
| Female | 91.6% (329) | 90% (45) |
| Race/ethnicity | ||
| Non-hispanic white | 42.9% (154) | 26% (13) |
| Non-hispanic black | 24% (86) | 44% (22) |
| Hispanic | 10.9% (39) | 10% (5) |
| Other or mixed race/ethnicity | 22.3% (80) | 20% (10) |
| Education | ||
| Postgraduate degree | 19.8% (71) | 12% (6) |
| Bachelor's degree | 51.8% (186) | 66% (33) |
| Years in nursing | 21.9 (11.9) | 19.3 (11.7) |
| Years at agency | 11.5 (9.1) | 10.6 (7.8) |
Nurses who participated in the studies overall were very experienced, ethnically diverse and had worked at the home care agency for an average of 10 years.
Survey
An overview of the key findings from the survey are presented in Table 2. Nurses reported high compliance with infection control practices, such as performing hand hygiene before and after care activities and the appropriate disposal of sharps. Adherence to practices associated with the use of personal protective equipment (PPE), such as using goggles or an eye shields, were lower. Overall nurses' knowledge of infection control procedures was high, as was their reported attitude towards infection control practices.
Table 2. Participant characteristics
| Self-reported infection control practices | Compliant response % (n) |
|---|---|
| I perform hand hygiene before and after patient care activities | 99.4% (357) |
| I wear gloves when I anticipate exposure to bodily fluids or blood products | 100% (359) |
| I wash my hands or use alcohol-based handrub immediately after the removal of gloves | 95.5% (343) |
| I wear a disposable face mask whenever there is a possibility of a splash or splatter | 81.9% (294) |
| I wear a gown if soiling with blood or bodily fluids is likely | 78.8% (283) |
| I wear goggles or an eye shield when I may be exposed to bloody discharge/fluid | 69.6% (250) |
| I dispose of needles in a sharps container | 96.4% (346) |
| I dispose of all potentially contaminated materials into an impermeable bag | 91.9% |
| Proportion of correct knowledge responses (mean/SD) | 0.85 (0.09) |
| Proportion of appropriate attitude responses (mean/SD) | 0.81 (0.14) |
Observation
We observed 2014 hand hygiene opportunities across the 400 patient visits, yielding an average of 5 (±2.2) per visit. The unadjusted average adherence rate was 47.6% (95% confidence interval (CI)=45.4%–49.8%). After adjusting for a clustering effect at the nurse level, the average adherence rate was 45.6% (95% CI: 41.3%–50.4%). Mean adherence was highest after removing gloves for a procedure involving contact with body fluid (65.1%) and lowest after touching a patient (29.5%). Overall, there was considerable variability in nurses' hand hygiene practices in the study. The study also found that nurses serving patients who are at higher risk for infection and who live in a dirty environment have more opportunities during a home care visit that require hand washing. Lastly, lower adherence was found when there were more opportunities.
Interviews
A key theme that arose from the interview data was the strategies that nurses use to prevent infection when conducting home visits. What was evident from the data was the impact a patient's environment and the availability and education level of carers had on the types of interventions nurses reported. In addition, the nurses also had to be mindful about what care would be covered by a patient's insurance.
One key strategy for managing infection control and prevention identified by the nurses in this study was patient and caregiver education, including the importance of good hand hygiene practices, and recognising and reporting the signs and symptoms of infection. Nurses also reported strategies they used to try and reduce the risk of infection transmission between homes, such as using a barrier for their bag or supplies or standing up so they did not sit on a patient's furniture. They highlighted that there were limits to what they could do with regard to patients' general level of cleanliness and their home environment, indicating how it was easier to provide education to patients and their families than it might be to try and alter the cleanliness of that environment.
Discussion
This paper reports key findings from a programme of work to explore infection prevention and control practices of home care nurses in the US. The study was conducted in a large agency situated in an urban area, which needs to be acknowledged when considering the study findings. The context and organisation of care between home care organisations in the US and community nursing practices in the UK are slightly different, in that, in the US, timings of nurse visits, types of interventions that can be delivered, and the duration of provision of home (community) care are influenced by the patients' Medicare/Medicaid or insurance provision. However, from an infection control perspective, the key similarity is that nurses in both countries are providing nursing care to patients in their home environments. So, although the context is different in the UK, the authors suggest that there are issues that have been raised by the study findings that have relevance for practitioners in the UK.
Given the increased number of older patients who receive care from community services, and the increasing number of patients being discharged from hospital who require skilled nursing care, the lack of evidence surrounding infection control practices in such settings is concerning. This study is the first large-scale study to explore home care nurses' infection control knowledge and practices and provides a basis for future research and education.
The survey indicates that, overall, the nurses who participated in this study had good knowledge and understanding of infection control practices and reported high adherence to guidelines, particularly those related to hand hygiene and disposal of sharps. However, the results from the observation study indicated that this was often not translated into practice, with overall hand hygiene adherence rates observed to be inconsistent with best practice. It is important to note that these findings are similar to those of studies conducted in acute care settings, where similar adherence rates have been reported (Erasmus et al, 2010; Lambe et al, 2019). Data from the interviews provided some insights into the potential challenges that home care nurses face when carrying out care in a patient's home, which is a less controlled environment than the hospital setting and where nurses have to be sensitive to patient and carer needs.
This study provides a valuable baseline to understand infection prevention and control in community care. Given the ongoing pandemic, it is likely that some of the adherence rates to infection prevention and control practices will have already improved significantly, and further research to explore this would be warranted. In addition, the agency that was the main focus for this study has used the findings to re-evaluate its infection prevention and control training for staff, to highlight hand hygiene areas that needed more attention to improve best practices as recommended in the WHO guidelines. Given the lack of comparative data available in the UK, the authors suggest that there is a need to carry out similar studies in community settings, to provide an international overview of the knowledge, attitudes and infection control practices of community nurses. Once the practices undertaken by community nurses and the challenges they face adhering to infection control guidelines are better understood, it can be ensured that appropriate support and training is provided to enhance practice.
KEY POINTS
- Healthcare-acquired infections are a significant issue in patients receiving community nursing care in their home
- It is important to understand community nurses' knowledge, attitudes and current infection control practices
- The present study found that nurses have good knowledge of infection control practices, but encounter a number of challenges related to nursing in a home environment that impact on those practices
- It is important to gain an understanding of community nurses' infection control practices and ways to provide education and support
CPD REFLECTIVE QUESTIONS
- Why is understanding infection prevention and control practices important?
- What are the main issues faced by nurses practising infection prevention and control in a home setting?
- How can you improve your own infection control practices?