Education of Healthcare Workers in the Prevention of Healthcare-Associated Infections
Karen K. Hoffmann
Eva P. Clontz
In the healthcare setting, ongoing education is required for several reasons. First, all healthcare providers need to participate in ongoing education to remain abreast of the scientific innovations in the field of infection control. Second, technological innovation demands learning new skills. Examples include the increasing use of computers in managing and analyzing healthcare-associated infection surveillance data and the increasing use of molecular epidemiology to evaluate healthcare-associated outbreaks. Third, regulatory bodies (e.g., Occupational Safety and Health Administration [OSHA] and The Joint Commission) require that workers receive ongoing training in a variety of areas depending on their job duties. Such training includes instruction on isolation techniques, aseptic practices, prevention of blood and body fluid exposure, and proper handling of hazardous chemicals.
The results of the national certification examination job analysis survey, administered to infection preventionists (IPs) between 1982 and 2010 by the Certification Board of Infection Control and Epidemiology (CBIC), consistently identified the task of education as one of the major areas of responsibility for IPs (1). The 2010 analysis includes tasks in education and research (Table 92-1) (2).
This chapter discusses education of healthcare personnel and patients/patient caregivers for the prevention of healthcare-associated infections and reviews educational requirements mandated by government and licensing agencies and research findings regarding education about specific areas in infection control. The chapter also includes a brief introduction to human factors engineering (HFE), learning theory, and the educational program planning process.
Practice competencies for infection prevention and control education were identified by a Delphi panel of experts in 2008. The final matrix of competencies may be a first step toward the development of a framework for standardized infection prevention education and training materials for hospital-based healthcare workers. The next step will be using the matrix to determine the validity of training materials (Table 92-2) (3).
INFECTION CONTROL EDUCATION FOR HEALTHCARE WORKERS
Regulatory Educational Standards
The Joint Commission expects that new employees will receive orientation that covers the organization’s infection control program and the individual’s role in the prevention of infection. Another suggested activity is that continuing education be part of a problem-oriented or outbreak response. When infection rates are not reduced by the feedback of surveillance rates alone, The Joint Commission suggests using innovative educational approaches beyond the routine or standard in-services. Another expectation is for at least yearly education and training of all personnel to maintain or improve knowledge and skills based on findings from infection control activities such as healthcareassociated infection rates or outbreak investigations (4).
The OSHA Occupational Exposure to Bloodborne Pathogens: Final Rule requires appropriate training for employees who are reasonably anticipated to come into contact with blood or other potentially infectious materials in the performance of their job duties. The standard mandates training initially upon an employee’s assignment and annually thereafter (5). The OSHA Compliance Directive CPL 2.106 Enforcement Procedures and Scheduling for Occupational Exposure to Tuberculosis (TB) requires worker training and information to ensure appropriate recognition and isolation of TB-infected patients (6). Specific training elements must be included for each of these standards. Training records for blood-borne pathogens must be maintained for 3 years and must include dates, contents of the training program or a summary, the trainer’s name and qualification, and names and job titles of all persons attending the sessions (5).
Educational Offerings Designed for Infection Preventionists
Formal education specifically designed for the training of healthcare professionals in infection control began with a
course offered by the Centers for Disease Control and Prevention (CDC) in 1968 (7). This course plus additional training courses were offered by the CDC for many years but were discontinued in 1988 (8). In 1989, the Association for Professionals in Infection Control and Epidemiology (APIC) assumed responsibility for offering training courses for infection control, and education remains the organization’s top priority (9). In addition to APIC, sponsors of infection control conferences, webinars, and workshops include APIC chapters in states and regions and specialized training programs, such as at the University of North Carolina at Chapel Hill. Graduate education in infection prevention was limited to master’s degree programs in public health and nursing until 2010 when the Health Resources and Services Administration funded the Infection Prevention and Environmental Safety track within the Doctor of Nursing Practice Program at Loyola University Chicago Marcella Niehoff School of Nursing. The Study on the Efficacy of Nosocomial Infection Control Project findings emphasized the need for physician training in infection control. In response, the Society for Healthcare Epidemiology of America and the CDC provide a training course in healthcare epidemiology for physicians (10).
course offered by the Centers for Disease Control and Prevention (CDC) in 1968 (7). This course plus additional training courses were offered by the CDC for many years but were discontinued in 1988 (8). In 1989, the Association for Professionals in Infection Control and Epidemiology (APIC) assumed responsibility for offering training courses for infection control, and education remains the organization’s top priority (9). In addition to APIC, sponsors of infection control conferences, webinars, and workshops include APIC chapters in states and regions and specialized training programs, such as at the University of North Carolina at Chapel Hill. Graduate education in infection prevention was limited to master’s degree programs in public health and nursing until 2010 when the Health Resources and Services Administration funded the Infection Prevention and Environmental Safety track within the Doctor of Nursing Practice Program at Loyola University Chicago Marcella Niehoff School of Nursing. The Study on the Efficacy of Nosocomial Infection Control Project findings emphasized the need for physician training in infection control. In response, the Society for Healthcare Epidemiology of America and the CDC provide a training course in healthcare epidemiology for physicians (10).
TABLE 92-1 Association for Professionals in Infection Control and Epidemiology (APIC) Major Educational Tasks Cited by Infection Control Professionals | ||||||
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TABLE 92-2 Infection Prevention and Control Competencies | ||
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A survey by the National APIC Education Committee investigated the use of outdated infection control practices or rituals. Outdated practices were more likely to be used by persons who were not certified by the CBIC and who worked in long-term-care facilities or in smaller hospitals rather than larger hospitals. However, certified respondents were no more likely than noncertified respondents to be interested in changing any rituals (11).
The CBIC administers the process for Certification in Infection Control (CIC). APIC founded CBIC in 1981, and the first examination was administered in 1983. CBIC is a voluntary, autonomous, multidisciplinary board that provides direction for professionals in infection control and applied epidemiology. The principal purpose of CBIC is to provide public protection by providing and measuring a standard of knowledge desirable for practicing professionals, to encourage professional growth and individual study, and to recognize individuals who fulfill the requirements for certification. Eligibility requirements include a current license or registration as a medical technologist, physician, or registered nurse, or a minimum of a baccalaureate degree. To use the designation CIC, the professional must meet the eligibility requirements and pass an examination. To maintain certification, professionals must recertify every 5 years (12). In 1999, The Joint Commission required that individuals who oversee infection control activities be “qualified in infection control practices through education, training, experience, or certification” (13). As The Joint Commission standards change, it continues to require specific education (Table 92-3).
APIC provides numerous educational resources, most importantly the curriculum manual, APIC Text of Infection Control and Epidemiology, and Certification Study Guide, continuously updated online. In addition, webinars, toolkits, and prevention guides are available.
Infection control education begins in college programs for healthcare workers; however, this subject is inadequately presented before clinical experience. Instruction in microbiology (the basis for understanding transmission of infectious diseases) is not required in many schools of nursing, and when infection control material is presented, it is frequently presented by someone lacking the expertise of an IP (14). Education of house officers on infection control is determined by individual training programs.
Survey responses from 158 of 381 (41%) internal residency programs in the United States showed that 79% of survey respondents relegate infection prevention to a general lecture for all new employees. Seventy-seven percent dedicated a lecture on infection control to new house staff. Only 34% reported using an online module for infection prevention education. Infection prevention training is not an integral part of medical education and thus does not translate into daily clinical practice activities. A standardized curriculum for ongoing infection prevention education should be developed (15).
Survey responses from 158 of 381 (41%) internal residency programs in the United States showed that 79% of survey respondents relegate infection prevention to a general lecture for all new employees. Seventy-seven percent dedicated a lecture on infection control to new house staff. Only 34% reported using an online module for infection prevention education. Infection prevention training is not an integral part of medical education and thus does not translate into daily clinical practice activities. A standardized curriculum for ongoing infection prevention education should be developed (15).
TABLE 92-3 The Joint Commission Accreditation Program—Education | |||||
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Although manufacturers are not routinely classified as sources of educational programs for healthcare professionals, they provide information in marketing their products. Such information must always be critically examined as to whether it is reliable and supported by scientific evidence. Manufacturers also provide training for use of their equipment, provide grants to support lectures, and produce products designed specifically for educational purposes such as videotapes and slides. These materials should be carefully evaluated for completeness of information and evidence of objectivity.
Targeted Infection Control Education
Standard Precautions Misinformation and confusion about the transmission of blood-borne pathogens have given impetus to infection control education. Studies of human immunodeficiency virus/hepatitis B virus bloodborne pathogens have emphasized the difficulty of changing behaviors and have shown that knowledge does not necessarily translate into changed behaviors. Several studies have recognized that the desired outcome has not been achieved through in-service educational programs that provide the standard information on risk behavior and ways to reduce that risk (16,17 and 18). A 5-year study found a decrease in the number of needlesticks through a combination of more convenient placement of needle disposal containers, communication, and education, but this study did not single out effectiveness of education (19). A variety of interventions, tested on personnel in an emergency department, improved compliance with universal precautions, including making gloves and eyewear more accessible, signage reminders, and hands-on training (20,21).
Tavolacci et al. (22) tested medical and nursing students’ knowledge. Medical students’ scores were highest in knowledge of hand hygiene and Standard Precautions and worst scores were in knowledge of healthcare-associated infections. To increase compliance, students must learn essential behaviors in medical school. Sax et al.’s (23) study showed that specific training for all individuals increases adherence to standard and isolation precautions. Specialized training must be received before healthcare students undertake any patient procedure involving sharps devices. Elliott et al.’s (24) studies of medical students showed that training and increased awareness of sharp injuries resulted in a significant reduction in needlestick injuries.
Hand Hygiene Compliance Larson et al.’s (25) study of 40 US hospitals before and after the publication of the CDC Hand Hygiene Guideline included site visits and surveys to measure healthcare-associated infection rates 1 year before and 1 year after the publication of the CDC guidelines. Site visits used direct observation of hand hygiene compliance and determined if facilities changed policies and procedures in compliance with guideline recommendations. Results showed that 90% of 1,359 staff members surveyed anonymously reported that they were familiar with the guideline but 44% of hospitals found no evidence of multidisciplinary programs to improve compliance, and hand hygiene rates remained low at 56.6% compliance. Rates of central line-associated bloodstream infections were significantly lowered in hospitals with higher rates of hand hygiene (p > .001), and there was no reported impact on other healthcare-associated infection rates (25).
A lack of compliance with the CDC hand hygiene standards has plagued infection control efforts using traditional strategies for education. In a longitudinal study of hospital workers, it was found that, despite a comprehensive educational and promotional campaign, hand washing frequencies returned to precampaign levels in 6 months. The authors concluded that a lack of motivation (failure to change attitudes), rather than a lack of education, was the most important cause of poor compliance (26). Similarly, Larson and Killien (27) found that current methods of focusing on the benefits of hand washing with a public relations approach (i.e., signs, lectures, or posters describing the importance of hand washing) missed the significant reasons given for infrequent handwashing, such as being too busy. Two sequential studies of intensive care unit (ICU) personnel found that education alone did not have a sustained effect, but that maintaining education and providing feedback on hand washing performance were critical to having a continuing effect on motivation (28,29).
A 2006 multihospital study found that a lack of IP time to implement hand hygiene educational tools, even when
provided a multimodal prepackaged educational tool by CDC, was the primary barrier (30). Significant improvement in hand hygiene was observed when senior healthcare workers were present and when educational promotion and feedback were made available (31).
provided a multimodal prepackaged educational tool by CDC, was the primary barrier (30). Significant improvement in hand hygiene was observed when senior healthcare workers were present and when educational promotion and feedback were made available (31).
A hospital-wide education program demonstrated that adherence to hand hygiene recommendations improved significantly (48-66%). The program involved using posters and other visual displays that promoted the use of bedside hand rubs. The posters featured messages submitted by healthcare workers that were then graphically illustrated in cartoons. The creativity of this program may be one reason for its success, giving recognition and ownership to local healthcare workers (32).
An evaluation of a patient-empowering model for increasing healthcare worker hand washing compliance on a 24-bed in-patient unit effectively increased compliance 56% and was sustained over 3 months. Compliance was measured through soap usage per resident day. The intervention was that patients asked their healthcare workers if they had washed hands before providing care. Interestingly, patients reported asking nurses 65% of the time to only 35% for doctors (33).
Noncompliance with the basic tenets of healthcare is evident in other areas of infection control practice, including aseptic technique, isolation, and Standard Precautions techniques. Ching and Seto (34) found that patient care practices for urinary catheter care were significantly improved when a nurse from the ward was chosen to act as an infection control liaison, promoting control measures and providing teaching, as compared to nurses receiving only in-service lectures. Two studies report successful outcomes in reducing either ventilator-associated pneumonia or central intravenous catheter infections. Both used a multidisciplinary task force to develop self-study modules, lectures, pre- and posttesting, and posted fact sheets as posters through the ICU. The studies using a multi-intervention approach showed significant reductions of 50% (35) to 66% (36) in hospital infection rates. These reports suggest a variety of educational methods may be needed to achieve and maintain adherence (32).
In summary, successful hand hygiene compliance is achieved through a combination of many strategies including observation and feedback, administrative support, senior staff modeling, product selection, and educational campaigns such as posters.
Human Factors Engineering Well-trained and educated healthcare workers continue not to comply with infection control mandates. Alvarado has stated that the educational methods themselves are at fault. “Search for the individual bad actor keeps us from looking at the design of the overall system” (37). The traditional way of “simply telling them” assumes that the healthcare workers have the information, that learning has taken place, and that they will change to the desired behavior. It may be time to consider multifaceted approaches that will achieve good and sustained results, for example, HFE, which has its origins in the Industrial Revolution (38). HFE looks at the causes and effects of human error and was originally applied to the design of increasingly complex airplane cockpits (39). It has been applied to numerous diverse systems such as software and computer control. In healthcare, HFE has been applied to the problem that 70% to 80% of adverse anesthetic events in the operating room involve human error (39). Evaluating the differences between visual and manual activities using the HFE model removed the problems and reduced the errors (40).
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