By Gary Evans, Medical Writer

Will an aging and potentially burned-out workforce be able to retain and recruit infection preventionists (IPs), capitalizing on the value they have demonstrated during the COVID-19 pandemic? The betting money says yes, but there are many critical issues to resolve. The larger question is if IPs can go beyond the hospital, bringing their expertise into many vulnerable areas exposed by the pandemic.

Sarah Smathers, MPH, CIC, FAPIC, director of infection prevention and control at Children’s Hospital of Philadelphia, delivered a plenary address recently at the spring 2021 conference of the Society for Healthcare Epidemiology of America (SHEA).

“We have been going through a pandemic where the spotlight has been on our departments in a way that it has never been before,” Smathers said. “We have proven our worth and our value to our organizations. We should leverage that to ask our leadership for what we need to recover and rebuild our departments.”

The pressures on IPs were many before an all-hands-on-deck SARS-CoV-2 pandemic compounded them immeasurably. These included device-related outbreaks, including infections with some reprocessed endoscopes and unusual, potentially fatal infections traced back to heater-cooler units in operating rooms.

“Things like multidrug-resistant organisms and Candida auris have been emerging, and we have been dealing with vaccine-preventable diseases like measles,” she said. “Whether they have impacted you directly, you have had to prepare and respond to these a long time before COVID-19.”

To that point, all of these problems remain, and many, such as vaccine-preventable diseases, likely will be worsened in the absence of school attendance. Yet, regardless of circumstance, the core tenet of the IP mission is patient safety, which is something of a double-edged responsibility.

“Over the last decade, there has been increased transparency around patient safety, including ways to prevent healthcare-associated infections,” Smathers said. “This has led to mandatory reporting requirements, which, again, are good for patient safety and core to the work that we do, but we need to acknowledge that this has increased our workload and burnout. [We] both track these infections and then are tasked with developing the programs to prevent them.”

Again, these were the challenges IPs faced before the pandemic, which immediately demanded more of their time and aggravated the ongoing staffing issues amid demographic change in an aging workforce.

“You put a pandemic on top of that — it’s been a real recipe for burnout and exhaustion,” Smathers said. “It’s [something] I don’t think we solve without growing our profession and advocating for our departments. I want us to all be thinking about that as we emerge from this pandemic. It is really an opportunity for us to not go back to the old way of doing things. Reimagine what our work could look like, and how we can support it and structure it in the future.”

Future Pathways

It may seem counterintuitive to see growth as a solution to exhaustion, but the Association for Professionals in Infection Control and Epidemiology (APIC) also sees these factors as critically related. There are questions about the levels of burnout and stress the pandemic is exacting on IPs as well as on the healthcare workforce overall.

“We are concerned about whether we will see that,” says Ann Marie Pettis, RN, BSN, CIC, president of APIC. “We know we have an aging-out group of IPs and nurses. Will [the pandemic] accelerate that? What it brings to mind is that one of our most important initiatives right now is the IP Academic Pathways. We have a task force working very rapidly on that — we can’t do that too soon.”

Moving away from the traditional IP coming into the role by serendipity or happenstance from another medical career, APIC is creating an infection prevention curriculum for colleges and universities based on the competencies outlined by the Certification Board of Infection Control and Epidemiology. (See “In a Time of Sea Change, Devin Jopp Takes APIC Helm.”)

The pandemic also has revealed the need for IP knowledge in non-traditional settings, such as entertainment, hospitality, sports, and school reopening strategies. “We recently had an important role in a school reopening document,” Pettis says.1 In addition, APIC conducted an “IP Recharge” series to help the profession with mental health needs and overall well-being.2

“Hopefully, one of the lessons learned will be when situations like this happen — or even in normal circumstances — we need resources to address the well-being of our healthcare workers,” Pettis says.

An obvious key to individual well-being is working in an adequately staffed department, which appears to be both an immediate and a long-term challenge.

“We have had a lot of retirements in the last five years,” Smathers says. “We also anticipate that we are going to see more retirements. A study that we did found that 52% of hiring managers were anticipating that they were going to have an IP retire in the next one to two years.”3

These retirements create vacancies that can take three to six months to fill. “Some places are taking up to a year to find a replacement,” Smathers said they found in the study. “That creates a huge burden on the staff that is left behind.”

IPs are needed but already understaffed or working in diluted roles in ambulatory care and long-term care.

“Our IPs are wearing multiple hats in these non-acute care settings,” she says. “They are in nurse management, quality specialists as well as infection preventionists. [Overall,] 58% report infection prevention is less than half their job.”4,5

Offering one novel solution to this problem, Smathers proposes a “plus one” initiative, where a highly experienced, well-paid IP trains two novice IPs to replace her or him upon retirement. Another option would be to hire a new IP as well as, for example, a data analyst who could help crunch healthcare-associated infection numbers and assist with antibiotic stewardship.

“That is a creative approach,” Pettis says. “And I do think we are we going to have to get really creative about this.”

The old formulas on how many IPs are needed for so many hospital beds are increasingly outdated by healthcare delivery changes. The ratio in the landmark SENIC study in 1980 was one IP per 250 beds, which has been updated over the years to one IP per 100 beds, and most recently to one IP per 69 beds.6,7

The authors of that last study concluded, “Size, scope, services offered, populations cared for, and type of care settings all impact the actual need for IP coverage, making the survey benchmarks available in the literature invalid.”7

Smathers said a key part of that study is “that they were not only looking at the things IPs do every day, but asking the chief stakeholders what is it that you want from us? What are the needs of the organization? Using that to assess what their program should look like.”

A finding that will surprise no one is that most IPs spend more than half their time doing surveillance, but only about one hour per week on professional development. This is one of the key reasons IPs leave the field, so Smathers created three levels of advancement and seeks diverse backgrounds in her program. The levels are Novice IP Level 1; Proficient IP Level 2; and Expert IP Level 3. She uses APIC competency levels to establish where the IPs should be placed.8

“We also have a nurse fellowship program where a nurse spends one day a week with us for 12 months,” she said. “They spend the rest of the time with their own unit. What was really great during the pandemic is that we were able to call back some of these fellowship graduates to support our department and our activities in infection prevention.”

Regarding educational diversity, Smathers recommended a study that sees benefits in adding IPs with different backgrounds than nursing, noting that “laboratory scientists and public health professionals are bringing knowledge attained through advanced degrees and diverse skillsets to infection control departments.”9

Noting that it is less like a ladder than a jungle gym, Smathers said diversity “has really strengthened our program and allowed us to bring a lot of different aspects to the table.”

Making the point that asking is not the same as receiving, Smathers encouraged IPs to emphasize the bottom-line savings and to be persistent.

“We are not revenue-generating and it is hard for us to make our business cases,” she said. “If you are told ‘no,’ don’t give up. Ask for feedback on what you can do to improve your presentation and pitch. Talk to people in your organization who have been successful at growing their departments.”

As disastrous as it has been, the pandemic and its aftermath will open a way for a new breed of IP.

“Now is our time,” she said.


  1. Allen D, Alleyne EO, Amler S, et al. Roadmap to healthy schools: Building organizational capacity for infection prevention and control (IPC). April 2021.
  2. Association for Professionals in Infection Control and Epidemiology. IP recharge: A well-being series.
  3. Gilmartin H, Reese SM, Smathers S. Recruitment and hiring practices in United States infection prevention and control departments: Results of a national survey. Am J Infect Control 2021;49:70-74.
  4. Pogorzelska-Maziarz M, Kalp EL. Infection prevention outside of the acute care setting: Results from the MegaSurvey of infection preventionists. Am J Infect Control 2017;45:597-602.
  5. Stone PW, Agarwal M, Pogorzelska-Maziarz M. Infection preventionist staffing in nursing homes. Am J Infect Control 2020;48:330-332.
  6. Haley RW, Quade D, Freeman HE, Bennett JV. The SENIC Project. Study on the efficacy of nosocomial infection control (SENIC Project). Summary of study design. Am J Epidemiol 1980;111:472-485.
  7. Bartles R, Dickson A, Babade O. A systematic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control 2018;46:487-491.
  8. Billings C, Bernard H, Caffery L, et al. Advancing the profession: An updated future-oriented competency model for professional development in infection prevention and control. Am J Infect Control 2019;47:602-614.
  9. Bartles R, Dickson A, Babade O. A systematic approach to quantifying infection prevention staffing and coverage needs. Am J Infect Control 2018;46:487-491.