APIC at 40: Full public awareness of IP role critical to future of infection prevention

Paradoxically, in order to lead IPs must 'let go'

Patti Grant, RN

The future of infection prevention hinges in large part on greater public awareness of the vital role IPs play in protecting patients throughout the health care system, an acknowledgement that is needed to preserve and expand program resources, said Patti Grant, RN, BSN, MS, CIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC).

"Until the public demands our presence in health care we are only going to go so far," she said recently in Fort Lauderdale in delivering the annual president's address at APIC's 40th annual conference.

While patients expect and demand clean hospitals, skilled surgeons and even good food, they rarely inquire about the number and expertise level of a facility's infection preventionists.

"When was the last time anybody from the general public walked into a health care facility, went over to the information desk and said, 'I need to know how many certified IPs are in this hospital?' Until the public demands our presence the way they demand all these other things we are not going to progress much further than where we are," said Grant, director of infection prevention and quality at Methodist Hospital for Surgery in Addison, TX.

For example, Consumers Union, publishers of Consumer Reports, began calling for more transparency and accountability on health care associated infections (HAIs) about a decade ago. As IPs began to dialogue with the consumer advocacy group on HAI prevention, Grant wondered why they had not come to APIC in the first place, which has been in existence since 1972. Grant was told the perception was that IPs were "under the radar," she said.

This has been a recurrent theme in infection control, a field that has long labored under what veteran health care epidemiologist Vicky Fraser, MD, once described as "a psychopathology of secrecy." Liability concerns and other HAI issues likely contributed to this early culture, which included arcane — and presumably protective — language like "nosocomial" infections. However, now the public is much more aware of health care infections, even forming groups like the MRSA Survivors Network.

"What are we not doing that people feel they need to make their own organizations to fight infections," Grant asked some 4,000 APIC attendees. "Why aren't they coming to us? I challenge everybody in this room to ask themselves the same question. We've come so far in 40 years, what can we do in the next decade so people will know that APIC is the place to come for not just HAIs but for all infections."

Agents of change

Infection prevention has dramatically moved away from the old passive mindset of benchmark HAI rates and inevitable infections, now pushing for HAI eradication and zero tolerance for non-compliance with proven methods of prevention.

"In order to be successful in the future we are going to have to be obsessed with failure," Grant said. "I'm not saying we have to do a root cause analysis on every infection. I'm talking about no longer tolerating non-compliance at the bedside, in the sterile processing department, anywhere in health care where we know evidence-based practices work and yet we let business go on as usual. That has to stop. We have got to become change agents. We have to stop rationalizing when we see infections happen."

This phenomenon is common in other medical specialties, Grant noted, citing the "Silence Kills" work that has been done by the Association for Operating Room Nurses and other groups. (See related story p. 87.)

"What is it about our health care system that people feel it is OK to watch a procedure or see something done — know it's wrong – and not speak up?" she said.

A rhetorical question that adds some "moral clarity" to the old issue of inevitable infections is: "If it's OK to give an HAI to someone — and we know under even perfect circumstances somebody is going to get an infection — then who is it OK to give the HAI to?" Grant said.

"My mom's had as SSI, my dad has had an SSI, my uncle Bob will never walk again without a walker because a hip got infected and he had to have three surgical procedures," she said. "Everybody in this room probably has a story."

The IPs in attendance should thank their predecessors and the early pioneers in health care epidemiology who established a scientific footing for the fledgling field, she noted. (See related story below) "It was their willingness to learn and their ability to adjust to new experiences," Grant said. "We are here because of their perseverance in paying it forward."

Imagine if an organization like APIC did not exist, she said, recalling her first conference when she entered the field in 1990.

"I have had some phenomenal mentors — I can't believe the people that have blessed me with their teachings — but it was APIC that was my constant through all these years," she said. "There is such an exceptional knowledge base through our membership because we share the vision of health care without infections. I am not talking about the number zero. Our vision of zero infections comes through as zero tolerance with things that we know prevent infections."

Leading by letting go

Now it is time to reach out to others for help in accomplishing the broader goals of infection prevention, no small task for IPs who are used to being relatively autonomous and self-reliant.

"[The future depends] on our collective ability, our collective willingness to ask for the help of others in the fight against infections," she said. "Who are these other people going to be – where are they going to come from? I'm suggesting that they need to come from outside, from beyond our traditional comfort zone. What I'm saying is to get through the next decade — to really push the envelope — we are going to have to let go."

Unless IPs empower others to take the lead in infection prevention initiatives, the field will not grow beyond the silos and turf wars that have held held sway for decades.

"This is a hard one for me to say because I'm like a control freak," Grant said. "But the best teams I've ever been on are ones I did not chair. As long as I continue to do it they are not going to see it as their own. And they quickly learn that it is a lot harder for me to sit back and plant seeds and allow them to do it on their own. They see that it is not done out of indolence — that I'm not being lazy. "

Of course, IPs must be present to inform and guide the process. "We have to always be there to reel them in when we start hearing things like changing [respiratory air] circuits every 48 hours," she says. "We knew 15 years ago that is not going to help. Remember our APIC tag line is 'spreading knowledge, preventing infections.' This is what IPs do. We've got to learn balance and facilitation."

This new role and increasing demands from other sectors have put IPs under considerable pressure, as inevitable tensions arise as more people are brought into the mission of infection prevention and protecting patients.

"Conflict is inevitable and should be embraced as an inescapable part of learning," Grant said. "Stop and think about everything you've ever learned — most of it was not easy, and certainly in health care, conflict will be involved. We need to learn from those experiences. As we continue to grow and serve, we need to always know when to lead astutely and know when we need to bravely follow."

The shift from the language of "controlling" infections to "preventing" them heralded this change several years ago, as the concept of prevention embraces a much larger group of clinicians and health care workers.

"We call ourselves infection preventionists today not because it's a job title; it's a description that unified us as a body that is fighting infections," Grant said. "It doesn't matter if you're an RN, an MD, an MPH, if you work in microbiology, a respiratory therapist — if your primary function is to help fight infection you are an infection preventionist."

Study: Changing IP role creates job 'tensions'

A fascinating look in the trenches

The changing role of infection preventionists is beset with "tensions" as the demand for data increases and IPs try to enlist other health care workers to achieve the broader aims of infection control and patient safety, a researcher reported recently in Fort Lauderdale at the 40th annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

The study included in-depth interviews with IPs, providing a fascinating look into the trenches at a time of transition for infection prevention. Adaptability and persistence are among the traits needed by IPs during this period of change, said Laurie Conway, RN, MPhil, CIC, PhD Student at Columbia University School of Nursing in New York City.

"The IP narratives revealed that the IP role is indeed changing," she said. "It is progressive in nature and like many changes it is associated with some friction and some uncertainty and what we called 'tension.'"

Conway and colleagues interviewed 19 IPs at hospitals across the U.S. between October 2010 and February 2011.1 By design, the hospitals were sampled for maximum variation in size, geographic region, health care associated infection (HAI) rates, and degree of implementation of HAI prevention strategies. Topics in the semi-structured interview guide included the structure and function of the infection control department, personnel and roles, education of clinicians, compliance monitoring, facilitators and barriers to infection prevention, and the impact of technological advances and mandatory reporting. Research team members received training in interview techniques from an expert qualitative researcher and engaged in regular peer debriefings. Two IP researchers conducted a qualitative analysis, systematically reviewing and coding the content of interview transcripts in order to derive contextual meaning. The transcripts were read line by line during an extended period of immersion; agreement on emerging themes was reached through consensus. Ideas shared by multiple IPs, as well as divergent opinions, were coded into categories within the themes and captured in "exemplar" quotations.

The interviews documented that the IP role has evolved in response to recent changes in the healthcare landscape, and revealed that this progression was associated with friction and uncertainty.

Tensions inherent in the evolving role of the IP emerged from the content analysis as four broad themes:

  • expanding responsibilities outstrip resources
  • shifting role boundaries create uncertainty
  • evolving mechanisms of influence involve tradeoffs
  • stress of constant change is compounded by chronic recurring challenges

'We're used to a certain autonomy'

IPs reported using personal interaction, data feedback, and education to influence clinical practices, Conway said. However, these mechanisms of influence competed for the IPs' time and were not always effective at ensuring compliance with institutional policies.

"The IPs explained to us that shared accountability for preventing infections is absolutely essential for their work, but it has blurred their role boundaries and to some degree limited their autonomy," she said.

A comment from one of the interviewed IPs in this area was: "I believe over the last three years unit ownership and departmental ownership of infection prevention measures has gone up significantly. We always recognize in our department that we're not going to do this by ourselves. It's only with their good collaboration that we're going to make progress in reducing infections."

On the other hand, "some IPs experienced a little bit of ambivalence about this shift," Conway said. "They described that if everyone is sharing a responsibility it is sometimes difficult to understand where their own responsibility begins and ends."

In that regard, another interviewed IP commented: "I think infection preventionists are the type of people that are usually self-motivated, they want what's best for the patient, but they tend to be…they like to be in charge of certain things….We're used to a certain autonomy."

Another IP who worked at an institution where the quality department took control of the hand hygiene program as part of expanding the infection control effort, had mixed emotions, commenting: "We were sort of offended at first because we felt like hand hygiene was our thing, our thing to teach, our thing to improve."

Many of the IPs interviewed reported their departments had been subsumed under quality or patient safety departments, Conway said. "They reflected that this was a positive change, however there were two problems that they identified," she said. "One was that they were further removed from key decision makers. The other was that the quality managers to whom they reported didn't always have the clinical expertise to understand infection control issues."

One IP told the researchers, "The most important thing for infection control is to be not too far from the top. The closer you are to the top, the easier it is to get things done. You put too many layers though and…things get lost in translation."

Regarding the lack of clinical expertise of their new supervisors one IP bluntly noted, "Our present COO…is very influenced by this quality department. And they don't speak the language. They don't know what they're talking about."

As IPs shift or refine their roles from being siloed experts to being facilitators of quality improvement, they are trying to bring colleagues from other areas into the overal mission of infection prevention. "This is a growth experience for them and they are having to develop new skills," Conway said.

In that regard, an IP with more than 20 years' experience said, "We're used to being very good at making decisions…What we're not as good at is getting everybody else's opinions first. And so we're really trying to drive that down and involve as many frontline people as we can before we make a decision to implement a change."

The responsibility, not the authority

The mechanisms IPs use to influence clinical practice are evolving, but the primary method remains personal interaction, the researchers found. As one IP put it, "I think if we hardwire processes, then we will eventually have good outcomes. And to hardwire processes you need to change behaviors. And you need to make people see why it's important and that it's real. And what it means to them, why it's important to them. What's in it for me? And in order to do that, I have to get out of my office and away from the computer, and stop crunching numbers and be out there."

The demands to collect and disseminate data were often described as "overwhelming" and the variety of reports were often confusing, Conway said. Even so, IPs on balance said that data collection and dissemination was still a key mechanism of influence. One IP said, "The whole mandatory data gathering…I am learning to live with it because it is extremely important when you see the outcomes that you can achieve because you have good information in front of you and you can kind of put it in people's face. It really does make a difference."

The fine line between being an educator and an enforcer is also an evolving issue. "One of the most complex challenges was how to operate on the border between being an educator and being an enforcer," Conway said. "It was evident to us that there is an assumption among some IPs that education leads to compliance."

The problem arose when the education did not lead to compliance and the IPs felt like they didn't have any authority over non-compliant clinicians. An IP with only one year of experience, said "We're given the responsibility…but we really don't have any kind of authority over the staff."

Another told the researchers, "I think that in the past the infection control practitioner was the police, and that's not the direction we are going in anymore, because that's just not getting the job done."

Some combination of the various methods of influence was cited as effective by some IPs, with one stating, "I think between bringing the key players to the table and slowly but surely getting their buy-in; and feeding them back information about the successes that they've had as a team on a frequent basis to keep them motivated; I think those are some of the qualities that have helped me be successful. As opposed to being the disciplinarian for bad outcomes."

Overall, the study found that the IP's role, responsibilities and repertoire are expanding. IPs primarily influence colleagues through personal interaction, feedback of local data, and education.

"They face barriers that include limited resources, uncertain role boundaries, and making necessary tradeoffs between their mechanisms of influence," Conway said. "We also found things that facilitate the IP role are a raised profile and their adaptability and persistence."

Reference

1. Conway LJ, Raveis V, Pogorzelska M, et al. Tensions Inherent in the Evolving Role of the Infection Preventionist: A Qualitative Descriptive Study. Presented at the 40th annual conference of the Association for Professionals in Infection Control and Epidemiology. Fort Lauderdale, FL: June 8-10, 2013.