Abstract
Background:
The Director of Infection Prevention and Control (DIPC) role was introduced into the UK in 2003 to address the need for effective leadership within Infection Prevention (IP). The role was embedded in English legislation in 2008. In one Independent healthcare organisation (with 31 acute hospitals spread geographically across the UK), the DIPC role is held by the hospital matron (known as Director of Nursing in the NHS), who influence resource allocation and ensure infection prevention is prioritised. A knowledge gap in microbiology, standard precautions and infection prevention regulatory requirements was identified and as there was no educational provision for this role, an accredited programme was developed. Twenty-five matrons completed the DIPC programme.
Aims:
Evaluate the impact of a DIPC educational programme on the delivery of IP services.
Methodology:
A post-course qualitative retrospective survey using open-ended questions was used to collect data from DIPCs who had completed the programme. Inductive thematic and content analysis methods were used to identify key themes from survey responses.
Results:
Out of 20 DIPCs, 16 completed the survey. Key findings included improvements in knowledge related to microbiology, IP and regulatory requirements of the DIPC role. DIPCs reported changes to service delivery including appointment of six IP nurses, improved surveillance processes, reduced infections and improved cleanliness standards. This small study demonstrates the impact of an educational programme for DIPCs who felt more empowered to manage the IP services effectively, resulting in improved patient safety through reduced infections.
Keywords
Background
The Director of Infection Prevention and Control (DIPC) role was first introduced in England in 2003 (Department of Health [DH], 2003), when a need for effective leadership in infection prevention and control (IPC) was identified. Organisations were required to appoint a DIPC and provide a direct line of accountability to the most senior executive leader responsible for managing the organisation; in the UK, this is the Chief Executive Officer (CEO). It was hoped that this would address concerns that evidence-based practice was not being implemented consistently in a majority of hospitals. Escalating antimicrobial resistance and emerging antibiotic-resistant organisms such as Methicillin-resistant Staphylococcus aureus (MRSA) provided further evidence that changes within healthcare delivery were required (DH, 2003).
The DIPC role was later embedded in legislation (DH, 2008a) when DIPCs were required to report directly to the chief executive and have the authority to challenge inappropriate practice and antibiotic prescribing decisions. The DIPC role has tended to be held by microbiologists, directors of nursing service (DNS) or infection prevention nurses (IPN); however, some of these individuals may lack appropriate leadership skills, knowledge, power and/or authority to drive changes and improvements in IP outcomes.
Despite competencies being developed for the DIPC role (DH, 2004), there was no form of educational training to help prepare DIPCs for their role which included leadership and change management skills as well as practical experience in dealing with infection control matters to a minimum standard of a diploma level (or equivalent) qualification in hospital infection control (DH, 2004). Gould (2016) highlighted the importance of leadership within IP and that this should include the ability to mobilise others to develop shared aspirations. Maister et al. (2002) believes that leaders wishing to engage and influence others need to be credible; this may be difficult for those without a sound knowledge of infection prevention and control.
The DIPC role within the organisation
Within the UK, one independent, not-for-profit healthcare organisation provides healthcare from 31 acute hospitals (1600 beds) spread geographically across England, Scotland and Wales. The organisation is managed by a CEO and senior clinical lead—the chief nurse, who also holds the DIPC role for the organisation. An organisational lead for IP (IP lead nurse) supports both the CEO and chief nurse DIPC.
A range of services are provided for both NHS and private patients, including surgery (largely elective including gynaecology, orthopaedic, cardiac, neurosurgery and cosmetics), oncology, diagnostic and screening services, preoperative fitness preparation and enhanced recovery programmes as well as a wide range of fitness and wellbeing services.
Each of the 31 hospitals is managed by a Hospital Director (HD). The HD holds the regulatory role of ‘registered manager’ and acts in a similar capacity to an NHS Trust CEO, with executive responsibility for IPC. The senior clinical lead within each of the 31 hospitals is the Matron, who also holds the DIPC role for the individual hospital, thus providing accountability for infection prevention at ‘local level’.
Matron is a member of the hospital’s senior management team, reporting directly to the HD and deputising for them in their absence. Matron provides professional direction and clinical leadership to all clinical functions within the hospital including nursing, allied healthcare professionals and the resident medical officer.
As DIPC, matrons are responsible for implementation of evidence-based practice, challenging poor practice and ensuring audit and surveillance processes are robust so that infection risks are promptly detected and reported (DH, 2015). To help facilitate this, matrons are supported within their hospital by an IP nurse (IPN) or an IP coordinator. An IP coordinator is a trained IP link practitioner (IPLP) who completes a two-day course to take on the role of their hospital IP coordinator. The decision to employ an IPN or IP coordinator is made by the matron and is based upon an assessment of infection risks within their hospital risk assessment (size of hospital, patient activity, complexity of services and infection risks identified locally). In 2014, three hospitals had a qualified IPN with 28 hospital DIPCs having an IP coordinator supporting them.
Figure 1 shows the structure of IPC within this organisation which differs slightly to the traditional NHS model.
Organisational framework for the management of IPC.
The matron is sufficiently senior to be able to exert authority and influence decision-making. However, to do this effectively requires an understanding of microbiology and the infection process as well as a sound knowledge base of standard IP precautions. This would enhance their credibility and enable them to be good role models and challenge practice (especially in relation to hand hygiene and protective clothing). DIPCs must also have an awareness of their responsibilities under the Health and Social Care Act 2008 Code of Practice for the prevention of healthcare-associated infections (HCAI) (DH, 2015) so that they can assure their board that they meet the regulatory requirements for patient safety through good IPC.
Through discussions with matron DIPCs and a review of infection surveillance data and procesesses, it became clear that DIPCs, who are clinical leaders but not IPNs, lack essential knowledge and/or skills relating to microbiology and HCAIs and did not fully understand the regulatory requirements for reporting infections to regulatory bodies. It was also identified that there was no provision for DIPC education within the UK.
The DIPC programme
A two-day educational programme was developed and piloted. Core programme content can be seen in Table 1.
Core content of the DIPC programme.
To present a credible programme that supported professional development, approaches were made to run the programme through a university (De Montfort University, Leicester). A postgraduate module was established (known as ‘Fundamentals of Infection Prevention and Control for Directors of Infection Prevention and Control within the Independent Sector’) which placed equal emphasis on theory and practice.
Assessment was through a Practice Assessment Module Portfolio, demonstrating achievement of learning outcomes (Table 2) and a 2500-word assignment to: ‘Critically analyse the role of healthcare practitioners in the provision of Infection Prevention and Control, evaluating the impact of knowledge and skills in delivering high quality patient outcomes.’
DIPC learning outcomes.
The first programme commenced at the university in April 2014, providing DIPCs with an opportunity to network and work undistracted by day-to-day work pressures.
Aims of the study
Evaluate the impact of the DIPC educational programme on the delivery of an IP service across the hospitals.
Methods
To identify DIPC feedback on the programme and to understand any impact the DIPC educational programme may have had on the delivery of the IP service within their hospital, a post-programme qualitative retrospective survey using six open-ended questions was sent to all DIPCs (Table 3).
Survey questions sent to DIPCs after completion of the programme.
Twenty-five DIPCs completed the educational programme during 2014–2017; five had left their hospital during or shortly after completing the programme. Twenty DIPCs were therefore contacted and asked to complete the survey.
Data were analysed using a combination of both inductive thematic and content analysis to identify key themes regarding any impact on service delivery.
Results
Sixteen out of twenty responses (80%) were received. This was deemed an acceptable response rate as advocated by Richardson (2005).
Question 1: What aspects of the programme were most helpful?
The most helpful aspects of the course were identified as the educational sessions on microbiology and the regulatory aspects of the DIPC role (Table 4). Some respondents quoted more than one answer, e.g. microbiology and regulations and/or responsibilities of DIPC role.
Responses to Question 1: aspects of the programme which most assisted DIPCs in their role.
Question 2: Have you made any changes to the structure of your IP team as a result of completing the programme?
Table 5 summarises the responses from Question 2. Of the 16 respondents, 13 reported changes to their IP structure: three hospital DIPCs had secured resources to appoint an IPN while an additional three hospitals had funded IP coordinators to become qualified IPNs. Twelve hospitals had trained additional link nurses within key clinical departments.
Responses to Question 2: have you made any changes to the structure of your IP team following the DIPC programme.
One matron said there had been ‘no real change to the structure; however, more involvement from myself following completion of the course. This is probably due to me having more confidence about the specialty following the programme of learning.’
Four hospitals did not have a service level agreement (SLA) for consultant microbiologist support but following the programme, had secured such an agreement.
Question 3: Have you made any changes to the way you manage infection prevention since completing the course?
DIPCs reported a range of changes in how they manage IP as a result of the programme (Table 6).
Responses to Question 3: have you made any changes to the way you manage IP since completing the programme.
Six DIPCs reported changes to the way they work including, weekly ‘walk the floor’ sessions with their IP lead. This has enabled them to ‘observe practice, have conversations with clinical staff and detect opportunities for improvement’.
Two DIPCs said they felt better prepared for their role and for the Care Quality Commission inspection process and nine DIPCs said they better understand and appreciate the role of the link nurse and the activities required to assist them in meeting their responsibilities.
Seven DIPCs have introduced changes to IP team meetings: agenda items to include antibiotic stewardship and formal process to review and sign-off infection data for external reporting.
Question 4: Have you seen any improvements in infection prevention since completing the course?
Six DIPCs reported improvements in their surveillance processes which they felt had led to an improvement in prompt identification of infection. DIPCs reported feeling more confident that infections were being detected and reported accurately with one hospital reporting an increase in infections (through better processes) and another reporting a decrease in infections (due to better knowledge of definitions for infections).
Table 7 shows the reported bloodstream infections, Clostridium difficile cases and contaminated blood cultures for the period 2014, before the DIPC course, to date.
HCAI data, 2014–2017.
Before completing the programme, six hospitals had failed to meet deadlines for submitting HCAI data to regulatory bodies. Since completing the educational programme, all DIPCs had met these deadlines.
Fourteen respondents had felt that there were improvements in communication and staff engagement, both inside the organisation and across the wider health economy; collaboration with NHS colleagues, microbiologists and commissioning groups resulted in better root cause analysis investigations and understanding of infections across local healthcare communities.
One DIPC matron reported that, following the programme, a patient had developed an E. coli bloodstream infection (BSI) following a transrectal ultrasound (TRUS) biopsy procedure. The subsequent root cause analysis (RCA) investigation had identified a previous history of lengthy antibiotics and resistance to the antibiotics used as prophylaxis for his procedure. It was felt that had this information been identified and communicated, precautions could have been taken to detect risks of resistance and a change in antibiotic prophylaxis may have prevented the BSI. The DIPC matron had invited the patient to return and discuss his care and look at lessons learned. She reported that, as a direct result of the DIPC programme she had felt confident to be challenged by the patient and to work with him to prevent such instances occurring again. She was able to explain changes in processes (introduction of rectal screening before the procedure and issuing of patient information leaflets on what to do after discharge following TRUS procedures). The patient had said ‘this means so much to me, to know that systems have been put in place to prevent this happening to someone else’.
In another hospital, as a direct result of the DIPC programme, the matron had worked collaboratively with the head of housekeeping to introduce an accredited training programme for cleaning. Cleaning standards were monitored and had shown a sustained improvement from 60% in January 2016 to 96% in September 2017.
Question 5: are there any aspects of the course you would change? If so why
Ten of the 16 responders would not change anything about the course.
Five DIPCs would have liked an additional day mid-course, to get to network before course assignment submissions.
Five responses felt the university learning portal presented some IT challenges when working remotely.
Question 6: what three words would you use to describe the programme?
The most common words used to describe the programme were: educational, reflective, relevant, worthwhile, enjoyable/fun (Table 8).
Responses to Question 6: words DIPCs used to describe the programme, ranked by most popular.
Discussion
The findings from this small study suggest the DIPC educational programme has had a positive impact on the way DIPCs manage IPC within their hospital.
The programme has improved both knowledge base and awareness of the DIPC regulatory responsibilities for IPC.
As members of their senior management teams, DIPCs can influence how resources are allocated and ensure infection prevention is prioritised. DIPCs now have a better understanding of their role and responsibilities for infection prevention and as a result of this, have made significant changes in the structure and management of infection prevention. Three hospitals have funded IPCs to complete IPN training and an additional three hospitals have appointed a qualified IPN, increasing the number of hospitals with IPNs from three to nine. Twelve hospitals had funded training for staff to become link nurses.
All DIPCs reported stronger relationships with their IP lead, with six DIPCs introducing ‘weekly walks’ around the hospital with the IP lead. ‘Being seen’ on the shop floor is thought to be an important aspect of a good leader: a report by the Care Quality Commission (CQC, 2017) into driving improvement in the NHS highlighted the importance of effective leadership. In those hospitals that went into special measures, leaders were seldom seen and there was disconnect between clinicians and managers. The report goes on to say that ‘Leaders need to lead and be seen to lead’ and senior staff need to spend time on the ‘shop floor’, meeting staff and setting up regular channels of communication. Effective leaders also need to be able to work through others to achieve safe healthcare (King’s Fund, 2012). This includes IPC, where effective leadership is required in order to ensure prompt response to sudden and unexpected crises such as outbreaks as well as the support required by frontline staff when implementing quality improvement programmes (Gould, 2016).
DIPCs are actively supporting staff to participate in national and global campaigns such as 5 May WHO clean hand and Infection Prevention Awareness Week campaigns including our ‘Glove Actually’ project which aims to raise awareness of inappropriate non-sterile glove use. Implementation of a standardised aseptic technique across the organisation was fully supported by DIPCs and has seen the number of contaminated blood cultures reduce from 20 in 2014 to eight in 2017.
Infection data are now believed to be more accurate as a result of DIPCs embedding weekly and/or monthly team meetings to discuss and review infection surveillance processes and outcome data. There has been a reduction in bloodstream infections and cases of C. difficile since 2014.
These findings suggest our matrons are engaged leaders who are supporting staff in implementing best practice to achieve lower infection rates and better patient outcomes.
Our DIPC programme is not just about providing technical information though, it is about providing motivation and coaching so that DIPCs engage with IP within their hospitals
Since completing the DIPC program, DIPCs have reported feeling more confident and empowered to manage the service within their hospitals. Evidence suggests (King’s Fund, 2012) that engaged staff are more likely to put energy into their work and that their positive approach may in turn motivate others which, in turn, may be why engaged staff raise performance.
Our hospital matrons are required to have a professional leadership/management qualification or training and their job description requires them to ‘be a leader, able to inspire, coach and motivate teams and individuals for the benefit of patient care’. Furthermore, the role requires them to ‘challenge professional and organisational barriers and act as an exemplary role model to others’. These skills, combined with their seniority (and authority held) within the hospital, place the matron in an excellent position to take on the responsibilities of the DIPC and this is included in their job description.
The case for leadership and engagement is compelling: staff who are more engaged deliver a better patient experience, have fewer errors, lower infection and mortality rates (Kings Fund, 2012). The DIPC as a pivotal (and regulatory) role in ensuring IP standards are met. This requires them to be skilled, knowledgeable leaders with the authority to challenge poor practice and engage with staff. Halton et al. (2017) reported the most serious challenges to implementation of evidence-based practice is related to lack of leadership or lack of interest in IP at an organisational level. Wong et al. (2002) concluded that strong organisational support is a key element of clinical governance and is essential for ongoing improvements in safety and quality. Knowledgeable DIPCs with strong leadership skills are therefore a critical component of an organisations patient safety and IP strategy.
In summary, this educational programme has provided our DIPC matrons with the fundamental knowledge underpinning IPC and has, according to their feedback, enabled them to make changes to the way they manage IP services.
Following the implementation of the programme, DIPCs appear more engaged in IP than before; attendance at DIPC study days in 2016 and 2017 has been excellent with all 31 hospital DIPCs participating.
DIPCs have twice-a-year meetings to review their programme and outcome date as well as discuss trends, risks and identify actions for the new year. These meetings include educational sessions on current themes (e.g. antimicrobial resistance, targets for reducing gram negative BSIs, new publications, etc). There is also the opportunity to network and share lessons, experiences and ideas. These meetings prove to be popular and well attended.
There are challenging aspects of running this programme. First, turnover of staff (four matrons have left their role since completing the programme) and a need to run the programme at least annually to capture new matrons joining the organisation. Second, running the programme requires a lot of commitment when there are only four or five candidates per programme. We have mitigated this by running the two-day programme alongside the first two days of our IP link nurse programme. This has had significant benefits including IPLPs and matrons working together for practical sessions (e.g. hand hygiene practice, how to clean equipment / put on/take of gloves and aprons). Both matrons and IPLPs report this networking opportunity to be a benefit of the programme.
This retrospective study does have its limitations: the nature of the programme has meant that it is a small study and, with staff turnover, some programme evaluations were not completed or returned. However, one of the strengths of the study lies in staff completing the evaluations once they have completed the programme and returned to their ‘day job’, enabling them to apply the learning to their role and provide a more accurate reflection of the programme. Another strength of this study lies in the fact that it is the first programme of its kind and provides a platform for others wishing to run similar programmes.
Safety and the prevention of infection is an issue for all patients, whether care is privately commissioned or funded by the NHS. Given that the person holding the DIPC role may have limited or no infection control training, an educational programme was clearly required. Our DIPC programme has had a positive impact both in terms of ensuring our DIPCs are equipped for their role and patient safety, through better surveillance processes and reporting which helps promptly detect infection risks and take appropriate action.
Other organisations wishing to emulate this programme may need to consider if those holding the DIPC role possess the leadership skills and the power and authority required to compliment this programme or if these aspects need to be included as an integral part of their programme.
Footnotes
Acknowledgements
With thanks to Nigel Goodrich, Jude Robinson at De Montfort University for support in running this course and to Dawn Hamill and Christine Finch for support with editing.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Peer review statement
Not commissioned; blind peer-reviewed.
