2A. Appraising Quantitative and Qualitative Research
Quantitative Study
One source of bias during data collection is the use of self-report data (Polit & Beck 2012). Chivers et al. (2001) obtained data through the SF-36 and Beck depression inventory which required the patients to answer questionnaires. If they failed to give accurate answers, it would have affected the validity of the findings. The study design also allowed patients to receive other clinically appropriate treatments that were beyond the study protocol (Chivers et al. 2001). Additional treatments are confounding variables but their influence on the study outcomes was not estimated in the statistical analysis. This reduces confidence in the cause-effect relationship between the intervention and outcomes (Polit & Beck 2012). The was also low-powered (Chivers et al. 2001), which decreases the chances of finding true effects thereby also reducing the reliability of study findings (Polit & Beck 2012).
Qualitative Study
2B. Reliability, Validity, and Related Issues
Qualitative research is best suited to answer certain research questions as compared to quantitative research. In evidence-based practice (EBP), clinicians consider the intervention’s effectiveness, its acceptability and impact, and the experiences of implementing professionals (Miller 2010). Qualitative research can contribute substantively to EBP by helping understand phenomena such as patient needs and gaps in health care, the care implementation process, and intervention effectiveness from the patient and family’s point of view (Miller 2010). Qualitative research can never be comparable with quantitative research in terms of the trustworthiness of evidence because they address different types of questions using widely different approaches. Qualitative research can be regarded as a complementary approach to enriching the understanding of phenomena which should result in better clinical guidelines, intervention protocols, and standards of care (Miller 2010).
It is not to say that trustworthiness is not a concern when it comes to qualitative research. There are strategies that qualitative researchers employ to ensure that their processes meet the criteria for trustworthiness, namely credibility, transferability, dependability, and confirmability (Johnson & Waterfield 2004). Qualitative researchers also concern themselves with ensuring that they accurately portray reality whether it is a patient or group experience or observed behaviors. Strategies to ensure credibility include prolonged engagement, triangulation, and member-checking whilst thick descriptions increase transferability (Elo et al. 2014). Audits assist in ensuring dependability whilst confirmability is assured through triangulation, reflexivity, and an audit trail (Johnson & Waterfield 2004). Qualitative researchers have also developed tools to assess the quality and trustworthiness of qualitative studies in order to assist clinicians in their appraisal and translation of evidence from such studies (Miller 2010).
Literature Review
Healthcare associated infections (HAIs) are infections that occur in patients whilst being treated in a hospital or other healthcare facility (CDC 2016). HAIs, including ventilator associated pneumonia (VAP) and central line associated bloodstream infection (CLABSI), which, although serious, are largely preventable (CDC 2016). Increased patient morbidity and mortality, lengthy hospital stays, and higher costs of care warrant HAI prevention. Healthcare professionals have the primary responsibility to protect patients from HAIs but this requires that they be knowledgeable about evidence-based preventive strategies. A search of the literature was undertaken to explore the knowledge base for increasing the knowledge of healthcare professionals in HAI prevention. Fifteen primary studies were located and reviewed.
Zingg et al. (2014), in a systematic review, found that there is strong evidence supporting the positive impact of education and training on HAI prevention based on quantitative and qualitative studies. In particular, education and training among physicians resulted in lower CLABSI rates (Zingg et al. 2014). Individual studies support this finding. Kirkland et al. (2012), in a time-series quality-improvement (QI) study in a teaching hospital, found that education and training led to a continuous decline in the HAI rate. Rello et al. (2013) also found that standardised infection prevention education led to a significant reduction in the VAP rate in 5 adult ICUs. Rosenthal et al. (2012) noted a decline in PICU CAUTI rates.
Besides improving outcomes related to HAI rates, educational and training interventions were also associated with enhanced knowledge on HAIs and prevention as well as compliance with prevention strategies. Jeong et al. (2016) reported an improvement in infection control nurses’ knowledge scores to 77.99% from 45.91% at baseline following participation in an education programme. Meanwhile, Aboumatar et al. (2012) reported a two-fold rise in hand hygiene compliance following hospital staff education, an improvement that was sustained for more than 20 months in all units and disciplines in the hospital. Kirkland et al. (2012) reported an overall hand hygiene adherence improvement to 87% during implementation up from 41% at baseline. Adherence further increased to 91% at 12 months post intervention (Kirkland et al. 2012). Su (2016) also found significant improvements in HAI knowledge especially among physicians in the surgical ward. The involvement of public health professionals in HAI prevention further enhanced knowledge sharing (Wiemken 2012).
Compliance was noted to be higher among nurses compared to physicians. Parmeggiani et al. (2010) reported that hospital nurses were more knowledgeable and adherent to hand hygiene policies than physicians. Kirkland et al. (2012) noted a 93-percent hand hygiene adherence among nurses compared to 78% among physicians at 78%. Similarly, Aboumatar et al. (2012) found the compliance rate among nurses to be 35% at 6 months after programme initiation and 77% during the final 6 months of the study. There was a lower compliance among physicians at 38% and 62% during the same time periods whilst it was 27% and then 75% among environmental services staff (Aboumatar et al. 2012). Su (2016) similarly reported an increase in hand hygiene compliance to 27% among surgical ward nurses and 22% among physicians. This seems to validate the findings of West et al. (2006) that nurses are the primary drivers of HAI prevention and control because they function as champions of hand hygiene and other preventive interventions.
Common in the interventions investigated was that education and/or training was an element of a multifaceted initiative. This implies that as a sole intervention, education and training is not sufficient in enabling prevention practices that are effective enough to decrease the incidence of HAIs. Kirkland et al. (2012) and Aboumatar et al. (2012) described their multimodal interventions as also consisting of the following interventions besides education and training – leadership and accountability, performance measurement, feedback, communications campaign, and marketing. Additional interventions were making hand sanitisers available (Kirkland et al. 2012) and environmental modifications (Aboumatar et al. 2012). Meanwhile, Rello et al. (2013) and Rosenthal et al. (2012) implemented a bundle of recommendations. Hand hygiene that employed an alcohol-based antiseptic prior to airway manipulation was also a key component of the bundle (Rello et al. 2013). Su (2016) described the other elements of the programme as a separate education and campaign for environmental cleaning, the use of chlorhexidine bathing, and active surveillance besides the education and campaign on hand hygiene. Patel et al. (2013) emphasised patient involvement.
The need for education and training on HAI prevention is evident because having a high knowledge of the topic and a positive attitude toward it does not always translate into enactment of preventive behaviors. Parmeggiani et al. (2010) validate this assumption as their survey showed that healthcare workers in 8 different hospitals had wide knowledge and favourable attitudes towards HAI prevention but compliance with hand hygiene remained low. In terms of specific figures, Ogoina et al. (2015), in a survey of healthcare workers in a hospital, found the median knowledge and attitudes pertaining to standard precautions high at more than 90%, but the median practice score was only about 51%. This meant that only a little more than half of those who participated in the survey actually adhered to standard precautions. In studies that investigated educational and training interventions as part of a multifaceted intervention, adherence was also suboptimal. For instance, Rello et al. (2013) found a hand hygiene adherence rate of 19% among ICU staff following the intervention. Despite physicians reporting greater improvements in HAI knowledge, they had lower compliance compared to nurses (Su 2016). This trend extends to nursing students (Kelcikova et al. 2011) and medical students (Kaur et al. 2016) with 70% reporting good or excellent HAI and hand hygiene knowledge but only 49% adhered to guidelines (Herbert et al. 2013).
Increasing the knowledge of healthcare professionals on HAIs requires choosing appropriate teaching approaches and strategies. The three studies that demonstrated significant improvements in hand hygiene compliance and HAI knowledge scores employed a structured approach to education. Aboumatar et al. (2012) employed the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model in determining the content of staff education. For instance, predisposing factors identified were beliefs about personal risk and the impact on patient safety whilst one enabling factor was knowledge of hand hygiene guidelines (Aboumatar et al. 2012). As such, the educational programme and resources were aimed at enhancing knowledge on risk, patient safety measures, and hand hygiene guidelines. Jeong et al. (2016) employed a different approach in that they referred to the literature and the results of a group discussion by HAI prevention experts in selecting the content of their educational intervention. Public health professionals can serve as content experts (Wiemken 2012). Meanwhile, a learning module was also developed in the study by Kirkland et al. (2012) which was based on the competencies that the staff needed to demonstrate.
The systematic review by Zingg et al. (2014) and the study by Patel et al. (2013) found that competency testing was also important elements of the structured learning activities. Only Kirkland et al. (2012) had such a system in place which employed certification to validate competence. The studies by Jeong et al. (2016), Kaur et al. (2016), and West et al. (2006) highlighted the value of eliciting feedback from learners in order to further improve the content and delivery of HAI interventions. Although improvements in knowledge and compliance rates were measured, Zingg et al. (2014) also recommended audits to identify barriers to knowledge acquisition and knowledge translation into practice.
Conclusion
Education and training on HAI and prevention measures is effective in increasing knowledge of these topics among healthcare professionals and in decreasing HAI rates. However, this intervention is most effective when part of a multimodal strategy to address the clinical issue. Improvement in knowledge does not always result in adherence to HAI prevention measures and nurses are consistently more compliant compared to physicians. Structured education is most effective as it standardises teaching content and delivery. Teaching content should be based on evidence, expert judgment, and also specific learner needs warranting tailored programmes. Teaching strategies should employ didactic methods and skills learning. Competency testing should be instituted following education. Knowledge improvement on HAI should begin in undergraduate education.
Recommendations
Available evidence does not support a single approach or strategy in developing structured HAI education and training nor does it endorse a single teaching strategy. Further research is needed to compare different approaches and strategies to further improve knowledge acquisition and facilitate translation into practice among professionals and students. In particular, studies should look into why physicians tend to have lower compliance rates than nurses as the success of HAI prevention also relies on the involvement of stakeholder disciplines. Studies should provide in-depth descriptions of educational programmes investigated to foster replication in research and adoption in practice.
References
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Centers for Disease Control and Prevention (CDC). 2016. HAI data and statistics [Online]. Available from: http://www.cdc.gov/hai/surveillance/ [25 July 2016]
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Elo, S., Kaariainen, M., and Kanste, O. 2014. Quantitative content analysis: A focus on trustworthiness. SAGE Open 2014, pp. 1-10.
Herbert, V.G., Schlumm, P., and Kessler, H.H. 2013. Knowledge of and adherence to hygiene guidelines among medical students in Austria. Interdisciplinary Perspectives on Infectious Diseases 2013, pp. 1-6.
Jeong, S.Y., Lee, J., and Kim, S.R. 2016. Development and implementation of an education program for novice infection control nurses. Korean Journal of Nosocomial Infection Control 21(1), pp.18-30.
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Wiemken, T., Polgreen, P.M., and McKinney, W.P. 2012. Knowledge sharing among healthcare infection preventionists: The impact of public health professionals in a rural state. BMC Research Notes 5(387), pp. 1-8.
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Appendix 1
Evidence Table
