VOL: 100, ISSUE: 36, PAGE NO: 56
Ann Shuttleworth, BA, is a freelance health care journalist
Yet while the science of microbiology advances, it often seems as if fundamental infection control battles are being lost. This article discusses whether better knowledge of microbiology would help nurses to practise more effective infection control.
Recent statistics on health care-acquired infections (HAIs) have caused well-publicised alarm. One in ten patients now leave hospital with an HAI, while deaths in which methicillin-resistant Staphylococcus aureus (MRSA) was implicated rose from 51 in the year 1993 to 800 in 2002 (Griffiths et al, 2004). Reports of MRSA increased from 7,250 in 2001-2002 to 7,647 in 2003-2004 (Health Protection Agency, 2004).
The Department of Health (2004) recently published proposals to combat HAIs, which place much of the onus on nurses (Beckford-Ball and Hainsworth, 2004). These measures aim to ensure that nurses clearly understand the principles of infection control.
But Jonathan Edgeworth, consultant microbiologist at Guy’s and St Thomas’ Hospital NHS Trust, says this is only part of the solution: ‘The most important thing for nurses is that they are empowered to challenge medics when they see poor infection control practice, and they need clear backing from management in this.’
Many factors contribute to HAIs in the UK. For example, growth in hospital admissions - from 3.3 million to almost four million in 1993-1994, was coupled with a reduction in acute and general beds from more than 140,000 to 138,000 (National Audit Office, 2000).
News reports have claimed this has led to almost 100 per cent bed occupancy (Boseley, 2004), but the DoH (2004) disputes this, claiming average occupancy is just over 86 per cent. The NAO (2000) recognises that when occupancy rises above 85 per cent, patient infections also rise, and staff shortages make it increasingly difficult to maintain hygiene standards.
Nurses’ knowledge of microbiology
While the factors discussed above cause practical difficulties in maintaining infection control standards, the author of a recent letter in Nursing Times believes that staff - particularly nurses - need better understanding of how infections spread if they are to combat them (Seewoodhary, 2004), and that this involves an understanding of microbiology.
Unlike practical procedures, which can be taught and reinforced in the clinical environment, microbiology requires academic study, and the most appropriate place for this is probably in preregistration education.
The preregistration syllabus varies between universities, and while many simply list microbiology on the syllabus outline, others give it greater prominence. For example, in 2002-2003 the University of Glasgow’s bachelor’s degree in nursing included 33 hours of lectures and 12 hours of practical exercises. Currently, the course involves 20 hours of microbiology lectures spread over the first two years.
Pressure on the curriculum has led to this reduction, although Dr Ian McKay, until recently the microbiology course leader for the university’s nursing curriculum, believes Glasgow still teaches more microbiology than most universities.
Dinah Gould, professor of applied health at City University, London, and co-author of Applied Microbiology for Nurses, recognises the problems of a crowded curriculum. ‘As an educationalist I understand the pressures on the syllabus, and that everyone wants their subject to be given priority,’ she says.
‘However, as an infection control specialist I believe microbiology is vital. People need more knowledge of basic infection control principles before they go into practice. You can reinforce it once they are in practice, but it should be there beforehand. Knowledge of applied microbiology and infection control is essential, but currently it is not as good as it needs to be.’
Professor Gould believes part of the problem is a lack of people able to teach infection control in imaginative ways. However, another significant issue is the level of students’ scientific knowledge when they begin preregistration courses. ‘I don’t expect them to have studied applied microbiology, but I do expect them to have a basic scientific education. Unfortunately this isn’t always the case, so we’re starting from a lower level than is ideal.’ says professor Gould.
Dr McKay agrees, citing numeracy as a particular problem. ‘Nursing students often have difficulty with simple calculations they will need in practice,’ he says. ’I once gave a group of around 20 students an exercise in which they were asked to calculate the number of bacteria in a millilitre of urine from a microlitre sample.
‘None of them came up with the correct answer - in fact they didn’t realise it was something they could calculate, and were guessing the answer.’
Professor Gould believes postregistration education in infection control is vital, both to teach and reinforce. However, attendance on these courses is often not easy for staff. ‘It’s difficult for them to be released from the ward to come on courses, so we’ll run them, but they can’t get there. It’s not that they aren’t interested - they often just can’t attend or can only come in the afternoon, so they miss half of it,’ she says.
What do nurses need to know?
While Diane Gill, head nurse/matron (medical specialties) at Queen’s Medical Centre, Nottingham, acknowledges that knowledge of microbiology is useful, she emphasises the need for practical postregistration education.
‘Students don’t always have the opportunity to put their theory into practice for some time, and often it’s not until the first time you barrier nurse or care for someone with HIV infection that it hits you,’ says Ms Gill.
‘You need a good, responsive infection control team who can come down and give you practical advice there and then. While a big hospital like Queen’s can do that, it’s not always possible in small district generals, or particularly in residential and nursing homes.’
Ms Gill says it is not only nurses and other qualified staff who need infection control training, and that applied microbiology may not be right for everyone. ‘A lot of hands-on care is given by unqualified staff, not all of whom would be able to take that on,’ she says.
‘What’s needed is a range of education to cater for different abilities, that focuses on things like when to use gloves and aprons, the importance of replacing IV cannulas regularly, and the infection control implications of this, and handwashing of course - you really can’t emphasise that enough,’ she says.
Dr Edgeworth believes that the priority should be for nurses to understand a specific group of bacteria (Box 1). ‘These bacteria probably generate around 50 per cent of microbiologists’ work, and nurses need to know about them and what they do,’ he says. ‘I don’t think they necessarily need to know in detail about things like Gram positive, Gram negative and rods.’
Dr McKay agrees: ’Not all microbiology is important to nurses - it would be a mistake to teach them how to diagnose infections or what goes on in the microbiology lab. But they do need to understand bacteria, and how they grow and are transmitted. They also need to know how to take specimens correctly - why it is important to take them in particular ways to avoid contamination, the bacteria growing in transit or killing the bacteria.
‘Sometimes the first signs of infection are more apparent to nurses than to doctors. For example, they may see a skin infection when bathing a patient, notice a patient reacting to pain when being handled, or find an area of inflammation and redness. While they do not need to diagnose or confirm an infection, they can alert the doctors to the symptoms.’
The problem of HAI is extending into patients’ homes. Changing health care services has meant that many vulnerable patients are now nursed at home, where infection control measures can be harder to implement, says Professor Gould.
’The boundaries between hospital and the community are becoming blurred, so you have nurse specialists doing domiciliary visits and the home is effectively a hospital. But people don’t always want their homes turned into a hospital, and we’re getting what are essentially hospital-acquired infections within the community.
‘The situation within the home is often poor, and nurses don’t have a lot of control over that. They may set everything up to do a dressing change, then the cat walks through the aseptic area, so what do you do?’
The priority must be to prevent infections occurring, but nurses in the community do not always have an infection control team on hand to advise them. A sound knowledge of microbiology may ensure they are better equipped to teach families how to minimise patients’ risk of infection, and also about its consequences.
A foundation for infection control practice
While there is some debate about how much knowledge of microbiology nurses need, Dr McKay believes they learn and apply infection control procedures better if they understand their necessity and why they are carried out as they are. Dr Edgeworth believes this has to be the focus of their education in microbiology.
‘Nurses need to be aware of the key things that cause the spread of infection,’ he says. ‘For example, if a patient is admitted from a hospital with a known MRSA problem, she or he should be isolated. Nurses must understand the principles of infection control.’