VOL: 102, ISSUE: 15, PAGE NO: 32
Laurence Lines, BSc (infection control), RGN, is community infection control nurse, Gateshead Primary Care TrustAim: To examine the extent to which staff nurses feel that MRSA is out of control and that any attempts by them to control it are unnecessary.
Aim: To examine the extent to which staff nurses feel that MRSA is out of control and that any attempts by them to control it are unnecessary.
Method: A qualitative research paradigm with semi-structured interviews to examine the perceptions, attitudes and beliefs of 10 senior staff nurses.
Results: In the study, 60% of participants believe that MRSA is out of control and state 'why should they bother worrying about it'. Furthermore, 80% of participants commented that prescribed courses of nasal mupirocin were frequently missed. The perception is that IV treatments were more important and effective than topical agents.
Conclusion: The study has established that a small section of experienced staff nurses perceive MRSA to be out of control and they are not overly concerned about its management.
In 1999 the Plowman report (Plowman et al, 1999) suggested that healthcare-associated infections (HAIs) were responsible for 5,000 deaths at a cost to the NHS of approximately £1bn a year. A more recent report by the National Audit Office suggests that these are still the best estimates available.
HAIs and methicillin-resistant Staphylococcus aureus (MRSA) attract considerable media interest, featuring frequently in the press and on the radio and television. Controlling MRSA appears to be a focus of the government, and it has issued a plethora of advice and guidance suggesting how trusts and healthcare workers should tackle MRSA.
While these initiatives are welcome and are supported by infection control teams, what is rarely considered and understood are the perceptions, attitudes and beliefs of those healthcare workers who have to implement them.
This may be an important factor as it seems that there are many senior staff nurses who believe that MRSA is out of control and feel that any attempts to control it are unnecessary. If this is true, efforts to implement control strategies such as those mentioned in the government's guidance will become increasingly difficult.
This study set out to examine the extent to which staff nurses feel that MRSA is out of control and that any attempt, by them, to control it is unnecessary. A qualitative research paradigm was chosen using semi-structured interviews examining the perceptions, attitudes and beliefs of 10 senior staff nurses.
Clinical importance of S. aureus
Staphylococcus aureus is an opportunistic pathogen that is estimated to have colonised the human body in approximately 30% of the general population, rising to 50% in hospitalised patients (Boyce, 1996). S. aureus ranks the second or third main cause of HAIs and first or second cause of all surgical site infections (Casewell, 1998). In England and Wales, nosocomial infections from S. aureus have emerged as the single most important infection control problem in the 1990s with surgical infections seriously compromising otherwise successful surgical procedures (Hori et al, 2001).
Carriage of S. aureus
Early studies suggest that the nose is the site most frequently found to harbour S. aureus. Williams et al (1967) demonstrated for the first time that people who were nasal carriers had increased rates of surgical sepsis compared with non-carriers. They also described the carrier state, which showed that 20-35% of individuals are persistent carriers, 30-70% are intermittent carriers and 10-40% are never carriers. These figures have remained consistent over time (Solberg, 2000; Casewell, 1998; Kluytmans, 1998).
Although the principal reservoir for staphylococci is the nose, carriage at other body sites appears dependent upon nasal carriage (Wenzel and Perl, 1995). The incidence of surgical wound infection in nasal carriers of S. aureus is in the range of 5.6-16.5%, compared with 1.1-6.7% in non-carriers (Casewell and Hill, 1986a).
Increased carriage rates have been confirmed in several patient groups.
Methicillin was introduced in 1959 (Casewell and Hill, 1986a) and the emergence of MRSA was reported in Europe in the early 1960s (Shanson, 1981). Shanson also reported that during the early 1970s there was a general decline in the incidence of MRSA, only for it to re-emerge again in the latter years of the decade.
Over 30 years later the spread of MRSA has become a major problem in hospitals worldwide (Solberg, 2000). It is the cause of 40% of S. aureus infections in hospitals (CDR, 2004).
Controlling the spread of MRSA is proving difficult. Adding to the problem are lack of side rooms, limited therapeutic options, increased bed occupancy and patient turnover driven at least in part by waiting list initiatives. To address these, infection control nurses (ICNs) have a range of infection control strategies to minimise the spread of resistant strains. These include strict environmental cleaning, isolation nursing, antibacterial body washes and strict adherence to hand hygiene. These methods have been used as a single measure or in combination. A key factor in controlling the spread of MRSA in colonised patients is the elimination of nasal carriage.
Elimination of nasal carriage by topical antibiotic treatment markedly reduces the infection rate in patients undergoing surgery (Kluytmans, 1998), haemodialysis (Boelaert et al, 1993) and continuous ambulatory peritoneal dialysis (Kluytmans, 1998). These studies conclude that a substantial proportion of infections are caused by endogenous strains of S. aureus, that the nose is an important reservoir for the bacteria and that the elimination of colonisation significantly reduces subsequent infection.
In a landmark study, Casewell and Hill (1986b) demonstrated that mupirocin eradicated nasal carriage of MRSA in all evaluable subjects, while a placebo failed to eliminate nasal carriage in any subject. Further clinical trials with nasal mupirocin have consistently shown it eradicates nasal carriage of S. aureus, including resistant strains, in 91-97% of cases (Walker et al, 2003).
However, a study by Lines and Weightman (2005) demonstrated an overall eradication rate of only 78% which is lower than those reported above. This may be explained by the fact that, in a research setting, the application of mupirocin is usually either performed or supervised by the researchers, or applied by healthy volunteers as directed, ensuring a high adherence rate. In a clinical setting, such as that in the Lines and Weightman study, lower eradication rates might be expected due to the poor adherence to prescribing and administration schedules, which may be related to nurses' perceptions, attitudes, values and beliefs. Many patients in this study received prolonged courses of mupirocin, and a potential consequence is the emergence of low or high-level mupirocin resistance (Eltringham, 1997). Rahman et al (1989) first reported high-level mupirocin resistance in 1987. Emergence of resistance has been reported since where extensive and sometimes inappropriate use of antibiotics has been used (Mehtar, 1998).
Casewell and Hill (1991) argue that, as with many antimicrobial agents, inappropriate or unnecessarily prolonged therapy may result in the emergence of resistance and loss of efficacy. They suggest that two parameters are important when assessing the efficacy of any regimen: the number of doses needed to achieve eradication; and the post-treatment interval to recolonisation. Therefore well-judged use of mupirocin is advocated, with short courses being preferable (Miller et al, 1996).
A qualitative paradigm using semi-structured interview techniques was chosen to explore the perceptions, attitudes and beliefs of senior staff nurses. The research setting was a 1,100-bed university teaching hospital and the inclusion criteria consisted of all staff nurses working in this setting who had five years' post-registration experience. This sample was chosen because of the nurses' experience and because they were potential 'gatekeepers'. Gatekeepers, in this context, are nurses who are perceived to be the most likely to influence the practice of junior staff (Lewis, 1990).
Permission and ethical approval from the trust was granted and the study began with a pilot to test, validate and refine the interview questions. Selection of 15 participants was conducted by randomly drawing names out of a hat, using a 'selection and replacement method' (Burns and Grove, 1999). Signed consent was obtained, all material was treated in confidence, participation in the study was voluntary and participants were reminded that they could withdraw at any stage.
The interviews were conducted at the staff nurses' convenience, usually at their workplace. They were audiotaped to assist interpretation, increase accuracy and to facilitate transcription, with each interview lasting approximately 30 minutes. Of the 15 nurses chosen for interview, data saturation was reached after 10 interviews. Those interviewed were asked to consider sharing personal perceptions, attitudes and beliefs concerning MRSA. After transcription, data was checked for accuracy and returned to the participants for verification. The transcripts were analysed, coded and emergent categories noted.
Each category was then developed into sub-categories. A colleague familiar with category generation read three transcripts and offered an opinion of the accuracy of themes and categories.
Analysis of the transcripts identified five primary categories. These were: knowledge of MRSA; trust policy; MRSA treatments; control of MRSA; and nurses' roles and responsibilities.
Knowledge of MRSA
The emergent themes were: definition of MRSA, antibiotic resistance and modes of transmission. All participants had a reasonable understanding of the term MRSA, with seven providing a correct definition. Eight participants understood it to be a serious organism that has become resistant to many antibiotics. Three participants made no reference to how MRSA may be transmitted and the remaining seven only made only vague references.
A similar picture emerged when participants were asked for their opinion about the trust's MRSA policy. These views ranged from 'I don't know' or 'I suppose it is OK, yeah it's not too bad' to 'It's good actually. I think it's very good because I will, if someone needs MRSA screening, I will always go to the policy.'
One participant said 'I think sometimes it can be a waste of time, really, from my point of view', when asked to explain the reply was 'the bed situation. We are always in a bed crisis and patients with MRSA must go in a side room and we never have enough side rooms.'
This was unsurprising and further probing revealed that isolation and screening were felt to be a chore. While all participants knew that isolation was necessary, their knowledge of screening was poor or inconsistent with the advice provided in the policy.Only one was able to state the correct screening procedure, though five were aware of the need to screen. Five felt frustrated because there were no side rooms available and blamed 'bed pressures' as a reason for not being able to provide adequate care. Frustration was expressed by four participants who said that doctors never follow infection control precautions, with one participant stating 'some of them won't even wash their hands'.
It was surprising to find that all 10 participants felt that staff should be screened on a regular basis. Comments included 'Well, you should screen every patient for MRSA' and 'We screen the patients but how often do we screen the staff? We could all be carriers.' 'The only way (to control MRSA) is to screen staff.' These comments were interesting as the MRSA policy explains the rationale for our screening protocol and staff are regularly updated on this subject.
Two notable themes emerged from this category: nasal (topical) and IV treatments. Nine participants said MRSA eradication was not important. Although all knew that nasal mupirocin was the treatment of choice for nasal colonisation, only one expressed a correct regimen, and it also emerged that adherence to prescribed regimens by these and other staff nurses was poor, with eight people commenting that non-adherence was common. Two issues stood out:
'I think it often gets missed to be honest. I have no way of proving that but I think they get missed,' and 'People assume that someone else has done it. Has it been signed for? Well, we just have to assume its been given but it might not have been.'
'Sometimes I am afraid the little tubes get mislaid and I don't think the patients always get the treatment exactly when they should get it. Which I know is a bad thing to admit but I think it's nursing practice sometimes.'
Most participants realise the importance of nasal eradication, yet fail to state appropriately prescribed doses of nasal mupirocin. The same result was clearly found in the study by Lines and Weightman (2005). When probed, not one participant could relate the importance of adherence to prescribed regimens to the eradication of MRSA or possible antibiotic resistance to a failure in adherence such regimens. When asked about IV treatments, it was clear these had considerably more credence than nasal mupirocin.
Interestingly, all participants stated robustly that no IV doses were being missed. Typical comments were: 'Well of course IV treatments are given, they have to be given don't they'.
This is a powerful statement and it suggests that nurses may not understand the epidemiology of MRSA and importance of topical agents. Furthermore, it is clear that for this control measure adherence was suboptimal.
When asked specifically about the importance of controlling MRSA and if nurses in general felt it was out of control, six said they thought that MRSA was definitely out of control. Typical comments were:
'I think it is out of control in some areas but whether it is as important as we are led to believe I don't know.'
'MRSA is on the increase and then they say it doesn't matter, we can treat the patient at home in the community as well. We are supposed to be protecting the other patients at the end of the day, but are we? We are not stopping it, just a temporary halt on it. We are playing at it, it's a show.'
In the context of controlling MRSA it was also important to understand how nurses felt about their roles and responsibilities. What emerged in this category as key factors were education and providing role models.
Roles and responsibilities
Six participants felt that as part of their responsibility as a senior staff nurse, education was important. They stated that they had a responsibility to ensure that their knowledge was passed on. Four said that they were a role model, five expressed no opinion and one participant said they were not. The nurse who thought she wasn't a role model said:
'I nurse in the way in which I want to nurse and the way I perceive nursing to be. If people want to see me as a role model, then great, but I don't see myself as a role model. As long as I walk out of here at the end of a shift and know that I have given good care then I don't care what colleagues think.'
When this was explored in more depth, the participant's response was:
'I suppose I see my role as a nurse as being the educator and looking after my patients' interests by doing that and also being educated myself because we have contact with the patient. If I am not educated then how can I teach anybody else?'
These quotes were particularly encouraging:
'I think it is my role to make sure the healthcare assistants and students keep washing hands between patients and wearing protective clothing, and making sure you know there is some kind of control.'
'I am a team leader on the ward. I have to be a good role model and I think education comes into everything.'
Despite the guidance in the trust's MRSA policy, there appears to be either a lack of clarity in the policy or apathy among participants regarding management of MRSA. This study found that 60% of participants believe that MRSA is out of control and state 'why should they bother worrying about it'. Furthermore, 80% said that prescribed courses of nasal mupirocin were frequently missed. This is despite the infection control team visiting wards regularly, supporting staff, and holding frequent induction sessions and education programmes on infection control.
It was also clear that topical nasal mupirocin does not hold the same importance as IV treatments, with every participant stating that all IV drug doses were given. This is because IV treatments are considered more important and effective than topical agents. It could be argued that among senior nurses these perceptions, attitudes and beliefs may lead to professional non-adherence (Ley, 1997). Ley suggests that professional non-adherence falls into two groups: unintentional and intentional. Those in the unintentional group forget, have poor subject knowledge and/or lack of familiarity within a particular scope of practice. Those in the intentional group fail to adhere due to their beliefs or attitudes or to social pressures. This study appears to be consistent with the views of Lewis (1990) who suggests that nurse gatekeepers may be influential in how daily routine is conducted. If so, problems may arise when there are a number of influential nurses whose perceptions reflect the fact that MRSA is out of control and consider it unnecessary to take appropriate action. It is these gatekeepers who may exert their influence on junior staff. In these circumstances the eradication and control of MRSA may become extremely difficult to achieve.
In addition, 60% of participants felt that education was vital not only to their professional development but also to that of others. There was evidence that nurses who take their roles and responsibilities seriously understand the importance of controlling MRSA. However, nurses with poor knowledge are indifferent to the importance of controlling MRSA but play an important part in how junior nurses are taught and developed. It is these staff who need education and training to modify their perceptions and behaviour.
When examining this study it must be borne in mind that it has its limitations. The results and interpretations may not be generalisable beyond this study's population, and therefore caution should be exercised in interpreting meaning from these results.
However, what this study has shown is that individual values and beliefs are an extremely important factor in the way nursing is delivered, and it is a complete understanding of these values and beliefs that is required, although a much wider study is needed to determine these findings conclusively.
This study has also clearly established that, in a small proportion of experienced staff nurses, MRSA is perceived to be out of control and they are not overly concerned about its management. These staff nurses believe this because they are extremely busy with many other added pressures and are not helped by the lack of side rooms.
Education and increased clinical awareness by infection control teams must be supported by the appropriate level of nursing management. This managerial support is fundamental for any lasting change to take place and requires strong leadership and clear direction. Infection control teams should reflect on the results of this study and begin to engage with staff more frequently - this will improve nurses' knowledge and understanding and help to provide assistance to nurses and nursing management in the clinical area. This combined approach will facilitate problem solving so that concerns can be addressed in an atmosphere that is conducive to change and does not apportion blame, at least not at the outset.
- This article has been double-blind peer-reviewed.
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