Jolley, S. (2008) Assessing patients' knowledge and fears about MRSA infection. This is an extended version of the article published in Nursing Times; 104: 27, 32-33.
BACKGROUND: Media coverage of MRSA has often been sensational and alarmist.
AIM AND METHOD: A survey was carried out to assess the effect of this on patients' knowledge and fears about MRSA.
RESULTS and DISCUSSION: One-hundred female patients completed questionnaires about MRSA before admission to an acute NHS trust for elective surgery. Results demonstrated the media is the main source of patient information about MRSA. They also showed high levels of anxiety about infection and the perceived associations between MRSA, dirty hospitals and death.
CONCLUSION: Healthcare professionals need to address these concerns by providing clear and factual information about MRSA.
Sue Jolley, BA, Cert Ed, RGN, is research/audit sister for gynaecology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust.
Waiting to be admitted for elective surgery is known to be an anxious time for patients (Mitchell, 2007; Hughes, 2002). When they attend for their pre-operative assessment, they have the opportunity to discuss any concerns and ask relevant questions. Usually this involves questions about the anaesthetic, the operation, pain levels and recovery time.
Over the past five years, nurses working in the gynaecology pre-admissions unit at Queen's Medical Centre in Nottingham noticed a marked increase in the number of patients expressing concerns about contracting MRSA while in hospital.
MRSA has received considerable media coverage, which has helped to shape public awareness (Wilson, 2004; Hamour et al, 2003). Unfortunately, most of the reporting has been negative and alarmist, so patients due for a hospital admission are more likely to be anxious about the risk of MRSA infection. Our gynaecology pre-admissions unit therefore seemed the ideal setting for a patient survey to assess such concerns objectively.
This study aimed to identify the nature and source of patients' knowledge and anxieties about MRSA before admission for elective surgery.
Staphylococcus aureus is a bacterium that is often carried harmlessly on the skin or in the nose and is the most common cause of wound infections in hospital (Department of Health, 2005a). MRSA is a strain of S. aureus that is resistant to the common antibiotics usually used for treating S. aureus infections. Therefore treatment of an MRSA infection is difficult, involving expensive and potentially toxic drugs. MRSA stands for meticillin-resistant Staphylococcus aureus, as meticillin is the agent used in laboratory tests for sensitivity. Sometimes the term multi-resistant Staphylococcus aureus is used. This may be more appropriate as it clearly indicates why this bacterium causes potential problems relating to treatment.
MRSA was first described in 1959, although it was relatively rare during the 1960s and 1970s (Brumfitt and Hamilton-Miller, 1989). There was a major increase during the 1980s and 1990s throughout Britain, North America and Australia. It was probably detected in these countries first due to better surveillance systems, but MRSA is now a problem in hospitals worldwide (Enright et al, 2002).
Various strains of MRSA are now endemic throughout Britain, and they are especially concentrated in hospitals because people who are ill are more vulnerable to infections (Health Protection Agency, 2006). Recognised as a healthcare-associated infection, MRSA infection is most likely to occur in areas such as intensive therapy units, orthopaedic wards, burns units and general surgical wards (RCN, 2005). This is due to an increased prevalence of breaks in the skin, such as surgical wounds, and the use of invasive medical care such as intravenous therapy.
Over the last two decades MRSA has also become an increasing problem in long-term care facilities, particularly affecting older and more vulnerable people with underlying medical conditions (RCN, 2005). In addition, around 30% of the general population is colonised by S. aureus, so increasing numbers of people carry MRSA (DH, 2005). This means it is now frequently imported into hospitals from the community (Guleri et al, 2007). Screening at Lewisham Hospital in south London found that 40% of elderly patients arriving from nursing homes carried MRSA and, at University College Hospital, London, half of all patients were carrying MRSA before they reached the ward (Hinsliff, 2005; StaffNurse.com, 2005).
MRSA is mainly spread on the hands of staff caring for infected patients. It may also be airborne, especially if dust contains skin scales. Therefore, handwashing is the most important factor in preventing cross-infection. Infected patients are nursed in a side room, where possible, to minimise the risk of airborne spread (Coia et al, 2006). Measures to reduce the introduction of MRSA from outside sources have also been considered, including screening patients with a previous history of MRSA, reducing visiting times and encouraging visitors to wash their hands when arriving and leaving the hospital (Coia, 2006; RCN, 2005).
Some hospital trusts have started to screen all patients before admission for elective surgery by collecting relevant swabs, and soon this is likely to become standard practice (RCN, 2005). This is more problematic with emergency admissions, but screening is still possible on or soon after admission.
There is no doubt that MRSA is a serious problem in the UK, and infection control teams in most hospital and community healthcare trusts devote considerable time and effort to controlling its spread.
However, the general public receives dramatic and sensational messages about the spread and effects of MRSA, rather than factual information and balanced debate (Hamour et al, 2003). Wilson (2004) observed that the UK media have developed a fascination with MRSA. Therefore, headlines such as 'Wards of filth' (Cox, 2003), 'Superbug crisis worse than feared' (Marsh, 2004) and 'Battle against the superbug' (Hawkes, 2005) have become all too familiar. This is an example of how the media can offer its own perspective on health issues and, unfortunately, the general public is exposed to media perspectives far more than to those of the healthcare community, especially with a 24-hour news culture.
A recent unpublished study analysed all newspaper articles on MRSA published between 1994-2005 in the UK and found the media largely constructed the association between MRSA and 'dirty hospitals', and that this was originally based on evidence from a rogue 'expert'. At one stage, newspapers published several reports on the activities of an unaccredited laboratory conducting clandestine environmental sampling, even though there was no validation of the tests or independent review of the results (Wilson, 2004). Government policy contributed to the 'crisis' by reinforcing the association between MRSA and general cleanliness in health reports. Informed debate was largely unreported. Newspapers in this unpublished research portrayed the problems with MRSA as the result of a number of failures: of government policy; of NHS staff; and of the NHS as an institution. Clearly this negative image must have increased patient anxiety.
One recommendation from this unpublished research was that staff should appreciate the effect that newspaper stories have on the public. However, a literature search found only one published study on public perceptions of MRSA (Hamour et al, 2003). In that study 113 surgical outpatients completed questionnaires about the issue. The media was the most frequent source of information and the majority of patients stated they would feel either angry or afraid if they acquired MRSA in hospital.
An unpublished patient satisfaction survey carried out by the infection control team at QMC also emphasised the power of the media. This survey found that, when patients were told they had an MRSA infection, they were initially shocked and frightened because of 'horror stories' in the press. There have also been reported increases in the number of patients travelling abroad for treatments and one of the main reasons, apart from waiting lists, is fear of contracting an infection such as MRSA in British hospitals (Daily Mail, 2007).
Before this survey, a 'diary' was kept for six months to record any concerns about MRSA raised by patients who came through the pre-admissions unit. These mainly consisted of questions about the likelihood of contracting MRSA and fears about having to stay in hospital for longer than predicted, not healing properly or becoming very ill as a result of the infection.
A questionnaire was then designed to find out more about these concerns, and modifications were made following review and discussion with the audit and infection control teams. There were eight questions altogether. Six questions asked patients: whether they had heard about MRSA; about their source of information on it; whether they knew anyone who had contracted the infection; whether they were worried about catching MRSA; how worried they were about catching it compared to undergoing surgery; and whether an information leaflet on the topic would be helpful. These questions involved a yes/no response or choice from a list of responses. The other two questions, which asked how people contracted MRSA and what happened if they did, were open questions designed to obtain more qualitative data.
A convenience sample of patients attending the gynaecology pre-admissions unit at QMC between August-September 2007 was used. Posters inviting patients to complete a questionnaire on MRSA were displayed in the waiting room. These explained that a survey was being conducted to find out more about patients' views on the issue, that participation was entirely optional and that all responses would be anonymous. The questionnaires were left in the waiting room, so patients could choose whether or not to complete one while they were waiting to see health professionals. Completed questionnaires were then posted in a box.
There were two main ethical considerations. First, it was important that patients did not feel in any way coerced or obliged to fill in a form. This could easily happen if they felt vulnerable about coming into hospital and were asked to cooperate by someone with an official role. This was avoided by keeping the survey low key and the questionnaires available in the patient area for patients to pick up and read if they wished.
The second consideration related to actually raising the issue of MRSA. Clearly there was the possibility that this might increase anxiety in some patients before their admission. However, after discussion with senior colleagues, it was agreed that the constant media attention meant the debate surrounding the issue was already in the public arena and it was appropriate that the health service should be addressing public concerns.
The senior nurse manager gave approval for the survey, which was reviewed by the clinical governance committee.
Quantitative data was collated and analysed using Microsoft Excel software. Content analysis was used for the qualitative data. This is a method of analysing qualitative data where the information gathered is coded into emergent themes. The data is constantly revisited after initial coding until it is clear that no new themes are emerging (Hewitt-Taylor, 2001).
During the survey a total of 165 patients attended the unit and 60% completed a questionnaire. The survey was stopped when 100 questionnaires had been completed, mainly because no new themes were emerging from the qualitative data and the sample was large enough to be relevant. Therefore, the final sample consisted of 100 women who were due to have elective gynaecological surgery.
Television and newspapers were, perhaps unsurprisingly, the main sources of information about MRSA (Fig 1). Although slightly less than half the sample (n=41) knew someone who had been infected with it, 74 were worried about contracting it. Patients were more worried about MRSA than the anaesthetic, the operation or the pain (Fig 2).
Dirty hospitals and poor standards of hygiene were the most frequently mentioned reason for people acquiring MRSA (n=45), followed by poor standards of handwashing (n=20). Fourteen respondents mentioned the risk of MRSA being carried and passed on by visitors to the hospital and nurses wearing uniforms outside work (Fig 3). The first category is mentioned more than twice as many times as any of the others. This suggests a high degree of consensus about the effect of a dirty environment, especially as many of the alternative beliefs were put forward by fewer than 10% of the sample.
Patients' views on what happens if people contract MRSA are summarised in Fig 4. Death (n=47) and becoming very ill (n=37) were most often identified as a consequence of an MRSA infection. Only a small number (n=10) recognised that it is possible to recover from MRSA. The 'miscellaneous' problems associated with MRSA were very varied, including paralysis, kidney failure and 'getting a scab'.
The vast majority, 94%, thought an information leaflet on MRSA would be helpful before admission. Of those who did not think a leaflet would be helpful, or were unsure, one commented that a leaflet would not prevent her contracting the infection and two commented that a leaflet might even increase levels of concern.
Limitations of survey
Although a response rate of 60% is generally accepted as good (Bowling, 1999), limitations of this survey are the fact that this was a convenience sample and a self-selecting one. Clearly there is no information on why some patients chose not to complete the questionnaire or on their views. Only those who were more concerned about MRSA may have completed the survey, possibly leading to some bias in the results.
However, there are many reasons why some patients would not fill in a questionnaire other than a lack of interest in or concern about MRSA. These include: a dislike of questionnaires; the fact it was yet another piece of documentation to complete in addition to admission forms; lack of time if they were called in to see staff very promptly; and general preoccupation or anxiety about attending a hospital appointment and preparing for an operation.
These, together with the obvious emphasis on MRSA, may have led to some bias in the results. However, the sample size and the congruence of results with anecdotal and research evidence suggest these findings are representative of patients' views and are therefore both relevant and useful.
Using only a female sample was also a limitation as we cannot necessarily assume that men would respond in the same way.
The results demonstrate, perhaps unsurprisingly, that the media is the main source of patient information about MRSA. This is strongly demonstrated by the data in Figs 3 and 4, which reflects the association between dirty hospitals, MRSA and dire consequences that has been portrayed in the media.
Interestingly, more recent views about transmitting infections were also expressed, including restricting the number of visitors, and nurses wearing uniforms outside work. The latest government guidance states there is no conclusive evidence that uniforms pose a significant hazard in terms of spreading infection but it seems the public believes there is a risk (DH, 2007).
There was also evidence that some respondents were confusing the information received about other organisms - described as 'flesh eating' or those causing diarrhoea - with MRSA, which may have been obtained from reports on other 'superbugs'.
More constructive media reporting would be welcome, including more clarity about: the different healthcare-associated infections; the actual rates of infection; and less alarmist language.
Although all the main methods of transmitting MRSA were mentioned in the responses, the questionnaire was not designed to assess the actual level of understanding. This is reflected in the themes that emerged during coding of the qualitative data. There was clearly some confusion between some of the methods of transmission, such as hand hygiene, contact and cross-contamination. It would therefore be interesting to interview patients about their understanding of some of these issues in more depth in order to produce effective patient information leaflets.
Although fewer than half the sample knew someone who had had MRSA, this was still more than expected because the actual number of people who develop MRSA bacteraemia (approximately 7,000 in England each year) still represents a very small proportion of the general population (DH, 2005b). Three respondents even knew someone whose infection had resulted in death. This might explain not only their willingness to participate in the survey but also their anxiety about MRSA. However, nearly three-quarters (74%) were worried about catching MRSA and it seems that many patients are now more afraid of catching an infection than having surgery, even though statistically surgery carries a greater risk (Hinsliff, 2005). Although Hamour et al's (2003) study explored patients' emotional response if they were to acquire MRSA and this survey looked at pre-operative anxiety about the issue, the level of concern is similar.
This level of concern should be addressed. Although we cannot assume that all patients want information leaflets, as demonstrated in the results, 94% felt that information before admission would be helpful. Nursing staff in this pre-admissions unit will now investigate how best to provide factual, patient-friendly information on MRSA and possibly other healthcare-associated infections. As well as advising patients about MRSA to reduce anxiety and change negative attitudes, information provision is an important aspect of delivering a quality service and ensuring patient satisfaction (Newton, 1996). The government report Information for Health (NHS Executive, 1998) includes access to information as one of its strategic objectives.
Patients need clear, factual information about MRSA, including relevant rates of infection and comparative risks. Individual trusts could provide this through their infection control teams to ensure the information is relevant and specific to the local situation. This could be easily achieved since the DH has introduced a mandatory MRSA surveillance system in acute trusts in England, and figures are published every six months. These show that, although there were 57 reports of MRSA bacteraemia at QMC between 2004-2005, the MRSA rate was only 0.19 per 1,000 bed-days (DH, 2005b).
This survey demonstrated a high level of anxiety about MRSA infection among pre-admission patients and the perceived associations between the infection, dirty hospitals and death. Fears of healthcare-associated infection and its outcomes are seriously disproportionate to the risk. Raising public awareness of issues around HAIs and providing clear and reliable information to patients can be helpful. However, alarmist reporting by the media, which creates a climate of fear among patients entering hospital, is detrimental to their psychological well-being and may affect their experience of healthcare.
Implications for practice
Healthcare professionals need to recognise and understand patient fears regarding nosocomial infection, such as MRSA, so these can be addressed before admission. Staff need to be able to give clear and objective information about the issue, including transmission routes, relative risks and infection rates in the local area or hospital. Infection control teams have a key role to play in issuing relevant and standardised written information.
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