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Informing the Future: 1. A review of nursing roles and responsibilities in community infection contr

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Heather P. Loveday, MA, RN, RNT.

Principal Lecturer (Research), Richard Wells Research Centre, Thames Valley University

...

This is the first of two papers summarising Informing the Future, a study of the role and responsibilities of community infection control nurses (CICNs) and communicable disease control nurses (CDCNs) in England, commissioned by the Department of Health (England) in 2000 (Loveday et al, 2002). This paper will:

- Highlight the aims and policy background to the review

- Summarise the methods used in the review

- Identify the organisational models for the provision of CICN and CDCN services

- Outline the educational preparation available to practitioners entering the specialty.

A summary of the main findings and conclusions of the review will be described in the second paper, which will appear in February 2003 and the full report is available at www.richardwellsresearch.com.

In 1998 the Community Infection Control Nurses' Network (CICNN) of the Infection Control Nurses' Association (ICNA) identified two distinct models of infection control nursing provision in community and primary care (CICNN, 1998). The first was community trust based and closely resembled the service provided in acute trusts; the second provided a nursing contribution to the communicable disease/infection control function within health authorities (HAs). The survey highlighted substantial variability in the roles and responsibilities undertaken by practitioners, the range of consumers of their services, and the random development of the role. In addition, practitioners identified that the current approach to preparation and continuing professional development for these roles lacked relevance and consistency.

The aim of our review was to provide the Department of Health with:

- A comprehensive description of the roles and responsibilities of CICNs and CDCNs

- A review of the education and practice preparation of these practitioners

- An analysis of the changes needed to develop their role in line with the future pattern of provision of infection control services in the NHS.

The titles CICN and CDCN are only two of the titles applied to nurses who provide infection control, communicable disease control and public health services and advice in community and primary care settings. In this paper, the term infection prevention and control nurse (IPCN) will collectively refer to these roles. Where role differences exist the appropriate role title will be used.

Study design
The review was undertaken in four stages, using a multi-method approach, to provide comprehensive descriptions of the roles under review (Table 1).

Stage 1. Situational analysis - A situational analysis provides valuable information about the context within which practitioners work. Our analysis focused on government policy, professional and educational issues and future changes. Policy documents were retrieved and synthesised to provide a situational analysis of organisational and professional issues that impacted on IPCN roles, responsibilities and education. The CICNN survey (CICNN, 1998), NHS Careers Website and the NHS Education Brokering Website, were used to identify educational programmes. Curriculum documentation was requested from programme leaders and course content was mapped against specified criteria and then analysed.

Stage 2. Scoping the role - Four case studies were conducted to scope the role and responsibilities of the IPCN from the perspective of the practitioner and the community infection prevention team. Data were collected through: structured interviews; retrospective activity audits; semi-structured interviews; and the collection of documentary evidence, such as role descriptions, service level agreements and local policies and protocols. Data were analysed:

- Individually to identify conceptual themes

- As single cases to identify categories

- Across cases to identify similarities and/or differences between cases.

Stage 3. Confirming roles and responsibilities - A national postal survey of IPCNs identified their current responsibilities and perceptions of issues that might impact on the future development of their role. The questionnaire contained structured and open-response items. The overall response rate was good (64%; n=119) but was probably affected by the timing of the survey as it coincided with the terrorist attacks on the USA. The resulting state of alert for public health services in the UK led to increased work pressure and subsequent drop-out from the survey.

Education provision - Data from the situational analysis supplied the basis for a smaller survey to identify practitioners' opinions of the educational preparation required for working in IPCN roles and the academic level at which future education programmes should be targeted. The questionnaire was based on the data extracted from the retrieved educational documents. It required respondents to identify essential elements of preparation and continuing development. The questionnaire was distributed to a purposive sample of IPCNs attending the CICNN meeting during the Annual ICNA Conference in September 2001 with a response rate of 96% (n=45).

Stage 4. Developing the agenda for change - Two focus group interviews, one in London and one in Manchester, were held to discuss the issues identified in the case studies and surveys as central to establishing the agenda for change. Participants were purposively selected on the basis that they would be able to inform the discussion. The groups of 12-15 participants consisted of IPCNs including consultant nurses, consultants in communicable disease control (CCDCs) and a regional epidemiologist. Box 1 shows the issues discussed by each focus group.

Interviews were audiotaped and field notes were recorded. The remainder of this paper summarises findings from each of the research stages in relation to policy, organisation of the IPCN workforce and educational preparation of practitioners.

The policy context
Successive governments have shifted the emphasis of health-care policy from treatment to preventing the causes of ill health, such as lifestyle factors and social deprivation (DoH, 1992; DoH, 1998), while continuing to recognise the threats to public health from communicable diseases and other infections. During the period of the review the modernisation agenda described in Shifting the Balance of Power (DoH, 2001a; DoH, 2002a) and the proposals within Getting Ahead of the Curve (DoH, 2002b) created an environment of change that had major implications for the possible future role of IPCNs.

Getting Ahead of the Curve (DoH, 2002b) discusses the global consequences of infectious diseases and the vulnerability of populations as a result of global trade and travel, adaptation of micro-organisms resulting in resistant strains, and changes in environment and land use. Action plans for target infections will set priorities for the prevention and management of key infections, such as tuberculosis, health-care-associated infections, blood-borne viruses and sexually transmitted infections. Box 2 highlights the main proposals within the strategy.

Although the nursing contribution to this strategy is not made explicit, IPCNs are key members of the team who will be required to develop and implement action plans.

Shifting the Balance of Power (DoH, 2002a) identifies primary care trusts (PCTs) as responsible for the majority of functions historically located in HAs, including improving the health of the community and securing the provision of services. Each PCT will appoint a director of public health and build a strong public health team, including nursing expertise. This team will be responsible for modernising the health protection function and combating the threat of infectious diseases as set out in Getting Ahead of the Curve (DoH, 2002b). Regional field offices of the Health Protection Agency (HPA) led by a specialist in infection control and health protection and drawn mainly from existing CCDCs and their teams, will provide an integrated source of nursing, medical and other expertise. These changes offer the opportunity to ensure that services at local, regional and national level make the best use of expert nursing resources to deliver a modern agenda for public health and prevention of infection.

Education and nursing leadership
The policy shift towards multi-professional and interdisciplinary education contained in Working Together - Learning Together (DoH, 2001b) stresses the need for those responsible for the development of post-registration and continuing professional development to work more collaboratively than in the past. It identifies the need for greater consistency in the standard, quality and accreditation of programmes. The emphasis should be on work-based, team-focused learning that crosses traditional and service boundaries and takes into account practice developments, research-based knowledge and, increasingly, input from knowledgeable consumers with high expectations of health and social care.

Post-registration education in nursing aims to facilitate practitioner development by enhancing both generic and specialist knowledge and skills, enabling competent and experienced practitioners to work independently in new and innovative ways. To do this, it must accommodate the shift in emphasis from secondary to primary care and the increasing need for practitioners to work flexibly and across traditional professional boundaries (DoH, 1999). Simultaneously, a strategy to enhance leadership skills while allowing skilled clinical nurses to retain their clinical focus, has led to the creation of consultant nurses (DoH, 2001b). The development of these roles offers the opportunity to raise the profile of nursing in community infection and communicable disease teams as PCTs and the HPA are being shaped.

The IPCN workforce
IPCN roles are relatively new, having emerged over the past 10-15 years to meet the threats of antimicrobial resistance and to support the communicable disease function of HAs (HLSC, 1998; Acheson, 1988; DoH, 1998). A study by the Regional Services Division of the Communicable Disease Surveillance Centre (CDSC), undertaken at the same time as our review, identified that half the districts surveyed had had IPCNs in post for five years (PHLS, 2002).

Nurses in these posts have numerous titles and our national survey identified 41 that could be placed in four broad categories (Figure 1). In this survey, 55% of nurses working in infection prevention roles were employed by HAs, 32% were employed by NHS trusts (NHST), 9% were employed jointly by HAs and NHSTs or PCTs, and 4% by the Public Health Laboratory Service (PHLS).

The current workforce is dominated by experienced IPCNs, with only 7% of practitioners new to the field and in post for less than one year. Forty-nine per cent of survey respondents had been in the specialty for between one and five years and 28% had been practising for between six and 10 years. Fourteen per cent of practitioners had more than 10 years' experience.

Three-quarters of practitioners held a specialist infection control qualification that included ENB 329 (Foundation Programme in Infection Control Nursing). In addition, 24% held a specialist community practice qualification in health visiting, community nursing or school nursing. A community practice qualification was felt to be an important area of expertise, with 67% of respondents identifying that previous experience in a community role was an advantage when practising as an IPCN. The other major qualifications held by respondents are shown in Figure 2.

The study undertaken by CDSC (PHLS, 2002) indicates that nurses working in these roles are graded at G or above with 52 districts employing at least one nurse at Grade I or its equivalent. At the time of the review there were nine consultant nurses working in the field, all of whom were employed by HAs.

Organisational issues
At the time of our review the community infection control nursing service was provided within three organisation-based models: the first within NHS community trusts; the second within HAs; and the third a shared service between community trusts or PCTs and HAs. In addition there were a number of services that used infection control nurses (ICNs) based in acute NHS trusts to provide the community NHS trust infection control function. A team of health professionals and scientific and administrative support staff deliver the infection prevention control service. The size of the team varies from two to 12 members with the average team being four members (but not necessarily whole-time equivalents) and consisting of one or more nurses, one or more medically qualified practitioners, usually a CCDC or medical microbiologist, and administrative support.

The CDSC study identified that a 'typical' population served by IPCNs has a population of approximately 464 000, of which 2.8% belong to ethnic minorities, with a Jarman index of -2.4, four primary care units, three community hospitals, 53 nursing homes, 166 residential homes, 233 schools, one university, one prison/young offenders' unit and no immigrant detention centres (PHLS, 2002).

To some extent the job titles of IPCN posts, and the range of responsibilities associated with the infection control nursing service, reflect these organisational arrangements. Those nurses with the title of either ICN and CICN, were predominantly employed in NHS community trusts and the major focus of their responsibilities is to provide a service for health-care settings that includes both ward and community homes.

Nurses with the title of CDCN and public health nurse (PHN) were predominantly employed in HAs and the responsibilities of practitioners in these roles are focused on supporting the CCDC function and providing infection control advice to primary care and a wide range of social care settings, including local authority and privately run services. In addition, these practitioners may have some responsibility for emergency planning and wider health protection.

Organisational support for the IPCN role
Over 90% of respondents to our national survey indicated that the contribution nursing makes to infection control was valued by the organisation. The contribution to communicable disease control was also positively perceived by 79% of practitioners. This confirms case study data, which identified that the nursing role was essential to the infection control and communicable disease team. The majority of respondents to our national survey considered that the relationships within their own team and with other organisations were collaborative in nature. Box 3 shows the skills that nurses were perceived to be particularly valuable in providing.

The support received from employing organisations to function effectively was perceived to be sufficient by 71% of respondents; however, 27% disagreed or strongly disagreed with this statement. Fifty-nine per cent indicated that the provision of support for education and training, including academic development, was very important. Other factors that were identified included managerial support (51%), autonomy (39%), and access to information technology (25%).

In contrast, 75% of respondents identified organisational barriers to effectiveness. These included: poor administrative support (25%); insufficient IPCN resources (42%); lack of financial and other resources (32%); and high workload (21%).

Service users
Respondents to our national survey identified that their everyday activities brought them into contact with a wide range of service users within primary care, including: general medical and dental practices; secondary care facilities such as community hospitals; local authority education and care facilities; private education and care facilities; and private businesses. Service users in the CDSC study (PHLS, 2002) identified a number of priorities for infection control that were perceived as not being met. These were predominantly preventive initiatives, such as training, audit and provision of consistent policies and guidelines.

The modernisation agenda and the establishment of PCTs will impact greatly on how the infection prevention and control nursing service is organised and delivered and consequently impact on IPCN roles and responsibilities. Although in the transitional period existing arrangements may serve as a bridge, there is a need for modernised organisations to review the needs of the local population and the service users to ensure that provision of IPCN expertise is appropriately placed and properly resourced.

Current specialist preparation
The CICNN survey (CICNN, 1998) indicated that the English National Board specialist programme 'Foundation Programme in Infection Control' (ENB 329) was the most common preparatory qualification held by IPCNs. Our national survey confirmed that this programme is the dominant specialist preparation, with 76% of respondents holding this qualification.

During the mapping process four providers of ENB 329 were identified and programme documentation was retrieved from all of them. Three of the courses were offered as individual modules in diploma/degree frameworks and one as a discrete single module programme. A detailed content analysis of these programmes revealed a considerable degree of variability between programmes in their modular structure, duration, academic level, credit rating and specific content (Table 2).

No programmes were targeted towards, or contained content specifically directed at, practitioners working in IPCN roles. Significantly, three-quarters of the respondents to our survey (77%) agreed or strongly agreed that the ENB 329 programme was primarily focused on infection control in acute care rather than primary or community care.

Relevance of current educational provision
All stages of the review explored the relevance of the current educational provision for IPCNs. In the educational survey specific content items, identified during the mapping process, were presented to practitioners who were asked to grade them according to how essential they were for initial preparation. Respondents tended to be inclusive rather than exclusive and a large proportion of the content achieved a consensus level of above 60% and was considered essential initial preparation. However, practitioners also rated a range of transferable skills very highly (Box 4).

Many practitioners identified a heavy reliance on these skills and indicated that they were central to their future role. However, these feature less frequently than microbiological content in the educational programmes currently undertaken by IPCNs. Only one of the programmes reviewed placed particular emphasis on transferable skills.

The focus groups confirmed that current initial preparation does not meet the needs of IPCNs. It was felt to be outdated in both content and delivery and the geographical location of programmes hindered access. In addition, it was felt that the current academic level of the programme did not facilitate the development of the sophisticated skills required for practice in this field or working across traditional professional boundaries.

The final shape and implementation of Getting Ahead of the Curve (DoH, 2002b) is an evolving story, but it has considerable implications and opportunities for strengthening the operational and strategic responsibilities of IPCNs at local, regional and national level. Together with the modernisation agenda and the development of consultant nurse roles, these changes set the organisational and professional framework within which IPCNs will function in the future.

Conclusion
This paper has summarised the aims, methodology and policy background to the review of CICN and CDCN roles and responsibilities, commissioned by the Department of Health (England) in April 2000.

Results from our study demonstrate that, although a relatively new specialty, practitioners in these roles are central to the delivery of the infection control and communicable disease service in a wide range of community and primary care settings.

Our study also shows that specialist preparation is failing to meet the needs of new practitioners to the field. Access to programmes is limited and there is little evidence of a discrete community and public health component.

In the next paper we will present the findings of our study related to the responsibilities undertaken by IPCNs and highlight the opportunities and priorities for the future developments of IPCN roles.

Useful websites
NHS Careers Website. Available at: www.nhscareers.nhs.uk/

NHS Education Brokering Website. Available at: http://www.education-brokering.org.uk/

Acheson, D. (1988)Committee of Inquiry into the Future Development of the Public Health Function. London: The Stationery Office.

Community Infection Control Nurses Network. (1998)A Survey of Community Infection Control Nurses (unpublished). Infection Control Nurses Association.

Department of Health. (1992)The Health of the Nation. London: The Stationery Office.

Department of Health. (1998)Saving Lives: Our healthier nation. London: Department of Health.

Department of Health. (1999)Making a Difference: Strengthening the nursing, midwifery and health visiting contribution to health and health care. London: Department of Health.

Department of Health. (2001a)Shifting the Balance of Power: Securing delivery. London: Department of Health.

Department of Health. (2001b)Working Together - Learning Together: A framework for lifelong learning for the NHS. London: Department of Health.

Department of Health. (2002a)Shifting the Balance of Power: The next steps. London: Department of Health.

Department of Health. (2002b)Getting Ahead of the Curve. London: Department of Health.

House of Lords Select Committee on Science and Technology. (1998)Resistance to Antibiotics and Other Antimicrobial Agents. (HL Paper 81-I, 7th Report session, 1997-1998). London: The Stationery Office.

Loveday, H.P., Harper, P.J., Mulhall, A. et al. (2002)Informing the Future: A review of the roles and responsibilities of community infection control and communicable disease control nurses in England: a report to the Department of Health (England). London: Thames Valley University. Available at: www.richardwellsresearch.com

Regional Services Division, Public Health Laboratory Service Communicable Disease Surveillance Centre. (2002)Infection Control in the Community Study. London: Public Health Laboratory Service.

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