Heather P. Loveday, MA, RN, RNT.
Principal Lecturer (Research), Richard Wells Research Centre, Thames Valley UniversityIn part one of this series (Loveday et al, 2002a) the authors summarised the aims and methods used to conduct Informing the Future: A review of the roles and responsibilities of community infection control and communicable disease control nurses in England, commissioned and funded by the Department of Health (England) (Loveday et al, 2002b). This identified that nurses functioning in these roles work in a range of organisational settings and hold different job titles, including public heath nurse (PHN), community infection control nurse (CICN) and communicable disease control nurse (CDCN).
In part one of this series (Loveday et al, 2002a) the authors summarised the aims and methods used to conduct Informing the Future: A review of the roles and responsibilities of community infection control and communicable disease control nurses in England, commissioned and funded by the Department of Health (England) (Loveday et al, 2002b). This identified that nurses functioning in these roles work in a range of organisational settings and hold different job titles, including public heath nurse (PHN), community infection control nurse (CICN) and communicable disease control nurse (CDCN).
Our review identified three discrete functions within the job descriptions of infection prevention and control nurses (IPCNs), around which their everyday responsibilities and activities were organised. These were:
- Providing infection control advice to prevent and control health-care-associated infection (HAI) in a range of settings
- Supporting the communicable disease function in the surveillance, investigation and management of communicable disease outbreaks
- Developing a wider health protection function that includes non-infectious environmental hazards and emergency planning.
The job titles and the key responsibilities of IPCNs were not clearly linked and 39% of practitioners stated that they performed multiple functions. The majority of IPCNs (83%) saw differences in the roles of PHNs, CICNs, and CDCNs, although the distinction was clearest between the definitions of PHN and other IPCNs.
The PHN was perceived as having a broad health-protection function that included health-needs assessment, health improvement and health promotion. Although communicable disease and infection control were part of this brief, they were seen as part of a much wider health focus that included target diseases such as heart disease, cancer and diabetes, and issues such as teenage pregnancy. There was also the perception that PHNs were involved in strategic planning and implementation of the modernisation agenda.
CDCNs were clearly identified as supporting the consultants in communicable disease control (CCDC) and focusing on the management and control of communicable disease outbreaks. Some 17% of survey respondents had roles that focused entirely on this function. However, some CDCNs also indicated that they had some responsibility for infection control in primary and social-care settings.
The role of the CICN seemed more blurred and was defined by the setting within which the responsibilities were exercised. The primary role was the provision of infection control advice and expertise within health- and social-care settings. These included community NHS trusts; community hospitals; and, in some cases, general practice premises; local authority nursing and residential homes; and private social and nursing care settings. Their input was directed primarily at health- and social-care practitioners with little involvement with the general public and lay carers.
The nature of the job
While the profile of activities undertaken by each IPCN are similar, the focus, client population and setting of these may be more proscribed in line with the role definitions already discussed. Lines of professional and managerial accountability were mixed, with 47% of the IPCNs responding to the survey having no professional accountability to a senior nurse. Some respondents identified that they had no local access to nursing advice.
The users of the IPCN service vary from a discrete number of community hospitals and community home premises to the wide range shown in Figure 1, and IPCNs develop extensive professional, inter-agency and communication networks to meet this varied role. Being able to work across agencies and professional boundaries was considered essential in meeting IPCN role responsibilities. The extract (see box, p329) from the report illustrates this.
Respondents identified a number of core activities that generated the majority of their workload (Figure 2). The primary responsibility of IPCNs currently lies in the investigation and implementation of strategies to deal with outbreak situations. In particular, IPCNs have direct contact with carers, client groups and health-care staff to provide information and advice; liaise with general practitioners; collect data and specimens and conduct contact tracing. Traditionally the response to these situations is medically led but in certain circumstances, or where protocols were in place, IPCNs were able to initiate and implement team activities. However, 11% of practitioners considered that they had very little autonomy and worked directly under the direction of the medical team. The following extracts illustrate the boundaries that exist in some teams and highlight the frustration that some IPCNs feel.
'The issue is that if a situation is solely infection control, then there is very little interest shown by CCDCs as to how the problem has been prevented or solved. However, if there is a situation where there is combined infection control and communicable disease issue, they try to take over and interfere a lot more' (CDCN survey response).
'If there are no registrars on call during the day, then you are expected to manage the whole event (communicable disease outbreak). If there is someone on call you are expected to revert back to pure infection control queries even though you may end up directing the new doctors on how to handle the situation. This is not very motivating, you feel 'not needed' when it suits, and put upon the rest of the time when it does suit' (CDCN survey response).
Situations that were viewed as coming under the title of 'infection control' rather than communicable disease incidents resulted in a different picture, with IPCNs perceiving themselves to have a greater degree of autonomy to initiate and implement activities and resolve problems. This was supported by interviews with CCDCs in the case studies, which indicated that IPCNs were the 'leads' for infection control advice:
'I would have total autonomy to deal with an infection control incident. However, I would work in collegiate way with the infection control doctor so that a 'consistent' approach is generated' (CICN survey response).
Although practitioners placed an emphasis on the non-infection, public health components of their role, health-needs assessment did not feature as a major component of PHN or other IPCN workloads. Half of the PHN respondents had some responsibility for emergency planning and non-infectious hazards.
Prevention - a Cinderella activity
A recurring theme in the case study interviews was that the service offered by IPCNs was concerned with 'fire-fighting' and that preventive work became a luxury or was carried out only following an outbreak, when it became a priority. In the background information for a consultant nurse post, the preventive elements of IPCN roles were referred to as 'traditionally the Cinderella activity'. Much of this is due to the fact that a large component of day-to-day work is concerned with reacting to situations and cannot be planned for. When incidents occur, IPCNs have to meet the most pressing needs. However, the relatively small numbers of community-focused IPCNs and the fact that the work may be spread over a wide geographical area or at a distance from the work-base means that this nursing resource is thinly spread.
Education and training, policy and guideline development and audit were the most commonly identified preventive or proactive activities included in the responsibilities of the IPCN (Figure 2). These were also seen as those that had the most impact on preventing infection and communicable disease and promoting public health. Health education was only identified by 11% as forming a major component of their day-to-day activity. Interestingly, health-needs assessment was only identified by four IPCNs as one of the activities having the most impact.
Although providing advice featured heavily in the interviews with staff in the case study phase, practitioners felt their time was consumed by answering telephone queries. This was more pronounced when media attention was focused on infection and communicable disease issues. While practitioners saw this as valuable contact with the public and colleagues it also created difficulties in 'getting the work done'.
Practitioners identified that nurses had lead responsibility for a number of key areas, including the introduction of decontamination standards (56%) and clinical and general practice audit (39%). Other projects included: auditing the uptake of influenza vaccine; follow-up of babies born to Hepatitis B-positive mothers; infection control issues surrounding tattooing and body-piercing; and auditing sharps injuries.
The responsibilities of IPCNs are wide-ranging and predominantly shared with other IPCNs or members of the team. A striking element from the case study interviews was the existence of close working relationships between IPCNs and medically qualified colleagues. Practitioners highlighted that a tacit knowledge of how members of the team worked led to individuals complementing each other's skills and strengths. This was further highlighted in a number of open responses within the survey:
'Communicable disease control is multidisciplinary activity, including doctors, nurses, epidemiologists, environmental health officers and notification officers, where each member is/should be equally respected for their individual contribution and expertise' (nurse consultant survey response).
However, this was balanced by a perception that the specialty was medically dominated and that this might hinder some working relationships. Nine per cent of survey respondents identified that their roles were poorly understood and that this was a barrier to effective teamwork:
'The service here is largely nurse led with doctors 'rubber stamping' activities. The existing service remains under-resourced, tribal and territorial' (CICN survey response).
Continuing professional development needs
The review indicated that continuing professional development was focused on undertaking masters degrees in public health or other nursing-related subjects. A quarter of survey respondents had a postgraduate degree and 57% believed that a masters degree was essential for continuing professional development. The advantages of postgraduate education were seen as preparing individuals at a level that was consistent with the requirements of the role to work independently with flexibility and solve complex problems. This level of preparation or development was seen as necessary to build confidence in practitioners and increase their credibility with other members of the team. In addition, some indicated that it would provide a foundation for the development of a discrete career pathway for IPCNs. The survey established the skills that IPCNs felt were essential for being effective in the job and how well developed respondents felt in each of the identified skills. However, practitioners' self-assessment of their own development indicated gaps in some areas. Importantly, critical reading, use of information technology and research skills were inadequately developed in this workforce (Figure 3).
The case study and focus group stages of the review indicated that the processes used to develop professional skills were predominantly ad hoc and achieved through practical experience rather than planned development because of workload and resource constraints. This was in contrast to 84% of respondents participating in an annual performance appraisal process and 77% preparing an annual professional development plan. Additionally, 69% of practitioners had access to clinical supervision, but only 59% of practitioners made use of the process.
The agenda for change
Nurses are key members of the public health and infection control teams in health authorities, NHS trusts and PCTs. Titles and responsibilities have developed organically within different organisational structures and with changing public health priorities. In some instances the skills of the IPCNs are used to their full extent, particularly with the establishment of consultant nurse posts in health authorities. However, there is also evidence that some practitioners have roles that lack clarity and authority, while others have roles that result in unwieldy workloads to the detriment of preventive activity. There needs to be greater clarity regarding the functions that are needed to meet the needs of specific populations and roles designed that strike a balance between meeting the reactive and proactive elements of the job.
The workload of IPCNs is largely unpredictable and requires the ability to prioritise and manage incidents effectively. Although they take the lead in managing infection control issues, it is traditionally the CCDC who leads in communicable disease problems. There is evidence that this need not be the case and that some IPCNs have the relevant knowledge and skills to mange a communicable disease 'caseload'.
The role of nurse consultant was first established in 2000, and the first IPCN nurse consultant was appointed in January 2001. At the time of the review there were nine IPCN nurse consultant posts. All the appointees previously worked in IPCN roles within health authorities. In the national survey IPCNs were asked if the infection control/communicable disease service could be nurse led, 76% strongly agreed or agreed and, in open-ended responses, suggested that the nurse consultant role could be the vehicle for bringing about this cultural shift in traditional professional roles:
'We would require a nurse consultant in infection control to lead the team. The team could consist of a CICN for each PCT and a mixed-skill nurse attached to each in a development role, to encourage more nurses to consider training in this field. A PHN should be part of the team to bridge gaps and encourage better links with health authority/PCT' (PHN survey response).
A nurse consultant leads the communicable disease unit in Buckinghamshire and there are other examples of IPCNs delivering the service during periods of annual leave and prolonged sick leave. The IPCN nurse consultant is ideally placed to lead and manage the changes in practice that are needed to place infection prevention and control at the centre of clinical practice in health- and social-care settings. They are also the most appropriate change agents for the future development of IPCN roles within the modernised public health and infectious diseases network.
Developing the IPCN role
If the objectives of Shifting the Balance (Department of Health, 2001; 2002a) and Getting Ahead of the Curve (Department of Health, 2002b) are to be achieved, there has to be a willingness to discard traditional professional boundaries. The IPCN of the future needs to be an expert practitioner, able to manage a caseload broadly comparable with that of medical or public health counterparts, and to work collaboratively within public health and nursing, midwifery and health visitor networks. The capacity to work in relative isolation, as part of a network or as the leader of a team and deal with complex situations is vital. The nurse consultant will provide the catalyst to create innovative and expert nursing roles to lead and provide a strategic overview of IPCN functions.
The three core functions identified by this review can strengthen the public health team in both PCTs and the Health Protection Agency (HPA). The PHN of the future has a broader remit than other IPCNs, requiring an in-depth knowledge of health inequalities and their impact on health and well-being, as well as a sound grasp of infection control and communicable disease issues. This function is primarily one requiring skills to assess health needs; develop strategies to meet those needs; monitor and analyse progress towards health improvement targets; and act as a health educator.
There is a continued need for IPCNs with a communicable disease and/or infection control function to work at operational level, dealing with the day-to-day management of outbreaks of infection in health- and social-care settings and in the wider population. This might be within individual PCTs or as part of a public health network that provides services across a number of PCT and other partners. There is also a need for IPCNs to be involved in strategic planning at local and regional levels and within the new HPA. The emphasis on preventing infection and communicable disease needs to have a much higher profile in IPCN responsibilities and should be regarded as a priority rather than a 'Cinderella' activity.
Developing a career pathway
Current specialist preparation is distributed sparsely across England, with only five centres offering a traditionally designed programme delivered on an attendance basis. The route to specialist qualification is presently through programmes based on the now-defunct ENB 329 Foundations in Infection Control Nursing. These fail to address the knowledge and practice needs of novice practitioners working at a population level and needs radical redesign. The lack of emphasis on transferable skills leaves a gap in the preparation of practitioners working in non-nursing environments and with responsibilities that involve considerable multi-agency working. In our view the preparation of practitioners should be at postgraduate level and must include greater emphasis on transferable skills to facilitate the development of the sophisticated knowledge required to function in IPCN roles.
Specialist preparation is currently undertaken while 'getting the job done' rather than in training grade posts, as is the case with health visitors and medically qualified counterparts on higher professional training rotations. Consideration should be given to establishing training grade posts to bring 'new blood' into the speciality and create a process for higher professional training.
Once qualified there is an absence of a clearly structured career pathway that will enable practitioners to develop. While IPCNs currently complete postgraduate academic programmes, these are not linked to career progression in a way that is comparable with that of their medical and public health colleagues. A career pathway should be established to enable practitioners to realise their professional aspirations and use their expertise, knowledge and skills in an appropriate public health role at operational or strategic levels within the modernised public health and infectious diseases framework.
Nurses currently develop their clinical skills in isolation from other professional groups working in the field of public health and infectious diseases. There is an opportunity for interdisciplinary learning in this field that would contribute to practitioners from all disciplines developing a common core of skills and shared ways of working. There is a clear need for a structured programme of interdisciplinary preparation and higher professional training that would enable IPCNs to build professional confidence and specialist knowledge and skills incrementally against occupational standards and with medical and non-medical specialists in the field.
The way forward
The conclusions of the Informing the Future review provide a framework within which new roles for a highly experienced and valuable nursing resource can be harnessed and used within the evolving public health and infectious diseases modernisation agenda, and provides a platform for discussion by government, professional organisations, practitioners and educators to decide on the most appropriate way forward.
A copy of the full report is available at www.richardwellsresearch.com
- 'A nursing home manager telephoned about a third scabies outbreak in 12 months. On the previous two occasions local GPs had treated residents and staff but were unwilling to do so on this occasion. I mapped all recent outbreaks over the past six months in nursing and residential homes and then started to look for a common denominator. There was a college teaching 'life skills' for teenagers with learning disabilities in the area where young people were going to nursing homes to help and to learn caring skills. Some of these young people were immunosuppressed or using topical steroids. Therefore they might also present with atypical scabies. A dermatologist diagnosed scabies in some students, their house carers and the physiotherapist. Treatment of 500 contacts took place over one weekend and I carried out some follow-up education sessions with carers' (CICN survey response)
This review was funded by the Department of Health (England).
The research team would like to thank all those practitioners who participated in this study either as respondents or in an advisory capacity, in particular the members of the Community Infection Control Nurses' Network of the Infection Control Nurses' Association.
Department of Health. (2001)Shifting the Balance of Power: Securing delivery. London: The Stationery Office.
Department of Health. (2002a)Shifting the Balance of Power: The next steps. London: The Stationery Office.
Department of Health. (2002b)Getting Ahead of the Curve. London: The Stationery Office.
Loveday, H.P., Harper, P.J., Mulhall, A. et al. (2002a)Informing the Future: 1. A review of nursing roles and responsibilities in community infection control. Professional Nurse 18: 4, 202-206.
Loveday, H.P., Harper, P.J., Mulhall, A. et al. (2002b)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.