Can ward rounds be used by infection prevention control teams to deliver education and enhance knowledge to clinical staff

Abstract

Background

Infection Prevention Control (IPC) education is a key aspect of training for all staff as it forms a fundamental aspect of patient safety. The majority of IPC education is carried out in the classroom, by e-learning or through simulation. Different models of education delivery have been evaluated in healthcare outside of IPC with some success, including ward rounds. Therefore, a ward round intervention was utilised using an action research model to evaluate if it was feasible to carry out IPC education in the clinical environment and determine if it improved education opportunities and knowledge for staff.

Methods

A mixed methods approach was used to collect qualitative and quantitative data in the form of questionnaires, interventions and reflections using thematic analysis.

Discussion

The results suggest that a ward round intervention for IPC education provides opportunities for staff to receive education. It also could contribute to an improved relationship between ward and IPC staff through collaborative working.

Conclusion

Whilst this was only a small action research study in one ward with limitations the findings suggest that IPC education can be delivered in the clinical environment and that IPC education delivery is an area that requires more research.

Background

Infection Prevention Control (IPC) is an important part of safe healthcare (Department of Health and Social Care, 2022). Prevention of infection can be as simple as appropriate hand hygiene or as complex as ensuring appropriate methods of decontamination are in place for pieces of equipment. Control of infection includes the intervention of measures to halt or limit the spread of infection or resistant organisms and requires risk assessment and understanding of how pathogens transmit. IPC is a very real problem in healthcare and studies have suggested without rapid interventions and control infection could be a leading cause of morbidity and mortality overtaking cancer by 2050 (O’Neill, 2014).

National guidance published by National Health Service England (NHSE) states that staff of all levels are expected to have the appropriate knowledge and skills to deliver effective IPC in practice (NHS England, 2023). To achieve this healthcare organisations should have effective education programmes and strategies in place which address IPC. Whilst programmes of education are not specified by NHSE learning outcomes are provided and an e-learning module is available to facilitate learning (NHS England, 2023).

It has been frequently observed that education relating to IPC practices can be perceived as quite prescriptive to staff and at times appeared to lack some fundamentals of nursing education theory such as recognition of Benner’s stages of clinical competence (Nicol et al., 1996). This has meant that the education delivered to staff was not always tailored to their level of knowledge or experience. Adult learning theory (Abela, 2009) and learner preferences were not always understood by those delivering education and education for IPC practitioners on how to deliver effective education was not always available. The literature seems to support these experiences and previous studies have identified that IPC education rarely seems to result in long term change in practice (Ward, 2011).

There is a growing awareness of how other education models in place within healthcare utilised different methods for education delivery. Examples of these include ward rounds led by clinical nurse specialists which have reduced patient falls, therefore improving patient outcomes. Evidence also suggests that although ward rounds vary slightly from speciality to speciality within healthcare, they frequently also create learning opportunities (Stanley, 1998). Patient checklists such as those used in theatres and central venous catheter insertion can be very successful but interestingly seem to depend on the culture in which they are introduced.

One exploration, linked to the development of educational opportunities within medicine, has included the implementation of a signature pedagogy (Shulman, 2005). This pedagogy or teaching method was of interest as it suggested three levels of understanding associated with education and supported the theory that education was not linear and could be influenced over time. The three levels are:

• • A surface structure-where there are observable strategies (hand washing).

• • A deep structure- where assumptions are made around knowledge.

• • An implicit structure- where underlying beliefs and values are explored.

Shulman (2005) had often observed the above structures being used within clinical ward rounds and medical training with discussions occurring between trainees, qualified doctors and experienced practitioners. This level of discussion associated with education delivery recognises the complexity of education in healthcare and medicine (Shulman, 2005) and highlights that IPC education may have been oversimplified. The result of oversimplifying IPC to staff delivering healthcare could be one of the reasons that a gap emerges between theory and practice, when staff know what to do but have not explored how it is possible to embed this into practice.

Action research is a key tool used by educators as an important way of reflecting on one’s practice (Liston and Zeichner, 1990). Through this reflection educators can identify an area of puzzlement which they wish to understand more about (Costello, 2003). Examples of this may include students in the classroom not engaging in debate and feedback. From this puzzlement comes the question what I can as an educator do to address this. The study aims to explore if the utilisation of a different model of IPC education could influence IPC delivery at the patient level. We utilised an action research education model to explore this as part of a short-term intervention to assess feasibility.

Methods

Study design

The action research intervention was implemented using a mixed methods design. Mixed methods involve the collection of both quantitative data and qualitative data (Migiro and Magangi, 2011). Using a mixed methods design allows for triangulation of the data (Greene et al., 1989), meaning that both quantitative and qualitative data can be combined to collaborate findings or outcomes.

During this intervention the spiral model proposed by Kemmis & McTaggart’s was used. The model was used as it suggests that action research is a collaborative process which involves change carried out by more than one person (Altrichter et al., 2002). The model is split into four areas and moves in a spiral downward motion over time:

• (1) Planning

• (2) Acting

• (3) Observing

• (4) Reflecting

Using this model allowed the adaption of research as it was happening in practice to ensure that it was meeting the stated aims.

The evidence suggests that if education is to be carried out in an environment outside the classroom it is important to have a structure to deliver that education within and ensure consistency if more than one educator is delivering the education (Gray et al., 2019). To facilitate this, an assessment tool (Figure 1) to facilitate discussion and deliver consistent education in the clinical environment was created.

Figure 1.

Assessment tool to support structured discussion of IPC practices.

Participants

The intervention was carried out on a high dependency cardiac unit within a paediatric tertiary care hospital. Band six nurses manage each shift on the ward, typically they will have been qualified as a registered nurse for over 3 years and will have experience of a range of different situations (Nursing Revalidation, 2022). The intervention focused on their knowledge and confidence in managing patients from an IPC perspective. They frequently hold the title of ‘Nurse in Charge (NIC)’ and co-ordinate patients daily care activities and are an important source of information for staff, patients and families. Other more junior nurses on the ward and other healthcare practitioners will refer to them as experts in their area and they are expected to know each patient on the ward in detail, including anything related to IPC. As part of the intervention, the ward was visited twice a week for 4 weeks and ward rounds were carried out with the NIC reviewing each patient utilising a bespoke assessment tool (Figure 1).

Method of data collection

Quantitative and qualitative data was collected. Three strands of data (two quantitative and one qualitative) were collected concurrently and are described in Table 1.

Table 1.

Methods of data collection.

What will happen?	How long? How often?	Who will be involved?
NIC was sent the link to a pre- questionnaire which utilises the Likert scale and asked to complete NIC was also sent a reminder and had an opportunity to complete if they had not done so at the beginning of any intervention that they participated in	NIC was asked to complete the pre- questionnaire once prior to the intervention. It is on microsoft forms and takes approx. 2 mins to complete	NIC on the ward was sent a link to the pre-intervention questionnaire
Teaching ward rounds took place with the NIC. During the ward round each patient will be assessed using the assessment tool SALT (see Figure 1. Each element of the tool was assessed and talked through with the NIC and any other staff present to identify any learning and improvements to patient care that should take place This was recorded (anonymised) against the assessment tool with any education carried out at the patient bedside with the NIC.	This took place a minimum of twice a week and a maximum of three times a week with the aim to complete the intervention a minimum of six to eight times The intervention is estimated to last between 30 and 45 mins, although this is dependent on staff engagement and the amount of education required/requested	NIC was involved in the teaching ward rounds with IPC educator
NIC was sent a link to the post intervention questionnaire and asked to complete NIC was also sent a reminder	NIC was asked to complete the post intervention questionnaire once when the intervention has ended. It is on microsoft forms and takes approx. 2 mins to complete	NIC on the ward was sent a link to the pre-intervention questionnaire

Method of data analysis

Quantitative data collection

Pre and post intervention questionnaires were collected. These were sent round and completed by the NIC’s pre and post intervention. The questionnaire was anonymous to encourage participation and uses a Likert scale to measure confidence around IPC knowledge. The same questionnaire was sent out pre and post intervention to allow comparison and to create a pooled data set.

The second piece of quantitative data is the number of education interventions that were applied by the IPC educator on each ward round, such as prompting to add or change the current allocated transmission-based precautions. These education interventions were prompted by use of the bespoke assessment tool (Figure 1) and allowed the provision of consistency throughout the ward rounds, so the same areas of practice are being examined each time. The tool also created a discussion point for each patient.

Data was analysed via excel and presented using a narrative description.

Qualitative data

At the end of each ward round, a short journal was completed describing how the ward round felt; how the educator was received by the staff, whether there was time to complete the round, if the staff asked any questions outside of the intervention and any other relevant observations. A period of structured reflection then took place to allow the identification of themes (Reymen, 2001). Structured reflection was a helpful tool when reflecting on the intervention as it allowed consideration of the intervention from more than one viewpoint. Reflections included rational reflections focusing on the intervention in terms or process, as well as a more reflective stance considering what was unique or artistic about the intervention. Thematic analysis was basic but looked for any common themes that appeared in the journal such as welcoming ward staff, a busy ward, being asked to come back later, feedback, and areas for improvement which could then be further explored to consider changes to the action research.

Results

Pre & post questionnaire

The pre and post intervention questionnaire demonstrated no apparent difference in confidence scales after the intervention although there did appear to be a small increase in staff knowing where to find information on the intranet as well as an increased awareness that not all patients were screened or had regular symptom assessments. Of note there were only 10 respondents in total: six pre-intervention and four post-intervention. Due to anonymous nature of the questionnaire, it is not possible to know if the same respondents participated in the pre and post questionnaire Figure 2.

Figure 2.

Graph showing results of pre & post intervention survey results.

Ward round intervention

During the ward rounds the number of education interventions was monitored and is shown in Table 2. The number of interventions decreased following the start of the intervention but was never less than five.

Table 2.

Table displaying ward rounds and number of interventions undertaken in proportion to number of patients on the ward.

Date of ward round	15/06/22	17/06/22	29/06/22	01/07/22	06/07/22	08/07/22	19/07/22	21/07/22
No of interventions	12	11	7	5	5	5	6	7
No of patients on ward	22	23	19	22	22	24	21	18
% Interventions undertaken	55%	48%	37%	23%	23%	21%	29%	39%

Reflective journal

A reflective journal was also undertaken following each intervention. This was followed by a structured reflection and thematic analysis. Four themes were identified, displayed in the Table 3 with the number of times the theme was noted. The most common theme identified was education with the least identified theme being areas for improvement.

Table 3.

Table displaying themes identified from reflective journal.

Theme identified	No of time theme identified
Welcoming	7
Education provided	11
Areas for improvement/ difficulties	3
Feedback from NIC	5

Discussion

This was a small study which set out to explore if a different delivery method of IPC education would provide education opportunities for staff and improve patient outcomes. The findings suggest that education opportunities were common as they were the most common theme identified from the qualitive journal.

The ward round interventions and the journal demonstrate that the education intervention provided some benefit and that a larger scale observational study may be warranted. The number of IPC interventions dropped over the time of the ward rounds and when combined with the themes from the reflective journal it is apparent that each ward round allowed different education topics relating to IPC to be discussed. The ward rounds and the use of an assessment tool to facilitate this intervention provided an opportunity to change the traditional IPC education delivery method and facilitated discussions focused around patients and patient care, as well as exploring what staff knew and understood about IPC. It also provided the ‘NIC’ a chance to challenge the IPC educators about the isolation statuses or care provision suggested, highlighting the need that IPC educators and practitioners have opportunities to learn from clinical staff in a bi-directional educational encounter. This reinforces the findings of Ward (2011). A more recent study by Dekker et al. (2024) identified and supported the earlier claim that IPC education is complex and that IPC teams need to work with clinicians to understand challenges that occur in clinical practice so that the education provided can be meaningful and implemented on a practical level. By carrying out education interventions in the clinical environment alongside ward staff we can work alongside them to understand and explore the real challenges that exist in providing best practice IPC.

Prior to the ward rounds the biggest risk was lack of staff availability and time for the ward rounds and as such it was not expected that the ward would be quite as receptive to carrying out the rounds as they were. On all but one occasion there was no hesitation in staff joining the round. Staff relationships are important and previous articles examined how the IPC nurse is perceived by other clinical staff. The paper highlights that work should be done by those working within IPC to engage with clinical staff and create and foster relationships with them (Ward, 2012). Furthermore, if education takes place face to face with clinical staff this enables the development of relationships and fosters understanding (Froneman et al., 2016). This also reinforces the theory put forward by Abela (2009) that adult learners want to know why what they are learning is important. Enabling staff to have the opportunity to provide professional, respectful challenge in a face-to-face environment fosters good relationships. During the time spent on the ward, as well as being welcomed by staff, queries were frequently raised about other infections or practices. Nursing staff also made suggestions about changes in education practice that could help make processes clearer for them, indicating additional benefits to embedding education in this face-to-face approach. These findings are reflected in themes constructed from the reflective journal and demonstrate the importance of using a mixed methods study for the evaluation of IPC practice. If a purely quantitative study had been undertaken it could have been perceived that staff were not engaged or interested due to low numbers completing the survey but allowing the inclusion of qualitative data has allowed the willingness of staff to engage and try this new method of education to be appreciated.

The ward rounds highlighted the positive impact of taking education to an area of clinical practice. Whilst this has been evidenced through various other professions (Basic et al., 2021; Cheong, 2020) and signature pedagogy (Shulman, 2005) it is not a well published method of education delivery within IPC. One ‘NIC’ likened the ward rounds as similar to ‘just in time training’ which provides training at the point it is needed (Coppus et al., 2007) and is commonly used as part of resus training within organisations. All the NIC’s were engaged and actively asked questions about education delivered. The assessment tool proved helpful as it allowed a focus and starting point for each conversation; which then led to education opportunities (Mohan and Caldwell, 2013). It also allowed provision of a consistent method of carrying out a task, and can be used in other areas if the intervention was to be trialled further at a later date. It was short and easy to use (Mohan and Caldwell, 2013) although some preparation was needed by the IPC educator before the ward round. Whilst checklists in themselves are not an education tool they are known to facilitate and improve communication (Pugel et al., 2015). We found that the assessment tool provided the focus of IPC around patient care and facilitated discussion and created learning opportunities.

The ward round created an opportunity for face-to-face training for staff in their work environment and was beneficial to them, providing them with education and information relevant to patients they were caring for and to the IPC educators and practitioners as it provided the opportunity to understand what knowledge was required by staff and explore any barriers in place to delivering optimal IPC care. The ward round demonstrated the importance of trying new teaching techniques and ideas to deliver effective IPC to improve and optimise patient outcomes. It also allowed IPC educators to develop problem-solving stances as the ward rounds could potentially present questions or queries that were unexpected, so being a subject matter expert and drawing on a variety of teaching styles to talk through and work out problems with staff was vital. IPC education programmes for specialist practitioners do not always contain aspects on education theory or different methods to deliver education and may be a reason why previous studies have often concluded that education interventions are not implemented in a robust manner and even when they were that practice often changed back to pre-intervention standard after a short period of time (Ward, 2011).

There are several limitations associated with this piece of education relating to the use of ward rounds as an opportunity to deliver IPC education differently. As this was a piece of action research the methodology used to underpin the findings were less robust than if it had been a piece of original research. Nevertheless, this opportunity did suggest that further exploration of this type of education delivery may provide benefits for staff. The pre and post intervention questionnaire was completed by a small pool of eligible NIC meaning that not all views and knowledge may have been identified. There is also a risk that the small number of participants in the questionnaire mean that it may not be generalisable. There were positive comments from those who took the time to complete the questionnaire and from the NIC who participated in the ward round suggesting that this was a worthwhile piece of work, but improved data collection would have demonstrated this. Other limitations include the short period of time the ward rounds were carried out over. It may have been beneficial and interesting to carry out the rounds over a longer period to see how knowledge and understanding and patient care changed over time. Another limitation at the time of the ward rounds was that it was only used by one IPC educator due to staffing challenges and the trial nature of the tool. Although recently there have been some IPC challenges on the ward that have meant it has been reinstated by another member of the IPC team who was aware of the ward rounds at the time. Informal feedback from staff and families suggests the ward round and assessment tool aid communication and improve IPC care and practices.

The ward round intervention and education opportunities have demonstrated that it is possible to explore different methods of carrying out IPC education that sit outside the traditional classroom, and e-learning. Further work could establish if these types of interventions could be trialled more widely within institutions and the wider health service. The ward round intervention highlights that education is a two-way dynamic and taking time to understand what staff find challenging to understand and implement in clinical practice can only enhance and lead to further development of achievable IPC practices. It is important that IPC staff gain experience and training in education methods and pedagogy to inform and develop IPC practice.

Conclusion

The ward round education intervention has demonstrated that there is a need to explore how we deliver IPC education and nurture relationships between clinical staff and IPC practitioners. Further research is needed in different delivery methods around IPC education to improve the delivery of care in the clinical environment. Every ward round created at least one education opportunity and created interventions that adjusted and optimised patient care. NIC were keen to engage and enjoyed the interaction between us as IPC educators and them as clinical staff delivering care.

IPC staff should also be provided with training that enables them to support the learning needs of staff in clinical areas. Those working within IPC should continue to explore opportunities to challenge and optimise how IPC education is delivered and the educational theories and pedagogies that inform them should be further explored within IPC.

Ethical statement

Ethical approval

The Ethics Review Committee at University of East London approved our intervention on June 8th 2022.

ORCID iD

Helen Dunn https://orcid.org/0000-0002-7033-5143