The NOSO-COVID study: a large-scale survey assessing stakeholder perspectives on patient and family engagement in infection prevention, informed by Q-methodology findings

Abstract

Background

Healthcare-associated infections are common in hospitalized patients, exacerbated by COVID-19. Engaging patients and families in infection prevention and control may enhance adherence, but optimal strategies remain unclear.

Objective

This study developed a large-scale survey, informed by previous Q-methodology research, to assess stakeholder perspectives on patient and family engagement in infection prevention, identify consensus and disagreement, and explore socio-demographic and work-related influences.

Methods

A cross-sectional survey was conducted in surgical and family medicine units at two Canadian university hospitals in 2023. The NOSO-COVID survey included 17 Likert-scale items derived from identified infection prevention engagement viewpoints. Data were analyzed using univariate, bivariate, and multivariable logistic regression.

Results

Among 212 participants (patients, family members, and staff), responses varied on infection prevention engagement strategies. Common suggestions included bedside disinfectants and monitoring staff compliance. Older participants, particularly in family medicine units, were more supportive of educational and behavioral measures. Comfort with advocating for infection prevention differed across units, with surgical unit participants expressing less confidence. Institutional culture influenced perceptions, with staff at one hospital reporting greater ease in engaging patients and families in infection prevention. Four consensus items were identified, emphasizing staff reminders for hand hygiene, availability of disinfectants, and providing accessible infection prevention information.

Conclusions

Our findings suggest that tailoring IPC engagement strategies to hospital unit cultures and stakeholder needs is essential. Strategies to enhance communication, address power dynamics, and promote shared responsibilities to improve IPC should be identified and their effectiveness evaluated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13350-z.

Introduction

Healthcare-associated infections (HAIs) affect 5–15% of hospitalized patients globally and remain a persistent issue in Canada, with over 200,000 cases annually [1, 2]. Traditionally, efforts to reduce HAIs focus on healthcare professionals (HCPs), while the role of patients and families (PFMs) in infection prevention remains underexplored [3, 4]. However, patient and family engagement (PFE) is increasingly recognized as a strategy to enhance quality and safety [5, 6].

The COVID-19 pandemic underscored both the importance and challenges of PFE in infection prevention and control (IPC). Hospitalized COVID-19 patients faced heightened risks of secondary HAIs—such as bloodstream infections and ventilator-associated pneumonia—due to strained healthcare resources, modified infection control practices, and severe illness [7, 8]. Hospitals promoted mask-wearing and hand hygiene but also implemented restrictive policies (e.g., limiting family presence) with reduced PFMs’ involvement in care [9, 10]. These measures, introduced rapidly for public health reasons, often lacked stakeholder input, creating uncertainty about the role of PFMs in infection prevention.

Despite these constraints, recent studies have shown that PFE interventions—such as bedside hand hygiene promotion, educational initiatives, and family participation in IPC campaigns—can contribute meaningfully to safer care [11, 12] The pandemic not only disrupted these efforts (e.g. limiting family presence) but also highlighted the importance of engaging PFMs in IPC to support adherence and reduce transmission risks. As healthcare systems transition to a post-pandemic context, there is a renewed imperative to develop feasible, acceptable, and sustainable PFE strategies.

Yet, engagement practices remain inconsistent. While some PFMs are willing to engage in IPC [13, 14], others feel hesitant, and some HCPs question whether PFMs should be involved at all [15, 16]. This lack of clear consensus leads to variability in PFE implementation across settings [11, 16].

This study seeks to identify areas of agreement and contention regarding PFMs’ engagement in IPC. Understanding these perspectives is key to developing evidence-based, stakeholder-informed strategies that ensure feasible, acceptable, and effective PFE.

This study is part of the NOSO-COVID project, a multi-phase initiative designed to generate consensus-based approaches to PFE in IPC. Earlier phases (phases 1 and 2) used Q methodology to explore perspectives of hospital staff, patients, and family members, revealing three distinct viewpoints on the roles of PFMs in IPC [17, 18]. While Q methodology provides in-depth qualitative insights, it does not aim for statistical generalizability. To build on these findings, the current phase (Phase 3) developed and administered a survey to quantitatively assess the distribution of these viewpoints across a broader stakeholder population.

Development of the NOSO-COVID survey

The survey design was directly informed by the Q-study findings. In phases 1 and 2, a purposive sample of 19 participants completed a Q-sort of 40 statements related to PFE in IPC, followed by interviews to contextualize their choices. Factor analysis identified three distinct viewpoints perspectives, ranging from passive to active roles for PFMs [18]. Statements that most strongly distinguished each factor, along with consensus items and additional insights from interviews, were used to construct a 17-item survey for Phase 3. This hybrid approach preserved the conceptual richness of the Q study while enhancing the reach and generalizability of findings [19] (Fig. 1).

Fig. 1.

illustrates the three interconnected phases of the NOSO-COVID project, detailing the objectives, design, and methodology underpinning the overall research

Objectives

The final phase of NOSO-COVID sought to validate previous Q-methodology findings by quantitatively assessing stakeholder perspectives on PFE in IPC. Therefore, this study aimed to:

1. Develop and administer a large-scale survey, informed by prior Q-methodology research, to assess stakeholder perspectives on PFE in IPC.

2. Identify areas of consensus and disagreement regarding how patients and family members should be engaged in IPC.

3. Explore how socio-demographic and work-related factors influence stakeholder perspectives.

Methods

Study design

This study integrates Q methodology findings from a previous phase with traditional survey techniques to quantitatively assess stakeholder perspectives on PFE in IPC. The survey, based on key themes and consensus points from the Q study (phase 2), ensured alignment with identified viewpoints. A cross-sectional survey was conducted in two university hospitals in Quebec, Canada (2023) to capture diverse stakeholder perspectives at a single point in time, enabling comprehensive analysis across different stakeholders, sociodemographic groups and hospitals.

Settings and Participants

The survey was conducted in four clinical units across two university hospitals in Quebec (January -April 2023). Hospital 1 is a major urban acute care and teaching hospital in Quebec, with 637 beds and a Level II trauma center designation—making it one of the province’s largest hospital sites. As an academic institution, it trains medical students and supports a strong clinical research infrastructure. Its comprehensive IPC program is integrated into its care, teaching, and research missions. Led by a specialized team, the program includes active surveillance, strict hand hygiene protocols, regular environmental audits, and targeted staff education. IPC is promoted as a shared responsibility across all roles, supported by clear institutional policies and continuous quality improvement initiatives. Hospital 2 is a large urban academic health network in Quebec, operating over 1,300 beds and employing more than 10,000 healthcare professionals. As a major teaching hospital, it trains thousands of medical, nursing, and research trainees annually. It maintains a robust multidisciplinary IPC program led by IPC specialists and stands out for its innovative collaborative initiatives. One such program engages frontline staff and patient partners in audits and improvement efforts to address persistent nosocomial infection challenges through strengthened hand hygiene and enhanced environmental disinfection practices.

Selection of clinical units

Units were selected based on: (1) willingness to participate, (2) infection prevention strategies, and (3) matched specialties, specifically, selecting the same types of units (family medicine and surgery) in both hospitals to enable cross-site comparison. Family medicine and surgery units were selected at both sites.

Inclusion and exclusion criteria

A convenience sample included clinical and non-clinical staff (HCPs, managers, support staff) and PFMs (patients and family members). Family members include non-family support persons. Patients were eligible if they were 18+, fluent in French or English, cognitively able, and capable of informed consent.

Targeted sample and enrollment

The study aimed to recruit 200 participants (50 per unit: 25 staff, 25 PFMs). The unit’s chief nurse first approached all staff members, patients, and family members to inform them about the study and assess their interest in participating. This initial contact helped foster engagement and ensured alignment with clinical workflows. The chief nurse collaborated closely with the research team to coordinate recruitment activities. Interested individuals were then met by a research assistant, who formally presented the study, provided detailed information, and answered any questions. Participants could choose to complete the survey on site with the research assistant’s support or receive a secure link to complete it online at their convenience. In total, 294 individuals were approached—157 patients and family members, and 137 staff members—to meet the recruitment target of 200 participants. Each received an information package containing a demographic questionnaire and a 17-item survey. Surveys were completed online or on paper, with research team assistance if needed.

Ethics considerations

The study received multicenter research ethics approval from the Research Ethics Board of the McGill University Health Centre (approval number: MP-37-2020-6404, dated May 14, 2020). All participants read and completed an information and consent form before completing the NOSO-COVID survey.

Content validation of the NOSO-COVID survey

A pilot test was conducted with 15 IPC and/or PFE experts from two university hospitals (January–April 2023), including patients, family members, managers, HCPs, and researchers. These individuals were not included in the subsequent survey. They assessed the survey’s purpose, readability, relevance, clarity, ease of use, and response scales using an evaluation grid. Each question required a Yes/No response, with space for comments. Feedback focused on rewording items, which were incorporated into the final version.

Presentation of the NOSO-COVID survey

Table 1 outlines the 17-item Q survey on PFE in IPC, along with seven sociodemographic questions (age, sex, education, employment status, profession (staff only), and work experience (staff only)). To ensure clarity, two versions of the survey—covering the same variable concepts—were developed: one for PFMs and one for hospital staff, with wording adapted to reflect each group’s role in IPC.

Table 1.

Dimensions and items of the phase 3 NOSO-COVID survey (n = 17 items)

Item n.	Label
Roles and responsibilities of stakeholders in IPC
Q.1	Families should wear a mask in the hospital (including in the patient’s room).
Q.2	Patients and families should disinfect certain equipment they use (e.g., wheelchair) or their immediate environment (e.g., bedside table) in the hospital.
Q.3	In the event of a new epidemic or pandemic (e.g. COVID-19), families should not go to the hospital but make phone calls or virtual visits instead.
Q.4	Staff members should encourage patients and families to say something if they notice that a preventive measure (such as wearing a mask, hand washing, or disinfection) has not been followed by a staff member.
Q.5	Staff members should check that families wear masks appropriately.
Q.6	Healthcare professionals should verbally remind patients and families to wash their hands regularly.
Q.7	Patient advisors* should explain infection prevention measures (or how to avoid infections) to hospitalized patients and families.
Q.8a (patients & families) Q.8b (staff)	Ask staff members to wear a mask if you notice that this is not done You are being asked by a patient or relative to wear a mask
Q.9a (patients & families) Q.9b (staff)	Ask staff members to wash their hands if you notice that this has not been done You are being asked by a patient or relative to wash your hands
Q.10a (patients & families) Q.10b (staff)	Ask staff members to clean and disinfect the room or equipment if you notice that this has not been done You are being asked by a patient or relative to clean and disinfect the room or equipment
Measures to encourage PFE in IPC
Q.11	Disinfection products (e.g., disinfectant wipes and hand sanitizer) should be available at the patient’s bedside.
Q.12	Information (e.g., posters) on infection prevention measures should be available and visible in care units.
Q.13	A video on infection prevention measures should be presented to patients before being hospitalized and to families before visiting a patient.
Q.14	In the event of a new epidemic or pandemic (e.g. COVID-19), only a limited number of families should be allowed to visit a patient in the room (e.g. 1 or 2 visitors/day/patient)
Q.15	Verifications of symptoms indicative of an infection (e.g., cough, fever) should be done for families at the hospital entrance.
Q.16	Once the pandemic is over, mask-wearing should be maintained for patients and families in the hospital.
Q.17	Replace visits with phone calls and/or virtual visits in the event of a new epidemic or pandemic (e.g. COVID-19).

*Patient advisors are individuals with lived experience as patients or family members who act as partners within the hospital setting. They support other patients, contribute to improving care experiences, and help ensure that care practices and information are aligned with patient needs

Participant enrollment and NOSO-COVID survey administration

Nurse managers assisted with recruitment by sharing study information and facilitating enrollment. Two research assistants oversaw recruitment and survey administration across the four units. The survey (∼10 min) was completed on paper by patients and family members, with research assistant support, while staff had the option of paper or REDCap (Research Electronic Data Capture, https://www.project-redcap.org/)

Data cleaning and analysis of survey responses

All responses were included (incomplete, partially complete (N = 23), and fully complete (N = 189)). A univariate analysis assessed the distribution of age, sex, education, and employment status, including staff work experience. Bivariate analysis compared response patterns across age groups, hospitals, clinical units, and PFMs vs. staff members. Multivariate analysis used only complete survey responses, categorizing them as negative/neutral or positive, (e.g., “completely agree,” “agree,” “feeling very comfortable,” or “feeling comfortable”). A multivariable logistic regression model was then developed for each binary response variable

Consensus item criteria

Using the regression model outputs, a survey item was classified as a “consensus item” if it met both of the following:

1. No statistically significant differences (p > 0.05) in positive response rates across age groups, hospitals, clinical units, or participant type (PFMs vs. staff members), indicating consistent responses across subgroups.

2. At least 75% positive responses, reflecting strong agreement. Diamond et al. suggest 75% agreement as an appropriate threshold for consensus [20].

Results

Presentation of the survey data

Socio-demographic characteristics of participants

Among our participants, more than three-fifths were aged 60 or younger. However, age distributions differed by subgroup; nearly 60% of staff were in the 18–39 range, while most PFMs were aged 40 or older. The sample was predominantly female—with a higher proportion among staff than PFMs. Most participants pursued education beyond high school, with nearly 80% of staff holding CEGEP or university degrees compared to about 55% of PFMs. Approximately 70% were employed or self-employed, though employment varied; over two-fifths of staff had less than five years of experience, while nearly 40% had more than ten years. Chi-square and Fisher’s Exact tests showed statistically significant differences (p < 0.05) in age, sex, education, and employment status between PFMs and staff. Table 2 presents the demographic characteristics of study participants.

Table 2.

Demographic characteristics of study participants

	PFMs	Staff members	Total	Chi-sq p-value*
	N (%)	N (%)	N (%)	N (%)
Age groups
18–29 yrs	5 (4.72%)	29 (29.00%)	34 (16.11%)	< 0.001
30–39 yrs	7 (6.60%)	29 (29.00%)	36 (17.06%)
40–49 yrs	9 (8.49%)	18 (18.00%)	27 (12.80%)
50–59 yrs	18 (16.98%)	18 (18.00%)	30 (17.06%)
60–69 yrs	21 (19.81%)	6 (6.00%)	27 (12.80%)
70–79 yrs	20 (18.87%)	0 (0.00%)	20 (9.48%)
80 + yrs	26 (24.53%)	0 (0.00%)	26 (12.32%)
Sex
Female	69 (63.3%)	82 (83.67%)	151 (72.95%)	0.0017
Male	40 (36.7%)	16 (16.363%)	56 (27.05%)
Education
Elementary	8 (7.84%)	0 (0.00%)	8 (4.06%)	< 0.001
High School	23 (22.55%)	4 (4.21%)	27 (13.71%)
Professional	16 (15.69%)	16 (16.84%)	32 (16.24%)
College (CEGEP)	20 (19.61%)	22 (23.16%)	42 (21.32%)
University	35 (34.34%)	53 (55.79%)	88 (44.67%)
Employment Status
Full-time	29 (27.36%)	75 (74.26%)	104 (50.24%)	< 0.001
Part-time	6 (5.66%)	24 (23.76%)	30 (14.49%)
Self-employed	6 (5.66%)	0 (0.00%)	6 (2.90%)
Retired	56 (52.83%)	0 (0.00%)	56 (27.05%)
Student	0 (0.00%)	2 (1.98%)	2 (0.67%)
Other	9 (8.49%)	0 (0.00%)	9 (4.35%)
Years in Profession
0–5 yrs	/	45 (44.12%)	45 (44.12%)	/
6–10 yrs	/	15 (14.71%)	15 (14.71%)
>10 yrs	/	41 (40.20%)	41 (40.20%)

*P-values were derived from the chi-square test comparing the distribution of age, sex, education, and employment status between patients and families and staff members. Fisher’s exact test was used as an alternative when the cell numbers were small

“%” are column percentages showing the percentages of each category of demographic variables within PFMs, Staff members and those two groups combined

“/” indicates that a comparison between groups is not available because patients and families and staff members received different versions of the questionnaire. Questions involving years in the profession were only included in the questionnaires assigned to staff members

Surveys completed

The global survey response rate was 72%, for the four clinical units involved in data collection (294 participants approached: 157 staff members and 137 patients and family members)

Among 212 participants, 189 completed the survey. Of the 109 survey questionnaires distributed to patients and family members, 95 (87.2%) were fully completed. While 103 questionnaires were given to staff members, with 94 (91.3%) fully completed. At University Hospital 1, 90 out of 96 questionnaires were completed (93.7%), and at University Hospital 2, 99 out of 112 were completed (88.4%). In the family medicine units, 98 out of 106 were completed (92.4%), and in the surgery units, 91 out of 102 were completed (89.2%). The Chi-squared tests (p > 0.05) indicated no statistically significant differences in completion rates across participant groups, hospitals and units.

Consensus items among participants

In our analysis, four items (Q.4, Q.6, Q.11, and Q.12) met the predefined criteria of consensus. Among these items, we found no statistically significant differences (p > 0.05) in response patterns across participant subgroups (age groups, hospitals, clinical units, and participant group) and demonstrated high agreement levels (> 75% positive responses). These items demonstrated a consistent distribution of responses across groups, indicating a shared agreement among participants. The consistent response patterns across participants supporting these items reflect broad agreement on the topics assessed.

Across these items, most participants selected neutral or positive responses (e.g., “agree” or “strongly agree”). For example, Q.11 had the highest proportion of positive responses (N = 186, 89.9%), while Q.4 had the lowest (N = 161, 78.2%). Fisher’s exact test suggested significant differences in the proportions of each response option across all four items. This indicates that while most responses were positive, the relative distribution of “agree” versus “strongly agree,” or “neutral” versus “disagree,” varied between items. These significant differences reflect distinct response patterns across the items, showing that participants’ views were not uniformly distributed across all items but varied in the degree of agreement, even though the overall trend remained positive.

Consensus items explored perspectives on PFE in IPC, ranging from active involvement (Q.4: staff encouraging PFMs to speak up if preventive measures are not followed) to strategies that promote the autonomy of PFMs regarding IPC compliance (Q.11: availability of disinfection products at the patient’s bedside and Q.12: availability of IPC information on units). Additionally, one item focused on a more passive role, where staff remind PFMs about hand hygiene (Q.6). Table 3 provides details of the proportions of each response option for consensus items among participants.

Table 3.

The proportions of response options for consensus items (Q.4, Q.6, Q.11, Q.12)

Q. number	Q. label	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	P-value*
Q.4	Staff encourage patients and families to speak up if preventive measures not followed	10 (4.85%)	14 (6.80%)	21 (10.19%)	28 (13.59%)	133 (64.56%)	0.0092
Q.6	HCPs remind patients and families washing hands	6 (2.90%)	8 (3.86%)	28 (13.53%)	44 (21.26%)	121 (58.45%)
Q.11	Disinfection products available at the patient’s bedside	0 (0%)	5 (2.42%)	16 (7.73%)	38 (18.36%)	148 (71.50%)
Q.12	Information on IPC available on units	6 (2.91%)	5 (2.43%)	18 (8.74%)	37 (17.96%)	140 (67.96%)

*P-value is derived from Fisher’s exact test

“%” are row percentages, representing the percentage of participants choosing each option within each question

Differences in response patterns for items between subgroups of participants

Based on the multivariable logistic regression models, participants who were staff members from family medicine units, who worked in the university hospital 1, and were aged 50 + were more likely to provide positive responses. We presented significant differences in the propensities of positive responses in Table 4. In the supplemental table (Table S1, Appendix 3), we further presented the numbers and proportions of participants with positive responses across various subgroups.

Table 4.

Significant differences in responses to each survey question among participants, based on multivariable logistic regression models

Questions	Clinical Unit	Hospital	Sex	Type of Participants	Age
	Surgery vs. family medicine (ref)	Hospital 1 vs. Hospital 2 (ref)	Male vs. female (ref)	Staff vs. pts + families (ref)	50 + vs. 18–49 (ref)
Questions: Roles and responsibilities of stakeholders in IPC
Q.1		+		+
Q.2				+
Q.3					+
Q.4
Q.5 Q.6		+		+	+
Q.7	-			+
Q.8		+		+
Q.9				+
Q.10	-
Questions: Measures to encourage PFE in IPC
Q.11
Q.12
Q.13				+
Q.14				+	+
Q.15	-			+
Q.16					+
Q.17					+

“+” indicates higher propensity of positive response (agree/feeling comfortable), when compared to the reference group. “-” means the opposite direction

A more informative version of the table is available in the Appendix 3 (Table S2). Among questions on engaging PFMs in IPC (Q.11 to Q.17), staff and participants over 50 were more likely to respond positively compared to patients, family members, and younger individuals. Specifically, for Q.13, which concerns presenting a video on IPC measures to patients before hospitalization and to families before visiting a patient, stakeholders over 50 years old were more likely to respond positively compared to younger individuals. Similarly, older participants were more likely to support maintaining mask-wearing even after the pandemic ended (Q.16) and to replace bedside visits with phone calls and/or virtual visits in the event of a new pandemic (Q.17). Regarding Q.14, which addresses limiting the number of visitors allowed during a new pandemic, staff members and individuals over 50 were more likely to respond positively than other stakeholders. For Q.15, which asks whether the hospital should verify symptoms of patients’ family members, a distinct pattern emerged: individuals associated with the surgical units, either as patients or staff, were less likely to respond positively compared to their counterparts in the family medicine units.

Regarding IPC roles and responsibilities (Q.1 to Q.7), staff and participants over 50 were generally more positive. This pattern mirrors the response pattern observed in Q.11 to Q.17. For example, staff members working at university hospital 1 were more likely to respond positively when asked whether families should wear masks in the patient’s room (Q.1) and whether staff should check that they are wearing the mask appropriately (Q.5). Finally, participants from the surgical units (whether staff, patients, or family members) were less likely to have positive responses to Q.7, which is about whether patient advisors should explain infection prevention measures to patients. Patients can be both employees or volunteers within HCOS, offering their patient perspective and helping to make information or educational handouts easier for PFMs to understand and use.

In comfort levels regarding PFMs’ proactive role in IPC (Q.8 to Q.10), different versions of questions (different wording) were distributed to patients, their families, and staff. Among PFMs, those hospitalized in surgical units were less comfortable asking staff to follow IPC measures. Among staff, unit affiliation did not significantly influence comfort levels when asked by PFMs to comply (p > 0.05). Staff at university hospital 1 felt more comfortable being asked to take anti-infection measures than those at university hospital 2.

Discussion

This is the first study to use Q methodology findings to develop a survey assessing diverse hospital stakeholders’ viewpoints on PFE in IPC. Examining a large sample of patients, family members, HCPs, and support staff, we identified consensus measures to enhance engagement and pinpointed areas of disagreement based on role, unit specialty, hospital setting, age, sex, and education level.

The consensus statements highlight the crucial role of staff in encouraging PFMs’ IPC engagement. One item (Q.6) shows most stakeholders believe HCPs should remind PFMs to wash their hands, positioning them in a more passive role. In contrast, Q.4 promotes a more active approach, empowering PFMs to express concerns about non-compliance. Similarly, Q.11 and Q.12 serve as empowerment strategies by facilitating independent hygiene practices - providing bedside disinfectants (Q.11) and displaying visible IPC information in care units (Q.12). Together, these measures illustrate a dual approach: HCP-led reminders ensure compliance, while autonomy-focused strategies encourage a proactive role for PFMs, potentially enhancing overall IPC effectiveness.

The four consensuses align with the three perspectives outlined in phase 2 of the NOSO-COVID study. Viewpoint 1 reflects HCPs controlling IPC adherence, (Q.6), Viewpoint 2 emphasizes autonomy in IPC of both PFM and staff members (Q.11, Q.12), and Viewpoint 3 sees PFMs as proactive IPC partners (Q.4). Notably, three of the four items (Q.6, Q.11, Q.12) align with Viewpoints 2 and 3, challenging the prevailing assumption that HCPs bear sole responsibility for IPC [15, 16, 21].

Multivariable logistic regression results suggest that several factors influence attitudes toward IPC engagement. Stakeholders in the medicine department, particularly at the University Hospital 1, and those aged 50 + were more likely to support strategies such as IPC education (e.g., videos) and behavioral regulations (e.g., continued mask-wearing, visitor restrictions). Educational interventions improve compliance with infection control practices, while behavioral regulation measures, like visitation restrictions, help manage hospital environments and reduce exposure to infections [22–24]. A recent study examined stakeholders’ perceptions of restrictive acute care visiting policies during COVID-19 in Canada, highlighting their negative impacts, including those on patient safety. Participants stressed that a standardized caregiver presence policy cannot meet al.l patient needs, advocating instead for flexible visitation approaches [25]. Older stakeholders’ support for IPC educational and behavioral strategies suggests that experience and risk perception influence adherence to IPC measures, consistent with studies showing older HCPs follow IPC protocols more strictly [26, 27]. Family medicine unit stakeholders, including PFMs and staff, were also more likely to endorse involving patient advisors in explaining IPC measures, reflecting a culture emphasizing holistic care and patient empowerment. Research indicates that departments prioritizing patient education and collaborative practices foster environments supportive of patient advisor involvement [12, 28].

Regarding comfort levels in advocating for IPC, PFMs in surgical units expressed less confidence in asking staff to comply with IPC measures (e.g., hand washing, mask-wearing). Previous research suggests that willingness to speak up is influenced by perceived power dynamics and the nature of interactions with HCPs. This aligns with literature on “speaking up” in healthcare, which highlights how hierarchical structures can inhibit patient and family advocacy in high-stakes environments like surgical units [29]. However, staff comfort levels remained consistent across departments, though University Hospital 1 staff reported greater ease responding to PFM requests. Institutional differences in IPC culture and supportiveness may explain these variations, as hospitals prioritizing patient safety and open communication often cultivate a stronger safety culture, leading to more receptive staff attitudes [30].

These findings offer several practical implications for hospitals seeking to implement or strengthen PFE in IPC. Participants across stakeholder groups showed strong support for concrete, low-barrier interventions—such as providing disinfectant products at the bedside and displaying visible IPC information in care units—that allow PFMs to adopt preventive behaviors autonomously, without requiring confrontation or assertiveness. In addition, older participants and those in family medicine units expressed greater support for structured educational strategies, such as videos shown prior to hospitalization or visitation. These preferences suggest that effective PFE may benefit from a tiered approach: combining universal support (e.g., environmental and informational resources) with targeted efforts to foster a supportive culture where PFMs feel empowered and safe to speak up when needed.

Strengths and limitations of the study

This study uniquely explored PFE in IPC, addressing a key gap in healthcare safety research. By combining Q methodology with survey techniques, it provides comprehensive insights into stakeholder perspectives. The inclusion of a diverse sample—patients, family members, HCPs, and support staff—enhances the findings’ relevance. However, the study focused on only two university-affiliated hospitals within a single Canadian province, which may limit the generalizability of the results to other healthcare systems, geographic settings, or non-academic institutions. In each hospital, only two types of units—surgical and family medicine—were included; while these offer relevant and contrasting perspectives, the study did not include long-stay or high-acuity units such as intensive care, rehabilitation, or transplant units. These settings involve prolonged hospitalization, complex care needs, and frequent family presence, which may shape distinct dynamics in PFE for IPC. Additionally, units were selected based on willingness to participate, which may introduce selection bias if participating units had a stronger interest or existing engagement in IPC. Social desirability bias may also have influenced participants’ responses, particularly regarding IPC adherence. No formal sample size calculation was conducted, as the study aimed to explore stakeholder perspectives rather than achieve population-level representativeness. However, this may limit the generalizability of findings and should be considered when interpreting the results. Finally, as data collection occurred during the pandemic, attitudes toward IPC and engagement may evolve in the post-pandemic period. Future research should expand to other types of units and institutional contexts to better understand how engagement strategies can be tailored to diverse clinical environments

Conclusion and practical implications for hospital settings

This study highlights the value of a collaborative IPC approach, where PFMs contribute alongside HCPs. Three of the four consensus items promote autonomy and shared responsibility, such as bedside disinfectant availability, visible IPC information, and reporting non-compliance. PFE preferences vary, with older participants and those in family medicine units favoring educational and behavioral strategies, possibly due to experience or risk perception. In contrast, surgical unit stakeholders, particularly PFMs, were less comfortable advocating for compliance.

To support meaningful PFE, hospitals should tailor IPC engagement strategies to unit cultures, ensuring access to hygiene resources, clear educational tools, and visible informational materials. For example, providing bedside disinfectants, displaying IPC posters, and using multimedia tools (e.g., videos) prior to admission or visitation offer low-barrier, feasible ways to foster engagement. These strategies can serve as entry points while laying the groundwork for more active roles—such as reminding staff or asking questions—especially when reinforced by a receptive institutional culture. Encouraging open communication, implementing feedback mechanisms, and offering staff training to address power dynamics can further support a more inclusive IPC environment. Finally, integrating PFE into national IPC guidelines may be a promising avenue to promote sustained engagement and support behavioral change; however, further research is needed to support the implementation and evaluate the effectiveness of specific interventions that promote PFE in IPC.

Abbreviations

COVID-19

Coronavirus Disease 2019

HAIs

Healthcare‑Associated Infections

IPC

Infection Prevention and Control

HCPs

Healthcare Professionals

PFE

Patient and Family Engagement

PFMs

Patients and Family Members

REDCap

Research Electronic Data Capture

HCOs

Healthcare Organizations

Authors’ contributions

The study concept and design were conceived by NCC with substantial feedback from CG, MLT, ABi, and ABr. NCC, JC, and JP conducted the data collection and analysis. NCC prepared the first draft of the manuscript, and all authors (NCC, JC, JP, ABr, MLT, LB, Abi, DB, AZ and CG) provided edits and critiqued the manuscript for intellectual content. All authors read and approved the final manuscript.

Funding

This study was supported by the Social and Sciences Humanities Research Council (Government of Canada) through the Partnership Engage Grant special initiative for COVID-19 (SSHRC 1008-2020-1062). Finally, research funds were provided by the McGill University Health Center and the McGill Nursing Collaborative for Education and Innovation in Patient-Centered and Family-Centered Care (Newton Foundation/McGill Faculty of Medicine).

Data availability

Data is available upon reasonable request. The datasets associated with this study are available from the corresponding author on reasonable request and only in accordance with the stipulations of the ethics approval.

Declarations

Ethics approval and consent to participate

As this research involves human participants, it adheres to the Declaration of Helsinki principles. The study received multicenter research ethics approval from the Research Ethics Board of the McGill University Health Centre (approval number: MP-37-2020-6404, dated May 14, 2020). Participants were asked to read and complete an information and consent form before completing the NOSO-COVID survey. Written informed consents were provided by all participants prior to the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.