Abstract
Background:
Over 4 million patients acquire a healthcare-associated infection (HCAI) in Europe every year, indicating possible shortcomings in hospitals converting evidence-based infection prevention and control (IPC) strategies into universal adherence. We present a literature review exploring whether insufficient adherence could be culturally based.
Aim:
To find empirical evidence if and how specific traits of organisational culture improve adherence to IPC strategies utilising HCAI rates as the marker of system failures or successes.
Methods:
PubMed, CINAHL, PsycINFO and the British Nursing index database were searched from January 2007 to June 2018. Hand-searching, Google Scholar and the snowball effect completed the investigation. The quality of the studies was assessed with the guidance of CASP and Cochrane tools.
Results:
Twenty papers were eligible for data extraction and thematic analysis. Studies predominantly report positive findings for the association, but none were determined high quality due to multiple methodological concerns. Analysing both quantitative and qualitative research revealed eight major themes: hospital cultures with better HCAI rates foster safety culture; have a generative leadership style; embrace innovation; ensure interventions fit local context; accept long-term orientation; engage and empower health professionals; promote collaboration and communication; and see the benefits of a non-punitive climate.
Interpretation:
The literature linking organisational culture and HCAI rates is suggestive, but not conclusive, indicating caution about their inferences. Leaving cultural growth to chance or allowing for weak or toxic cultures impedes on our IPC strategies and equivalently our HCAI rates.
Keywords: Infection prevention, adherence, healthcare-associated infection, organisational culture, culture change, safety culture
Introduction
Many healthcare facilities describe themselves as ‘centres of excellence’; however, the numbers of preventable infections do not always reflect this statement. In Europe, over 4 million patients acquire a healthcare-associated infection (HCAI) every year and approximately 37,000 die as a direct consequence (PHE, 2016). In addition, the United States report HCAI as the fifth leading cause of death in acute care hospitals (Septimus et al., 2014).
Improving resources and knowledge help appropriate infection prevention and control (IPC) behaviour but may reflect capability for change rather than the eagerness to do so (Weiner, 2009). Investigating HCAI often depends on the ‘find and fix’ model, including actions such as root cause analysis, accident reporting and failure assessment (Braithwaite et al., 2015). The difficulty with this approach, the ethos of ‘culture of blame’, is that it may lead to healthcare workers (HCW) hiding errors rather than reporting them. No matter how qualified, experienced or vigilant a HCW might be, mistakes will always occur, especially in an environment that places substantial demands on HCWs (Jackson, 2014). Furthermore, HCWs admit that they do not always challenge bad practices from fear of being seen in a negative light, or that they may lower personal standards to fit in with local practice (Cioffi, 2015). Therefore, there is a need to develop a better understanding of the underlying hospital system, metaphorically ‘seeing the forest for the trees’.
In non-healthcare organisations, culture traits are predictors for the performance and success of a company (Warrick, 2017). The claim that ‘culture eats strategy for breakfast’ (Torben, 2014), implies that the underlying organisational culture can aid or limit strategy implementation.
A well-known characterisation of organisational culture is ‘the way things are done around here’, a statement that encompasses the shared behavioural patterns, attitudes and beliefs throughout an entire hospital (Braithwaite et al., 2016). A ‘strong’ organisational culture has core values and beliefs held by a large number of staff and may lead to improvements in behavioural uniformity and performance (Pellegrin and Currey, 2011). However, strong cultures potentially influence staff’s performance in a negative way, where bad practice becomes the norm, a process known as cultural entrapment. Cultural entrapment can lock staff in to poor practice while allowing justification of substandard performance by rationalising and legitimising their behaviour within the workplace environment (Weick and Sutcliffe, 2003). Any organisational culture, positive or negative, can become self-reinforcing and difficult to change. Organisation culture works at local level, with an investigation of 140 English NHS acute hospital trusts reporting variations across hospitals predicting routine measures of performance (Jacobs et al., 2013). For that reason, we hypothesise that organisational culture could impact on HCAI rates.
Studies associating organisational culture and HCAI often investigate HCWs and their knowledge, attitudes and IPC practices, but do not report statistics on HCAI rates (Bernard et al., 2017; Sinkowitz-Cochran et al., 2012; Zingg et al., 2015). Improvements in IPC practice scores are an outcome of interest, but frequently observed performance (Hawthorne effect) or expressed conduct may differ from actual long-term behaviour. Measurement and use of HCAI statistics following interventions can identify organisations that fully merge IPC into their hospital management agenda (De Bono et al., 2014). For example, a pilot study by Borg shows significant variations in organisational culture scores and correlation with the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) (Borg et al., 2015). To discover if specific organisational cultures influence IPC performance, studies providing statistical data on HCAI rates are required.
This review aims to identify ‘if’ and ‘how’ specific traits of organisational culture improve adherence to IPC strategies utilising HCAI rates as the viable marker of system failures or successes. Thematic analysis provides learning opportunities and identification of specific cultural elements that bring out the best in HCWs.
Methods
Critical literature review
This comprehensive and systematic review utilises the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement (Moher et al., 2009). PubMed, CINAHL, PsycINFO and the British Nursing index database were searched between January 2007 and June 2018 to identify relevant articles. Google Scholar, reference lists and the snowball effect discovered further eligible studies. Multiple search terms in various combinations applying Boolean operators were used while truncations addressed the possible differences in spelling.
Search terms included ‘organisational culture’, ‘organisational climate’, ‘safety culture’, ‘safety climate’; ‘healthcare associated infection’, ‘healthcare acquired infection’, ‘hospital associated infection’, ‘hospital acquired infection’, ‘nosocomial infection’; ‘catheter related infection’, ‘bloodstream infection’, ‘surgical site infection’ and ‘ventilator associated infection’.
We use the terms ‘climate’ and ‘culture’ interchangeably in the search for evidence as the complex, often contradictory and sometimes extensive debates about the precise nature of organisational culture were outside the scope of this review. Safety culture was regarded as a subset of organisational culture and part of the search terms. As the term ‘culture’ created a lot of incorrect hits on microbiological culture, searching for ‘culture’ as a search term on its own was excluded. Inclusion criteria were empirical, peer-reviewed articles with a quantitative, qualitative or mixed-method approach. Both quantitative and qualitative approaches were considered to enrich the accuracy and detail of the research and encourage new lines of thinking by providing different viewpoints (Reiter et al., 2010). Quantitative research was used to obtain breadth of understanding, while the qualitative research created depth of understanding. Studies advocating culture change as part of a care bundle approach were included, if data relating to the culture change were given separately. Exclusion criteria included non-English language publications or if data on the predefined outcomes (HCAI rates) were not present or incomplete. The search was not restricted to any specific infection, but a hospital setting was required. Patient and setting characteristics needed to be available to secure comparability. Although systematic reviews and meta-analysis are often seen as the ‘gold standard’ in research design (Sullivan, 2011), to allow for independent judging, they were part of the exclusion criteria. Narrative reviews, discussion papers, editorials and conference papers were excluded due to high chances for bias. Grey literature was excluded if not peer-reviewed. Studies that were unclear about conflicts of interest such as financial, personal, academic or political gain which could have influenced the research were also eliminated.
Titles, abstracts and sequentially full texts were screened to identify studies that met the eligibility criteria. Significant data from the included studies were extracted with the use of a standardised template. The CASP checklists were applied for appraising the quality of the studies as they provide a detailed understanding and assessment of the strengths and limitations of the studies (CASP, 2017). The COCHRANE tools assisted in determining the forms and risks of bias such as: selection bias; performance bias; detection bias; attrition bias; and reporting bias (Cochrane, 2017).
Following this process, themes were constructed from both the quantitative and qualitative data and described irrespective of study design or type of infection. The reviewer manual of Joanna Briggs institute and the ‘phases of thematic analysis’ acted as a guideline in this process (Braun and Clarke, 2006; JBI, 2014).
Results
Following removal of duplicates, the initial search identifies 1934 records with 1379 exclusions on title. Assessment of 555 abstracts for eligibility excludes 498. Fifty-seven potentially relevant studies underwent full-text screening, with 37 predominantly lacking information on HCAI rates (Figure 1). In total, the remaining 20 papers have empirical data, describe a link between cultural elements and HCAI, and satisfy the inclusion criteria (Table 1).
Figure 1.
PRISMA flow chart of study selection.
Table 1.
Summary of included studies.
Author /Journal | Study design | Study aims | Methods | Study setting/country | Outcomes |
---|---|---|---|---|---|
Pronovost, 2008, American Journal of Infection Control | A state-wide collaborative cohort study | Reducing CR-BSIs state-wide | The Keystone project; Implementing the CUSP | 108 ICUs; Michigan, USA 2006–2008 |
Improved unit culture and sustainable reduction of CR-BSI rates |
Jain et al., 2011, New England Journal of medicine | Longitudinal intervention study | Reducing HCA-MRSA rates | Implementing a MRSA bundle making use of the ‘Positive Deviance’ methodology | 150 nationwide Veterans Affairs hospitals;
USA 2007–2010 |
Improved organisational culture and decrease in HCA-MRSA |
Raveis et al., 2014, Qualitative Health Research | Multi-centre qualitative study | Examining the variations in IPC adherence to prevent HCAI | In-depth semi-structured interviews examining the organisational elements that can improve HCAI rate | 11 hospitals across the USA 2010–2011 |
The necessity of promoting an institutional culture to sustain IPC adherence |
Fedorowsky et al., 2015, American Journal of Infection Control | Cross-sectional study | Investigating the link of organisational culture variables and CRE acquisition rates | Questionnaire from Ohman-Strickland et al., correlated with CRE-rates | Two healthcare facilities in Israel 2013 |
The organisational culture variable of staff engagement can predict CRE rates |
Johnson et al., 2014, American Journal of Infection Control | Longitudinal intervention program; time series study | Reducing CR-BSI | Multifactorial quality improvement project | 570-bed academic health centre, > 50 clinics; Missouri,
USA 2006–2012 |
Improved organisational culture, increased HH, decreased CLABSI rates |
Weaver et al., 2014, American Journal of Infection Control | Secondary analysis of an intervention study | Examine the role of safety climate on patient safety outcomes | A pattern-based approach to investigate the relationship between ICU profiles and CLABSI rates | 237 adult ICUs; Baltimore, MD, USA 2009–2010 |
Relative CLABSI risk was related to safety climate profile shapes |
Palomar et al., 2013, Critical Care Medicine Journal | Prospective cohort study design; time series | Prevention of CR-BSIs | The Keystone project; Implementing the CUSP | 192 ICUs throughout Spain | Culture change and a significant reduction of CR-BSIs |
Fan et al., 2016, Journal of the American College of Surgeons | Cross-sectional study | Investigating the role of safety culture on surgical site infections after colon surgery | Combining surgical unit safety culture survey data with postoperative SSI data | 7 surgical units at Minnesota community hospitals;
USA 2012–2013 |
Safety culture is associated with the incidence of SSI after colon surgery |
Vigorito et al., 2011, Joint Commission Journal on Quality and Patient Safety | Longitudinal intervention study | Reducing CLABSI and VAP rates | Introducing a Safety Attitudes Questionnaire Action Plan | Rhode Island ICU Collaborative with 23 ICUs in 11 hospitals;
USA 2007–2010 |
Improvement in unit culture and reduction of HCAI |
Robbins and McAlearney, 2016, American Journal of Infection Control | Exploratory qualitative study | Examine if a stronger safety culture improves speaking up and prevents CLABSI | Interviews with participants of ‘On the CUSP-Stop BSI initiative’ | 6 hospitals and 158 key informants; Ohio, USA 2016 |
CLABSI outcomes are linked to safety culture |
Stone et al., 2007, Medical Care | Correlation study | Examine the effects of working conditions on safety outcomes in ICUs | Correlating data from the NNIS and Medicare with an organisational climate survey | 51 adult intensive care units in 31 hospitals; New York, USA 2007 |
Organisational climate effect was not consistent, but working conditions were associated with HCAI |
Latif et al., 2015, Infection Control & Hospital Epidemiology | Prospective cohort collaborative | Reducing CLABSI rates | Implementing the CUSP | 18 ICUs of the Abu Dhabi Health Services
Company 2012–2014 |
Improved safety culture and a reduction of CLABSI rates |
Borg et al., 2012, Journal of Hospital Infection | Correlation and multiple regression model | To investigate the impact of cultural dimensions on the epidemiology of MRSA in Europe | Correlation of median proportions of MRSA bacteraemia and national cultural dimension scores of Hofstede et al. | European countries participating in the EARS-Net surveillance
network; Malta 2010 |
Cultural dimensions impact on MRSA epidemiology |
Su, 2016, British Journal of Nursing | Quality improvements initiative | Reducing / prevent HAIs | Kotter’s eight-step change model | A surgical ward; Australia 6 months |
Improved workplace culture and a reduction of HCAI |
Miller et al., 2016, American Journal of Infection Control | Longitudinal intervention program | To reduce CLABSIs, CAUTIs and VAPs | Implementing the CUSP | 2 ICU with similar inpatient acuity; Delaware,
US 2009–2014 |
Improved safety culture, decreased CLABSI, CAUTI and VAP |
Escobar et al., 2017, Epidemiology and Infection | Time series analysis | Reducing HCAI rates | Using Positive Deviance methodology for MRSA control | 222-bed general hospital; Colombia 2006–2012 |
Culture change and a reduction in MRSA HCAIs |
Lin et al., 2018, Journal of the American College of Surgeons | Pre-post cohort study | Reducing SSI | Implementation of the CUSP | 15 hospitals across Hawaii 2013–2015 |
Improved patient safety culture and a decrease in colorectal SSI, but weak correlation between the two |
Meddings et al., 2017, BMJ Quality and Safety | Secondary analysis of 2 prospective cohort studies | Examining the effect of safety culture on CAUTI and CLABSI | Examining the association of HSOPS and catheter-associated infection rates | 1821 units from 1079 hospitals (CLABSI); 1576 units 949
hospitals (CAUTI); USA 2008–2011 and 2011–2013 |
No association between safety culture and catheter-associated infection rates |
Sood et al., 2017, Infection Control & Hospital Epidemiology | Observational interrupted time series; quasi-experimental | Reducing CLABSI in a regional burn ICU | An organisational-level and unit-level intervention utilising the CUSP | BICU serving 300–400 patients annually; Baltimore, MD, USA 2011–2016 |
Changed unit culture and sustained reduction in CLABSI |
Salge et al., 2017, Health Services Research | Longitudinal study based on trust-level panel data | Finding evidence on the factors associated with within-trust changes in MRSA infection over time | A balanced panel dataset, including data of PHE, the English Department of Health and the Healthcare Commission examined organisational factors associations with MRSA bloodstream infection prevalence | 173 acute trusts in English NHS; UK 2004–2009 |
A climate conducive to error reporting emerged as one of the factors closely associated with trust-level reductions in MRSA infections over time |
Most studies take place in high-income countries and 60% come from the US. Validated tools for culture measurement include the safety attitudes questionnaire (SAQ) and the hospital survey on patient safety (HSOPS), both employing the 5-point Likert-scale. There are a variety of study designs, yet no randomised controlled trials (RCT) were discovered. One quasi-experimental study reduces infection rates by addressing the cultural components of the organisation (Sood et al., 2017). Their multifaceted intervention results in a sustained reduction of central-line bloodstream infections (CLABSI) from 15 per 1000 central-line days to zero over three years (95% confidence interval [CI] = 8.54–22.48). The ‘Rhode Island ICU collaborative’ (Vigorito et al., 2011), demonstrates a fall of > 10% in CLABSI and ventilator-associated pneumonia (VAP) numbers after interventions deliberately targeting culture. Introduction and use of a safety attitude questionnaire action plan identifies measurable areas for improvement. This study unfolds to a quasi-experimental design due to development by only 39% units with the remainder units acting as a control group, which likely caused the results to be statistically insignificant.
The majority of studies are longitudinal cohort studies (45%) where researchers track HCWs and HCAIs after a cultural intervention. A hospital in Colombia reports significant reductions in their HCAI with the positive defiance approach (Escobar et al., 2017). This bottom-up approach achieves a culture change by putting forward HCWs who exhibit desired or noteworthy behaviour to enable them to discover better solutions to obstacles. A multicentre study of 153 Veterans Affairs hospitals using the same approach demonstrates a 62% (P < 0.001) decline in the ICU and a decrease of 45% (P < 0.001) outside the ICU of MRSA rates (Jain et al., 2011).
Su demonstrates a positive change in the workplace culture with significantly fewer HCAIs within six months by applying Kotter’s eight-step change model in a surgical ward in Australia (Su, 2016). This model believes that to successfully change HCWs’ behaviour is to connect with their emotions to help them see and feel, allowing them to change. A culture change with a top-down approach by Johnson et al. reduces their infections by directly confronting and holding all healthcare professionals accountable for inadequate IPC behaviour (Johnson et al., 2014).
A state-wide collaborative cohort study in Michigan introduces a comprehensive unit-based safety program (CUSP) and significantly decreases (57%) catheter-related bloodstream infection (CR-BSI) incidence rates after 16–18 months (Pronovost, 2008). The CUSP improves safety culture and engages HCW while learning from safety errors. The strategy involves outlining the evidence, recognising the local barriers, determining baseline performance and ensuring all patients receive the defined evidence using the 4E’s model (engage, educate, execute and evaluate). A large-scale implementation of the CUSP in Spain produces a similar significant reduction in CR-BSI (Palomar et al., 2013). Miller et al. report a fall in CLABSI rate as well as VAP and catheter-associated urinary tract infections (CAUTI) in two intensive care units (ICU) after launching the CUSP program (Miller et al., 2016). Success reducing HCAI with the CUSP model in 18 ICUs of seven hospitals in Abu Dhabi, known for their multicultural and multilingual setting, indicates the possible use in different socioeconomic contexts (Latif et al., 2015).
The correlational studies (35%) determine the link between two or more variables of culture and HCAI rates. One study links the high scores of the organisational culture variable of staff engagement with lower Carbapenem-resistant Enterobacteriaceae (CRE) acquisition rates (Fedorowsky et al., 2015). Another relates the variance in within-trust (NHS) MRSA infections over time to an organisational climate conducive to learning from errors, near misses, and incidents (Salge et al., 2017). Borg et al. report a significant association between countries’ median hospital MRSA quantities and several national cultural constructs (Uncertainty avoidance, Masculinity, Power Distance and Long-term orientation [LTO]) (Borg et al., 2012). Higher safety cultures in surgical units are correlated with reduced incidences of lower colon surgical site infection (SSI) (Fan et al., 2016). However, Lin et al. report an increase in safety culture and a decrease in their colorectal SSI after introducing the CUSP, yet correlation between the two is weak for most domains of safety culture in this study (Lin et al., 2018). Stone et al. show similar results when the links between organisational climate and HCAI vary in outcomes and is often not significant (Stone et al., 2007). Meddings et al. find no statistically significant association at all between safety culture and CLABSI or CAUTI measures at baseline or over time (Meddings et al., 2017). Weaver et al. explain in their research why studies examining cultural dimensions individually reveal a weak relationship with the HCAI in question. To prevent this, they apply a pattern-based theory of organisational culture and climate to examine the link with CLABSI rates in adult ICUs. After stratification for unit size and unit type, climate profile shape and non-punitive climate were significant predictors of infection (Weaver et al., 2014).
Although qualitative studies are often non-generalisable as they are context-specific, they may provide insights and interpretations (Aveyard, 2014). The inclusion criteria (statistics on HCAI rates) limit this review to only two qualitative studies. The qualitative studies describe the elements that support speaking up to foster a safety culture (Robbins and McAlearney, 2016) and the necessity of a systems approach to prevent HCAI at unit and organisation levels (Raveis et al., 2014).
Discussion
Of the 20 located studies, 90% produce supportive evidence for the hypothesis of a link between organisational culture and HCAI-rates. Although an encouraging result, the multiple methodological concerns including different forms of bias, confounding factors and the cohort designs lacking a control group reduce the evidence strength. Additionally, the before-and-after studies report great successes in reducing infection rates, but multifaceted approaches complicate how to disentangle which active component is causing the reduction in HCAI. The vast majority of the identified literature focuses on the US and other high-income countries. The lack of research in different socioeconomic and cultural environments makes findings difficult to generalise. Limitation on stratifications according to setting, size or (socio)-demographic characteristics increase confounding and the self-reporting evidence is high. We judge the evidence for the association between culture and HCAI weak to moderate in strength; nonetheless, the review provides a valuable summary on how hospital culture may augment or interfere with IPC efforts.
Analysing both quantitative and qualitative research reveals eight major themes (analytical summary of the major themes and representative phrases available in Table 2). Briefly, the themes indicate that hospital cultures with better HCAI rates foster safety culture, have a generative leadership style, embrace innovation, ensure interventions fit local context, accept LTO, engage and empower health professionals, promote collaboration and communication, and see the benefits of a non-punitive climate.
Table 2.
Major themes, representative phrases and how many papers contributed to each theme.
Major themes |
Representative/illustrative phrases |
---|---|
Leadership (n = 18) | • ‘Strong leadership is critical for success in any quality
improvement project’ (Vigorito et al.,
2011) • ‘This leadership model allows everyone to take ownership of both the problem and the solution’ (Escobar et al., 2017) • ‘Leaders followed through on their communication with consistent action’ (Robbins and McAlearney, 2016) • ‘Authentic engagement of a project team leader encourages staff participation’ (Su, 2016) • ‘Culture change, in large part, is attributed to formal and informal leadership’ (Miller et al., 2016) • ‘Leadership established and shared a commitment to a system level goal of “zero CLABSI”’ (Latif et al., 2015) • ‘Senior leaders celebrated successes with rewards and recognition when the unit reached milestones’ (Sood et al., 2017) |
Fostering safety culture (n = 16) | • ‘Safety cultures have been positively associated with higher
quality outcomes in healthcare organizations’ (Stone et al.,
2007) • ‘Foster alterations in practice so that IPC would become the responsibility of everyone involved in the care of patients’ (Jain et al., 2011) • ‘The Comprehensive Unit-Based Safety Program (CUSP) was designed to improve safety culture’ (Pronovost, 2008) • ‘Attention to patient safety and quality is making prevention of HCAI a global priority’ (Latif et al., 2015) • ‘Hospital leaders, managers, clinicians, and staff should work to foster a safety climate’ (Weaver et al., 2014) • ‘Safety culture is a possible driver of patient outcomes and can be appropriately measured to determine the efficacy of programs’ (Fan et al., 2016) |
Innovative culture (n = 12) | • ‘A team checkup tool was developed and pilot tested to help
senior leaders assess their role in ensuring compliance’ (Pronovost,
2008) • ‘The use of the safety attitude questionnaire action plan; a culture check-up tool, to structure group discussions and actions’ (Vigorito et al., 2011) • ‘The approach to achieve culture change was Positive Deviance’ (Jain et al., 2011) • ‘The CUSP was implemented to improve safety culture’ (Latif et al., 2015; Miller et al., 2016; Palomar et al., 2013; Pronovost, 2008) • ‘Measurable national traits can impact heavily on patient safety and quality of care initiatives’ (Borg et al., 2012) • ‘Implementation of the Kotter’s eight-step change model; this project proved that it is always possible to do better in improving healthcare quality’ (Su, 2016) • ‘The Hawaii collaborative also included an online learning platform’ (Lin et al., 2018) |
Transparent/non-punitive (n = 14) | • ‘Processes were implemented in such a way that they were
perceived as non-punitive and learning focused’ (Robbins and
McAlearney, 2016) • ‘Names and professions of the HCWs observed were recorded during observations, to allow for direct feedback’ (Johnson et al., 2014) • ‘A challenge to convince administrators for no-blame approach” (Borg et al., 2012) • ‘Reporting bias and underreporting of harm created a non-punitive, safety climate’ (Weaver et al., 2014) • ‘When surgical units are transparent and willing to discuss errors in order to prevent them from reoccurring, patient outcomes should improve’ (Fan et al., 2016) • ‘A climate in which staff members feel comfortable reporting, discussing, and learning from errors’ (Salge et al., 2017) • ‘Report transparently and create accountability’ (Sood et al., 2017) • “Staff are fearful of punitive repercussions if they “speak up”’ (Latif et al., 2015) • Teams were encouraged to investigate all SSIs to identify opportunities to improve (Lin et al., 2018) |
Fitting local context (n = 11) | • ‘Crucial that interventions transposed from a different
background are adopted to the local culture’ (Borg et al.,
2012) • ‘Identify opportunities to help tailor the intervention to local needs, resources, and existing culture’ (Latif et al., 2015) • ‘The potential benefit to patients when a homegrown quality improvement initiative is developed’ (Fan et al., 2016) • ‘The necessary modifications of the intervention, due to cultural and organizational factors’ (Palomar et al., 2013) • ‘Interventions must be modified to fit the local context of a clinical area’ (Pronovost, 2008) • ‘The coordinator dealt with local challenges’ (Jain et al., 2011) • ‘Through creative innovation, we were able to develop strategies unique to this patient population’ (Sood et al., 2017) |
Engaging/empowering (n = 18) | • ‘Empowerment can be used to enable personnel to act for the
collective good where power differential might hamper their
behaviour’ (Raveis et al., 2014) • ‘High scores on the organizational culture variable of staff engagement can predict lower CRE acquisition rates’ (Fedorowsky et al., 2015) • ‘Engage staff to identify defects’ and ‘allowing staff to contribute to effective problem solving’ (Miller et al., 2016) • ‘It helped create a sense of community among like-minded folks’ (Lin et al., 2018) • ‘Increased engagement in the decisions and actions that involved or affected them’ (Escobar et al., 2017) • ‘To see staff empowered to make positive changes while taking ownership of proposed changes’ (Su, 2016) • ‘Engage front line clinicians and connect them in peer learning communities’ (Sood et al., 2017) • ‘Engagement was sought through regular and structured awareness raising and problem-solving meetings’ (Palomar et al., 2013) • ‘Physicians and nursing champions showing leadership skills and strong commitment ensured engagement of the ICU-teams’ (Latif et al., 2015) |
Collaboration/Communication (n = 17) | • ‘The problem is regarded as a hospital-wide issue, rather than
one in which the individual HCW can make a direct impact’ (Borg et al.
2012) • ‘Collaborative rounding between physicians and nurses increased cohesiveness between professionals’ (Robbins and McAlearney, 2016) • ‘The importance of interdisciplinary care in prevention of CLBSI and/or other non-measured factors’ (Stone et al., 2007) • ‘The inclusive and collaborative approach could reduce resistance and increase capacity to change’ (Su, 2016) • ‘Bringing various stakeholders to the same table allowed everyone to share their concerns and ensure their voices were heard’ (Latif et al., 2015) • ‘Identify ways to communicate the importance of expected HH practices to patients and their families’ (Johnson et al., 2014) • ‘If you don’t attack it with a team approach, multidisciplinary approach, you’re not going to be able to attack it’ (Raveis et al., 2014) • ‘Declare and communicate a goal of zero infections’ (Sood et al., 2017) |
Long-term orientation (n = 10) | • ‘This program can significantly reduce the global morbidity,
mortality and excess costs associated with CLABSI’ (Latif et al.,
2015) • ‘Eliminating these infections throughout the US will prevent 30,000–60,000 deaths and $2 to $3 billion annually’ (Pronovost, 2008) • ‘Although we did not make a formal cost-benefit assessment, others have reported their cost-effectiveness’ (Jain et al., 2011) • ‘Infection control programmes may need considerable investment over several years before showing reductions in infection rates’ (Borg, 2014b) • ‘In the present era of budget and economic constraints, the repercussion of this strategy to reduce CRBSI in ICU patients is very relevant’ (Palomar et al., 2013) • ‘50 fewer infections per year translates into a $2.26 million annual reduction in health care expenditures related to treatment of CLABSIs’ (Johnson et al., 2014) • ‘Infections are costly in terms of lives lost, patient morbidity and financial burden on the healthcare system’ (Lin et al., 2018) |
Reviewing the identified themes in light of other research
Safety culture
Reports link safety culture to positive patient outcomes and include reduced mortality, length of stay, falls and improved patient satisfaction ( Braithwaite et al., 2017; Huang et al., 2010), establishing that measuring safety culture provides actionable components for risk management. Cultural assessment of different units can create a spirit of competition (internal benchmarking) or allows measurement of divergence between hospitals, health systems or even other industries (external benchmarking) (Ettorchi-Tardy et al., 2012). The research within this review confirms that measuring is important, for example, the association of poor safety culture to increased SSIs (Fan et al., 2016). Measuring safety culture also allows for the creation of interventions addressing the weaker elements of the culture (Vigorito et al., 2011). However, the ideal instrument for cultural exploration may not exist (Jung et al., 2009), a possible explanation of the weak, inconsistent and/or lack of association in three studies (Lin et al., 2018; Meddings et al., 2017; Stone et al., 2007). The complex elements of safety culture are difficult to encapsulate in a survey and HCWs’ responses in a safety survey might be quite different from beliefs and practice (De Bono et al., 2014).
Innovation
Standards and values for better quality, productivity and efficiency within an organisation often determine the extent to which a facility is willing to innovate (Weiner, 2009). The papers include various innovative interventions to improve organisational culture, with the CUSP the best known and established. However, Positive Deviance, Kotter’s eight steps and other comprehensive action plans all improve organisational culture and reduce HCAI rates. The different methodologies, numerous study settings and a variety of unique interventions targeting organisational culture imply that success may be more dependent on the facility rather than the intervention.
Interventions fitting local context
The research advocates an initial assessment of the facility to establish opportunities to modify an intervention to fit the local context, resources and existing culture (Latif et al., 2015; Palomar et al., 2013; Pronovost, 2008). Naturally, strategies are more likely to be successful and sustainable when implemented in a compatible cultural background (Borg, 2014a). IPC interventions sometimes clash with HCWs’ widely held beliefs, former training or threaten professional autonomy and authority (Raveis et al., 2014). These require understanding and implementation of distinct approaches and management strategies. The literature within this review promotes stepping away from the ‘command and control’ mentality and using frontline staff for ideas and expertise, i.e. a bottom-up approach with top-down support beneficial for IPC initiatives. However, the creation of proactive instead of reactive responses to this concept may be easier said than done. Soh et al. report that the social and cognitive divisions between various professions might retard spread of innovation in multi-professional healthcare facilities. They also argue that hierarchical relationships and non-disclosure might inhibit quality improvement initiatives (Soh et al., 2013). The possible local social–cultural barriers with measurable national traits require investigation to allow for a better choice in the most appropriate IPC interventions (Borg et al., 2012).
Leadership
Hospital leadership has an unmistakable and powerful part in shaping the organisational culture in this review. Generative leadership climate appears to offer the most positive and balanced climate shape (Weaver et al., 2014), with inspiring leaders that strengthen and support patient safety as the greatest organisational priority. Research shows that formal and informal leaders can hold a powerful role as they can trigger, emphasise and reinforce patient safety and invigorate the culture change (Miller et al., 2016; Weaver et al., 2014). Leaders that provide a clear, well-thought out vision not only provide guidance, but also inspire nurses and bring a sense of purpose to their work (Larson et al., 2007). Good communication with staff and following through on promises builds trust in leaders (Jacobs et al., 2013). Birk claims that 75–80% of interventions requiring behaviour change fall short due to lack of engagement and active involvement of leaders. Managers, physicians and senior leaders who do not value the culture of safety in their hospitals results in complacency of other HCWs, who then may view safety as ‘the flavour of the month’ (Birk, 2015). A possible challenge in healthcare is the tension between professional versus corporate leadership and alignment of what is needed, important, beneficial or worthwhile (Weiner, 2009). Management techniques may need to differ between the transactional approach (getting daily tasks done) and the transformational (setting challenging new directions) determined by local performance, capabilities and priorities.
Collaboration and communication
We identify collaborative rounding between nurses and physicians to elevate cohesiveness between healthcare professionals and foster open communication about possible barriers and solutions to prevent future infections (Robbins and McAlearney, 2016). However, productive interdisciplinary collaboration and communication between different healthcare professionals can be a challenge in countries with high power distance scores (Borg et al., 2012). Hierarchy and tradition can restrain communication and limit effective team building (Sacks et al., 2015). Ineffective communication is frequently the root of medical error, with reports that 36.4% of communication failures effect system processes such as efficiency, teamwork, resources, patient care and procedural mistakes (Lingard et al., 2004). Education in communication skills may improve the quality, the level and the technique of communication, helping harmonious working between different disciplines. For example, the TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) framework is an intervention with reports enhancing team performance (Thomas and Galla, 2013).
Transparent and non-punitive reporting cultures
Reasons for HCWs’ reluctance to report non-compliance include fear of vengeance, shame associated with ‘blowing the whistle’ or repercussions of challenging a professional higher in hierarchy (Chassin and Loeb, 2013). In this review, research indicates that error reporting is a learning opportunity and anonymous reporting systems are helpful to encourage transparency, allowing for non-disclosure of HCW feeling fearful of punitive repercussions (Robbins and McAlearney, 2016). The report by Weaver et al. of a 77% increase in infection incidence rate in units with a non-punitive climate shape seems counter-intuitive but is possibly due to willingness to identify IPC dangers and documenting HCAI occurrences more accurately (Weaver et al., 2014). To step away from blame gives an organisation the chance to learn from their mistakes and use this knowledge to manage improvement efforts resulting in positive outcome for patients (Kaplan et al., 2013). Nevertheless, accountability is essential for reckless behaviour or individuals disregarding IPC policies and procedures (Birk, 2015; Johnson et al., 2014). Clear hospital-wide IPC policies with support by hospital administration in implementation may benefit from a confidential reporting system for non-compliant or disruptive behaviour (ACOG, 2017). Governmental, legal and medical facilities can work together to stop the culture of blame while retaining accountability and exchange the blame-shame structure with a prevention and education structure (Rodziewics and Hipskind, 2018). Promoting reports on how frequently things go right and develop ways to support, augment and encourage these features can help to take away the negative sentiment of reporting (Braithwaite et al., 2015).
Engaging and empowering
Education is the first step to engage HCWs in preventing patient harm and understanding the importance of a safety culture. Physician and nursing champions who exhibit leadership and strong dedication to IPC practices can engage HCWs in guideline uptake and use (Latif et al., 2015). These champions or role models can come in the form of hospital administrators, IPC professionals, team leaders or regular frontline staff. Engaging chief executive officers through feedback is beneficial as it reveals the need for resources and possible IPC barriers that HCWs encounter. Without feedback on IPC initiatives, management can be overly optimistic about the impact (Pronovost, 2008). Supportive senior leaders and hospital administration can empower HCWs to address non-compliant behaviour of professionals higher in hierarchy. This generates and promotes the sense of group accountability and ownership (Raveis et al., 2014).
Long-term orientation
LTO is a cultural dimension describing an organisation’s focus on future rewards (eminently saving), persistence and adaptability to changing situations. In other words, the focus includes long-term targets rather than only the short-term and instant consequences (Hofstede, 2001). Actively decreasing HCAIs needs substantial investments before producing financial incentives (Borg, 2014b). Although formal cost–benefit assessment of IPC initiatives is not provided, some authors advocate that programs actively reducing HCAIs will be cost-effective (Borg et al., 2012; Jain et al., 2011; Latif et al., 2015). Besides the financial benefits, constructing an effective safety culture will accommodate a reduction in length of stay and morbidity and mortality (Vigorito et al., 2011). Eliminating CR-BSI across the USA is estimated to prevent 30,000–60,000 deaths and save $2 to $3 billion annually (Pronovost, 2008).
Summary
The themes reveal that hospitals are complex, multi-layered social systems and leaving cultural growth to chance or allowing for weak or toxic cultures can impede on our IPC strategies. Successful organisational cultures are achieved through a chain of events, but this review indicates a bottom-up approach with top-down guidance and good teamwork and open communication to be constructive in reducing HCAIs. For IPC interventions to be effective in healthcare facilities worldwide acknowledgement of sociocultural factors is essential with interventions adapted to the local culture.
This review outlines eight organisational themes that can build a culture that supports—and drives— IPC-improvement efforts. The themes are interconnected and complementary to each other, so maximum effect requires a united approach such as specified in Figure 2. This organisational culture model can be a supportive tool for IPC by tackling the adaptive challenges or guide future research. While some might argue that culture change is extremely difficult and cultures cannot be shaped, this literature review shows that culture can be improved by mindful attempts for the benefit of both patients and HCW.
Figure 2.
Beneficial organisational culture for IPC efforts.
Study limitations
While utilising well-recognised systematic review methods, the search terms may not fully represent organisational culture, resulting in the unintentional exclusion of appropriate studies. As peer-reviewed journals often do not accept failed interventions there is publication bias. The improvements in culture, HCAI rates and IPC performance may also simply be an artefact of other changes to patient care. A strong limitation is the lack of randomised designs or control groups in the research and the use of outcome data that is often self-reported. Social pressure to improve could have biased several of the observations and measurements, rather than actual changes in practice taking place.
Conclusion
This study examines whether an organisational culture influences HCAI rates continues to interest HCWs and researchers. This review presents a summary that suggests a positive association between culture and HCAI but is not conclusive due to limited solid evidence. While scrupulous appraisals of scientific evidence using standardised criteria is extremely important, this practice unfortunately regularly results in a shortage of guidance around prevailing and imperative HCAI prevention issues (Septimus et al., 2014). Therefore, although the literature did not provide strong evidence, it did offer valuable insights and provides guidance for IPC-improvement efforts. The review promotes utilising culture to accelerate IPC efforts and reduce the HCAI rates. Changing culture in hospitals is demanding and requires positive actions of hospital leaders welcoming the challenges, work with rather than against performance inconsistencies and take more advantage of what we already have: a great deal of accomplishments in healthcare where things go right. The chain for the suggested organisational culture maybe overly optimistic and presumes that common cultures are possible and desirable. Still, not utilising the findings due to lacking evidence strength can be challenged on the fact that the potential benefits outweigh the potential risks to patient safety.
Supplemental Material
Supplemental material, Supplementary_table_A for Does a hospital culture influence adherence to infection prevention and control and rates of healthcare associated infection? A literature review by Adriana van Buijtene and Dona Foster in Journal of Infection Prevention
Acknowledgments
This review was revised from a dissertation which was undertaken for a Master in Infection Prevention and Control by AB at Oxford Brookes University, UK.
Footnotes
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Adriana van Buijtene
https://orcid.org/0000-0002-1885-8502
Peer review statement: Not commissioned; blind peer-reviewed.
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Supplementary Materials
Supplemental material, Supplementary_table_A for Does a hospital culture influence adherence to infection prevention and control and rates of healthcare associated infection? A literature review by Adriana van Buijtene and Dona Foster in Journal of Infection Prevention