Individual, social, and environmental factors for infection risk among home healthcare patients: A multi-method study

Abstract

There has been limited research into the individual, social, and environmental factors for infection risk among patients in the home healthcare (HHC) setting, where the infection is a leading cause of hospitalisation. The aims of this study were to (1) explore nurse perceptions of individual, social, and environmental factors for infection risk among HHC patients; and (2) identify the frequency of environmental barriers to infection prevention and control in HHC. Data were collected in 2017–2018 and included qualitative interviews with HHC nurses (n = 50) and structured observations of nurse visits to patients’ homes (n = 400). Thematic analyses of interviews with nurses suggested they perceived infection risk among patients as being influenced by knowledge of and attitudes towards infection prevention and engagement in hygiene practices, receipt of support from informal caregivers and nurse interventions aimed at cultivating infection control knowledge and practices, and the home environment. Statistical analyses of observation checklists revealed nurses encountered an average of 1.7 environmental barriers upon each home visit. Frequent environmental barriers observed during visits to HHC patients included clutter (39.5%), poor lighting (38.8%), dirtiness (28.5%), and pets (17.2%). Additional research is needed to clarify inter-relationships among these factors and identify strategies for addressing each as part of a comprehensive infection control program in HHC.

1 |. INTRODUCTION

The ageing of the population, coupled with an increasing prevalence of chronic conditions among older adults and healthcare shifting towards home-based care delivery, have all contributed to rapid growth of home healthcare (HHC) services in the U.S. (Landers et al., 2016; Sisko et al., 2019). Roughly 3.4 million U.S. Medicare beneficiaries received HHC in 2018 (MedPAC, 2020). Quality oversight groups, including the U.S. Centres for Medicare and Medicaid Services, have focused on infections and required HHC agencies to maintain and document an infection control program as a condition of their participation (CMS, 2018). Reported rates of infections that developed in patients while receiving HHC have ranged from 5.1% to 11.5% (Shang et al., 2014). Infections are a leading cause of hospitalisation among HHC patients and have been attributed to as much as 17% of unplanned hospitalisations (Shang et al., 2015).

Existing literature suggests that four types of factors shape infection risk among HHC patients; these include biomedical, individual beliefs and behaviours, social, and environmental factors. At least three previous studies have outlined biomedical factors that are linked with a higher risk of infection among HHC patients. First, a study of HHC patients in the U.S. found that older age, previous hospitalisations, fragile health condition, and limitations in ambulation were each independently associated with hospitalisation or emergency care for infection of respiratory systems, urinary tract, or wounds (Shang et al., 2020). This study also found that HHC patients assessed as needing assistance in specific situations with cognitive tasks had an increased risk of hospitalisation due to urinary tract infection compared to patients assessed as being alert (Shang, Wang, et al., 2020). Nurses interviewed as part of a second study in the U.S. suggested that patients with a higher risk of infection included those with diabetes, antibiotic prescriptions, dehydration or inadequate nutrition, and portals of entry such as intravenous lines or Foley catheters (Dowding et al., 2020). A history of prior infections was also found to be associated with the development of infection among district nursing patients in the United Kingdom (Thomas et al., 2007).

In addition to the biomedical factors mentioned above, research suggests that individual beliefs and behaviours, social and environmental factors also contribute to infection risk among HHC patients. In qualitative interviews, nurses asked about key issues related to the assessment of infection risk in the HHC setting regarded patient knowledge and understanding of their illness, infection prevention behaviours, and hygiene practices as being closely linked to their risk of infection (Dowding et al., 2020). This is consistent with findings in hospital-based settings indicating that the beliefs and attitudes of patients may play an important role in shaping health behaviours that can prevent infection transmission, such as hand hygiene and influenza vaccination (Alabbad et al., 2018; Khuan et al., 2018). In addition, informal caregivers and nurses also represent important social resources in the prevention and control of infections among HHC patients (Council, 2011). HHC patients rely extensively on informal caregivers for assistance with physical functioning (Chase et al., 2019). Informal caregivers often perform hands-on, complex medical and nursing tasks for older adults with chronic health needs including wound care, symptom monitoring, and incontinence management (Reinhard, 2019). Likewise, nurses in community settings can also help prevent infections through infection control practices, such as performing hand hygiene and using sterile equipment, and educating patients and informal caregivers on these practices (Higginson, 2017). Finally, environmental factors have been highlighted in previous research as contributing to patient infection risk, including the role of environmental contamination (Knox et al., 2016). The environment in which HHC is delivered is both dynamic and unpredictable and can present barriers to infection prevention and control such as clutter, uncleanliness, and infestations which can hinder nurses in caring for patients by increasing their stress and difficulty in completing tasks without feeling rushed or distracted (Markkanen et al., 2017; Sitzman & Leiss, 2009). Findings from HHC workers suggest that they may encounter a range of safety hazards and unsanitary conditions in the homes of patients that may inhibit their adherence to infection prevention and control practices (Adams et al., 2020; Gershon et al., 2008). While this previous research provides a strong rationale for considering biomedical, individual beliefs and behaviours, social, and environmental factors as potential sources of infection risk among HHC patients, to our knowledge no studies have described in empirical detail the range and content of these factors.

One framework for examining the range of factors underlying infection risk among HHC patients includes the ‘Health Field Concept,’ which envisages that a person’s health is related to their biology, lifestyle, environment, and healthcare organisation (Laframboise, 1973; Lalonde, 1974). We adapted this framework for the present study to conceptualise infection risk among HHC patients as being shaped by biomedical aspects of human systems and medical treatments, individual beliefs and behaviours, social and healthcare support from caregivers and nursing personnel, and environmental hazards and contaminants (Figure 1). Using qualitative interviews with HHC nurses and structured observations of their visits to patients, the present study aimed to fill this gap by: (1) exploring nurse perceptions of individual, social, and environmental factors for infection risk among patients; and (2) identifying the frequency of environmental barriers to infection prevention and control in patients’ homes.

FIGURE 1.

Conceptual model adapted from the health field concept

2 |. METHODS

2.1 |. Study design and sampling

Data for this study were collected as part of a larger program that focused on infection prevention and control in the HHC setting. This program included the development and validation of a predictive model for infection risk among HHC patients, surveys and observations to assess HHC nurses’ knowledge, attitudes, and practices towards infection prevention and control, and qualitative interviews to understand how HHC nurses identify patients at risk of infection and perceive the barriers and facilitators to infection prevention and control within the HHC setting (Dowding et al., 2020; McDonald, 2020; Russell et al., 2018; Shang, Russell, et al., 2020).

The setting for this research included a large not-for-profit certified HHC agency located in New York. This HHC agency employs 1,520 nurses and provides more than 1 million HHC visits each year to over 100,000 patients across New York City. Fifty nurses employed by the HHC agency were recruited to the study through a combination of purposive, convenience and snowball sampling methods. Recruitment strategies included sharing information about the study at staff meetings and handing out flyers, posting flyers in supply rooms and other offices where nurses gathered, and emailing all nurses employed at the agency to share information about the study and encourage them to contact the research team if they wanted to volunteer their participation (Dowding et al., 2020). Purposive sampling methods, such as targeted recruitment through regional managers, were also used to ensure adequate representation of nurses with a range of work experience and who cared for patients living in different areas of the city. Nurses who participated in the study were also asked to refer a colleague, whom our research team would then contact via telephone to further explain the study and what was involved. All nurses providing direct patient care at the agency were eligible to participate, including both registered nurses and licensed practical nurses who worked full-time, part-time, or per diem. Additional inclusion criteria were that the nurse agreed to be observed and interviewed.

The two primary sources of data for the present study included qualitative interviews with nurses and structured observations of their visits to patients’ homes. All data were collected from December 2017 to September 2018. All participating nurses received a $100 gift card. A researcher obtained the informed written consent of each nurse prior to their participation for both the qualitative interview and observation of home visits. Nurses were told that their participation in the study was voluntary and that they could stop or withdraw at any time. All study procedures were approved by the Institutional Review Boards at the HHC agency (IRB#E16-005) and Columbia University (IRB#AAAQ9226).

2.2 |. Structured observations of the patient home environment during nurse visits

Each of the 50 nurses was observed as they visited the homes of eight different regularly scheduled patients (i.e. patients whom the nurse had planned to visit during their shift irrespective of the study protocol) by one of two research fellows employed on the study. The research interviewers had graduate-level training in qualitative methods and had no established relationships with the nurse participants prior to the study. Nurses did not take the research fellows into homes where patients could not assent to observation, either because of severe cognitive impairment or a language barrier in the absence of a caregiver/translator. An eight-item home environment checklist was developed based on a review of four previously published research articles describing home environment conditions that could reasonably be expected to hinder the HHC nurse’s ability to adhere to infection prevention and control practices (Markkanen et al., 2007; Polivka et al., 2015; Sitzman & Leiss, 2009; Wills et al., 2016). The research fellows used this checklist to indicate the presence (=1) or absence (=0) of the following environmental factors observed during the home visit: clutter, poor lighting, dirty environment, pets, poor patient hygiene, infestations, unruly children, no running water. An additional (ninth) category was used to indicate the presence of ‘other’ environmental factors that were not listed on the home environment checklist but could potentially present barriers to infection prevention and control. The research fellows recorded notes during their observations to describe these ‘other’ environmental factors.

2.3 |. Qualitative interviews with nurses

A single qualitative interview was conducted with each nurse by the research fellow after completing all eight of their structured observations and establishing some rapport. Most nurses were interviewed by phone (n = 47), with the remainder interviewed in-person (n = 3). Each nurse completed a demographic questionnaire prior to the interview that included their age, sex, race/ethnicity, education, agency position (i.e. full-time, part-time or per-diem), and HHC experience (in years). A semi-structured interview guide was used to elicit a response about how nurses evaluate patients for their risk for developing infections, modifications they make to the plan of care and their own infection prevention and control behaviours based on their patients’ risk for infection, knowledge of agency policies and procedures, training and education, and barriers and facilitators to infection prevention and control in the home environment. All interviews were audio-recorded and transcribed verbatim.

2.4 |. Data analysis

Transcripts from qualitative interviews were imported into NVivo Version 11 for analysis (QSR International Pty Ltd., 2020). Draft thematic coding schemas were independently developed by three authors with training and experience in qualitative methods using the qualitative interview guides and three interview transcripts. These coding schemas were synthesised into a single schema and applied to three new transcripts. Interrater reliability was calculated to confirm coding agreement (κ = 0.57; 95.9% agreement). All areas of disagreement identified from this analysis were discussed by the researchers and the coding scheme was modified to reflect the consensus reached from that discussion. A final coding schema was agreed upon and applied to all 50 transcripts in rounds of 10. Each of the transcripts was double-coded, with one coder applying the schema to all 50 transcripts and the other two coders applying the schema to 25 transcripts each. The coders held regular meetings to discuss their analysis and resolve differences. Key themes were synthesised from the coded excerpts regarding nurse perspectives on individual, social and environmental factors for infection risk among HHC patients. Unique identification [ID] numbers were used to distinguish between illustrative quotes from individual nurse respondents.

R Statistical Software (https://www.r-project.org/) was used to calculate descriptive statistics, including frequencies, percentages, means, medians, interquartile ranges and standard deviations, for nurse demographic characteristics and home environment barriers (R Core Team, 2021).

3 |. FINDINGS

3.1 |. Demographic characteristics of nurse participants

Nurses ranged in age from 25 to 69 years (Mean = 47.4, SD = 10.6; Table 1). Nurses were mostly female (90%). The sample was racially/ethnically diverse and included representation among African American (44%), Asian (18%), or Hispanic (10%) nurses. Most nurses held either a Bachelor’s (66%) or Master’s degree (12%). Median nursing and home care experience were 18 years (range = 1.5–44 years) and 13.5 years (range = 0.25×26 years), respectively. Nurses served patients across New York City, including Manhattan (26%), Brooklyn (26%), Queens (24%), Bronx (14%) and Staten Island (10%).

TABLE 1.

Demographic characteristics of nurse participants

	Count (%)	Mean (SD)
Total respondents	50 (100.0)
Age		47.4 (10.6)
25–34 years	8 (16.0)
35–44 years	10 (20.0)
45–54 years	17 (34.0)
55–64 years	13 (26.0)
65+ years	2 (4.0)
Gender
Female	45 (90.0)
Male	5 (10.0)
Race/Ethnicity
Black Non-Hispanic	22 (44.0)
White Non-Hispanic	13 (26.0)
Asian	9 (18.0)
Hispanic	5 (10.0)
Other	1 (2.0)
Education/Qualification level
Master’s Degree in Nursing	6 (12.0)
Bachelor’s Degree in Nursing	33 (66.0)
Associates Degree in Nursing	7 (14.0)
Licensed Practical/Vocational Nurse (LPN/LVN)	4 (8.0)
Years of nursing experience		19.3 (11.7)
Years of home care nursing experience		12.9 (7.9)
Position at home care agency
Full-time nurse	44 (88.0)
Per-diem (part-time) nurse	6 (12.0)
Region of home care service
Manhattan	13 (26.0)
Brooklyn	13 (26.0)
Queens	12 (24.0)
Bronx	7 (14.0)
Staten Island	5 (10.0)

3.2 |. Themes from qualitative interviews with nurses and environmental factors observed during home visits

Three themes related to nurses’ perceptions of individual, social and environmental factors for infection risk among HHC patients were identified from qualitative interviews. These included: (1) individual beliefs and behaviours - patient knowledge, attitudes and practices toward infection control, (2) social and healthcare support - the role of nurses and caregivers in cultivating infection control practices and (3) environmental factors - home environment barriers to infection control. Themes are described below with supporting quotations. We also highlight the frequency of environmental barriers to infection prevention and control recorded during structured observations of nurses’ home visits to patients and describe those findings alongside the theme for environmental factors.

3.2.1 |. Individual beliefs and behaviours: Patient knowledge, attitudes and practices toward infection control

Nurses perceived a higher risk of infection among patients who lacked knowledge about hygiene and care practices and/or who had unfavourable attitudes toward infection prevention and control: Some of them just don’t have the want or care to even, basically, take forward the actions needed to prevent infections within their homes [ID310]. Practices that nurses viewed as placing patients at greater risk of infection included gaps in wound care (If they have a wound, not covering it up. [ID202]), a lack of cleanliness or cautiousness (They’re not being clean. They’re not being cautious [ID207]), or unresponsiveness to changes in their health condition (Patients don’t go to the doctor in time when they start developing a wound [ID219]). Patients who refused the influenza vaccination were also seen by nurses as having a higher risk of infection:

There are [patients] who tell you point blank, ‘I don’t take [the] flu shot. I don’t like it.’…They are at risk for infection from their comorbid conditions, their environment, and also their vaccination, if it’s up to date, or whether if they don’t take it.

[ID300].

Nurses communicated that patient infection risk could be reduced through greater knowledge of infection risks and infection control practices, including being knowledgeable about hand hygiene [ID310], favourable attitudes that included holding infection prevention and control to a high standard [ID200], and compliance with practices such as handwashing, safe sharps usage, vaccination, wound care, general hygiene and prompt response to the signs and symptoms of infection.

Social and healthcare support: The role of nurses and caregivers in infection control practices

Nurses described their efforts to cultivate knowledge, attitudes and practices among patients by engaging them repetitively with educational interventions: Teaching. Lots of teaching and lots of repetition. [ID210]. Nurses provided instruction to patients about when they should engage in handwashing, take a bath or shower, clean their household, or clear areas of their home where nursing tasks are performed. Nurses modelled these behaviours themselves by washing their hands in front of patients to demonstrate adherence. Nurses took note of the attitudes that patients displayed towards their educational interventions, including those directed at wound management, diabetes care and personal hygiene - strategies that were highlighted by nurses as important for preventing infections. These attitudes included the nurse’s own evaluation of the patient’s willingness to change and improve [ID650], as well as whether patients were perceived as receptive or they demonstrated that they’re good learners, and they will follow your instructions [ID207]. They contrasted these productive encounters with others in which information communicated to patients about infection risks and prevention was going in one ear, then going out the other [ID320]. Nurses felt that these educational efforts were less effective among patients with cognitive, psychiatric and/or behavioural conditions.

Nurses also noted that it was important to find a caregiver who’s available and willing to learn [ID209]. One nurse noted how If they have a caretaker and this person knows what they’re doing, then they’re fine. The risk of infection is down to nothing practically [ID370]. Informal support from family caregivers and more formal assistance from privately hired and/or agency-assigned aides were instrumental in maintaining a clean household and performing essential infection control tasks such as changing wound dressings for patients with pressure ulcers or diapers for patients with incontinence. Caregivers were also relied on by nurses to pick up their cues [ID214], checking in with patients and noticing they exhibit the signs and symptoms of infection. Nurses worked at getting caregivers involved [ID217] by educating them about their role in preventing the spread of infection, especially among patients who were viewed as being more vulnerable (If it’s someone who is on chemo or something [ID300]), advising them to wear gloves, masks and minimising physical contact. However, some informal caregivers were perceived by nurses to also be unreceptive to their educational interventions. One nurse described:

Teaching family members how to be careful, how to take— I had one time…I was getting to the door opening, and I see the man taking off [the patient’s] dressing. He said, ‘Oh, I didn’t know you were coming.’ The leg is exposed. He’s got these three little kids running around between— they looked like they were 3, 2, and 1, and he had a baby in a baby carrier. Didn’t have any gloves on, and it just was like— it was a horrible beginning, to say the least. And so, when I kind of tried to discuss it with him, he got a little offensive with me.

[ID730].

Environmental factors: The home environment and barriers to infection prevention and control

Nurses described a wide range of environmental factors encountered during home visits and frequently underscored the importance of the home environment in shaping HHC patients’ risk of infection. The spectrum of home environments encountered by nurses during their day-to-day work was wide and ranged from large and opulent homes to much smaller and dilapidated tenement apartments with shared washrooms and toileting areas. The environment was immediately noticeable to nurses upon entering the patient’s home. Indeed, one nurse we interviewed stated that the environment is the first thing you look at [ID207]. The general cleanliness and tidiness of patients’ homes was evaluated by nurses as part of their routine assessment upon each home visit. Nurses also noted to themselves how supplies, including for wound care and other nursing/medical tasks, were stored in the home. Nurses felt that the cleanliness of the home environment contributed to keeping wounds clean to promote healing, while uncleanliness was perceived as increasing the patient’s risk for developing a wound infection.

Nurses identified a range of environmental factors within patients’ homes that they viewed as increasing their risk of infection and presenting barriers to infection prevention and control. These factors included dirt and filth, mould, smoke, poor air circulation, clutter and garbage strewn on the floor such as exposed needles and soiled diapers, pet and rodent droppings, cockroaches, flies, bed bugs and other infestations. Many of these environmental factors were recorded during the structured observations of nurse visits to patients’ homes (Table 2). Five of the most frequent environmental barriers encountered during home visits included clutter (observed during 39.5% of home visits), poor lighting (38.8%), dirtiness (28.5%), pets (17.2%) and poor patient hygiene (12.8%). More than a quarter of observations (26.3%) revealed other environmental barriers that were not listed on our checklist, including extreme temperature (8.3%), smoking (3.5%) and mould (2.5%). An average of 1.7 (SD = 1.6) environmental barriers were documented in homes visited across the 400 observations. Two or more environmental barriers were observed in nearly half of the homes visited (47.2%), while fewer than one-third of homes had no environmental barriers (29.5%).

TABLE 2.

Home environment barriers identified during observations of home visits

	Count(%)	Mean (SD)
Total number of observations	400 (100)
Home environment barrier
Clutter	158 (39.5)
Poor lighting	155 (38.8)
Dirty environment	114 (28.5)
Pets	69 (17.2)
Poor patient hygiene	51 (12.8)
Infestations	20 (5.0)
Unruly children	4 (1.0)
No running water	2(0.5)
Other environmental barrier	105 (26.3)
Total number of home environmental barriers		1.7 (1.6)
0 home environmental barriers	118 (29.5)
1 home environmental barrier	93 (23.2)
2 home environmental barriers	80 (20.0)
3 home environmental barriers	52 (13.0)
4 home environmental barriers	34 (8.5)
5 or more home environmental barriersa	23 (5.8)

^aRange of Home Environmental Barriers was 0–7.

Nurses spoke about how they adapt [ID217] their infection prevention and control behaviours to perceived barriers within the patient’s home environment (I have had to conform to whatever environment that I have to work in [ID221]). Nurses noted that some rooms and areas in patients’ homes were places that you don’t even want to go into [ID204] because they were perceived as being unsanitary. In some cases, environmental conditions led nurses to adapt their hand hygiene practices based on the availability of supplies, including using hand sanitiser in place of washing their hands when soap and/or running water were unavailable (I had a patient this morning who— the building’s undergoing construction and there’s no water, so I couldn’t wash my hands [ID310]), leaving their nursing bag outside the home or keeping it zipped [ID217] when taking it inside the home. Illustrative of this point, nurses noted that some patients don’t have a sink [ID310] and sometimes you can’t even wash your hands because the sink is piled high with dishes and fruit flies [ID205]. One nurse described:

I’m not going into a bathroom that’s teeming with roaches because [the agency] insists I wash my hands. I’m slopping some hand sanitizer on my hands and as long as I don’t have nothing on them, we’re good to go

[ID370].

Nurses often contrasted their experiences providing home care to that in the hospital (in the hospital you know that you’re in a controlled setting [ID310]). Nurses generally perceived having limited control over the patient’s home environment (I have no control over the home environment [ID216]). However, nurses noted that in more extreme cases they initiated a referral to a social worker to assess the environment or directly reported poor environmental conditions and patient hygiene to government agencies. Nurses noted that this was important because the conditions inside a patient’s home may not be visible to neighbours and others (The house outside can look very nice but it’s cluttered with all the old stuff magazines and all the other stuff, like roaches sometimes and stuff. [ID219]). Nurses expressed that some patients lived alone and/or lacked caregiving support and that this presents a barrier to personal and environmental hygiene:

The patient has no supportive services in the home, so they have nobody to help them clean

[ID215].

Older patients who lived alone were viewed by nurses as facing greater difficulty with maintaining a clean home and engaging in personal hygiene practices such as hand washing:

Well, like I said, it’s the hand washing. It’s the clutter. Some patients have a lot of clutter, which— and they’re elderly. And they don’t have time to dust, and clean, and throw out the garbage, and all that because they are elderly and they live alone

[ID219].

Decisions by nurses to initiate referrals to a social worker were often made based upon perceived threats to patient safety and allowed them to remove patients from unsafe situations or address issues within the home environment to improve conditions to the extent that would allow them to remain home. One nurse described an unsafe home environment that led them to initiate a referral to a social worker:

If she stayed home and the house was clean and sanitary and we kept her on as the patient, then everything would have been fine. But to try to keep her on the caseload and service her under those conditions, like she had everything that was going to cause her to have an infection, which I’m quite sure when she was sent out. When I sent her out, she did have several infections because the wounds were open and they were soiled. It was dirty, had feces, had urine, and the husband couldn’t tell me how long she’s been lying like that

[ID690].

Nurses associated socioeconomic disadvantages with the patient’s risk of exposure to contaminants and other barriers in the home environment. Nurses described patients who lived in impoverished neighbourhoods whose homes lacked running water or who did not have enough money to purchase basic hygiene or other needed supplies (some patients don’t even have money to buy soap, believe it or not [ID310]), as having an especially high risk of infection.

4 |. DISCUSSION

Nurses described in qualitative interviews a range of individual beliefs and behaviours, social and environmental factors for infection risk among HHC patients. Consistent with the conceptual model that was developed for the present study and adapted from the ‘Health Field Concept,’ nurses viewed infection risk among HHC patients as being shaped by multiple categories of factors. Individual knowledge, attitudes and practices of patients, including adherence to hand hygiene and influenza vaccination, were seen by nurses as preventing infections. Social factors, including educational interventions by nurses and support from caregivers who were knowledgeable about infection risks and prevention strategies, were also viewed by nurses as being instrumental in reducing infections among patients. Finally, nurses detailed how factors in the home environment of patients such as contaminants like smoke or mould, and barriers to infection control such as clutter and poor lighting, impacted their ability to adhere to infection prevention and control practices. Observations conducted during home visits with nurses confirmed the presence of many environmental factors spoken about during interviews. One or more environmental factors that could impinge on infection control were observed in more than 70% of homes visited in this study.

Our study findings detail the range of individual beliefs and behaviours, social and environmental factors for infection risk among HHC patients, clarify and delineate their respective content, and expand upon previous research that has mainly focused on biomedical factors for infection risk within this population and care setting. While these findings from qualitative interviews with nurses help to describe the types of individual knowledge, attitudes and practices of HHC patients they see as playing an important role in the development of infections, their relative prevalence and contributions to infection risk among patients remain understudied. The descriptions of factors obtained from this study could be used to inform the development of a future survey to more directly examine the individual knowledge, attitudes and practices of HHC patients towards infection, and explore inter-relationships with characteristics of the social and environmental context. Indeed, nurses pointed to the presence of knowledgeable and engaged family caregivers as an important social factor for reducing infection risk among HHC patients. However, many family caregivers do not fully understand their patient’s condition and may need frequent guidance and attention from HHC nurses to keep informed about diagnoses and treatments, as well as to fully assist with what is often an increased set of care responsibilities in the home (vs. hospital) setting (Knudsen et al., 2018). Thus, any comprehensive infection control program developed for the HHC setting will need to include educational resources and supports for nurses to support family caregivers.

Our findings point at several recommendations for policies and interventions aimed at preventing infections among HHC patients. First, interventions will need to systematically address individual, social and environmental factors. These may include educational interventions among patients, caregivers and nurses to increase their knowledge of infection risks and improve adherence to practices that prevent the development of infections or control their transmission once they are present. Nurses should assess patients and caregivers for their knowledge and competence in performing infection prevention and control measures on an ongoing basis, to ensure that they understand the importance of infection prevention as well as strategies to perform care activities safely (McGoldrick, 2008). Providing professional training to nurses and other HHC staff on hand hygiene practices may represent a promising opportunity for intervention. Findings from one study revealed that HHC nurses were adherent to hand hygiene in less than half of all opportunities observed during visits to patients (McDonald, 2020). Interventions are also needed to reduce contaminants present within the home environment and remove barriers to infection prevention and control practices. One potential approach for improving environmental conditions in HHC could include training nurses and other care staff to identify common household conditions that compromise patient safety. These environmental factors, including those which increase infection risk among HHC patients, can be identified using multi-hazard checklists administered during home visits to patients (Gershon et al., 2012). Reducing environment barriers encountered by nurses may help to significantly increase adherence to infection prevention and control practices (Adams et al., 2020).

There were limitations to our study that may affect the conclusions drawn from our results. First, our findings drew on interviews and observations from a single HHC agency located in an urban area of the north-eastern U.S. Factors for infection risk identified by nurses in our study may differ from those discovered in other areas, such as rural locations where HHC patients face greater obstacles to accessing healthcare and community services due to workforce issues and financial limitations faced by rural agencies (Skillman et al., 2016). Second, while our inclusion criteria allowed for home visit observations of patients with cognitive impairment who could provide informed assent, those who were severely impaired were excluded from the study. This represents an important omission considering that cognitive impairment is associated with risk of chronic infection (Katan et al., 2013). Therefore, our findings may not be fully representative of the environmental barriers present within the HHC context (i.e. home environment barriers may be more prevalent among patients with severe cognitive impairment). Alternative methods for recruiting patients with severe cognitive impairment, including community outreach and partnerships, may help to address this limitation (Grill & Galvin, 2014). Third, our research relied solely on nurses and trained observers to gather data on factors for infection risk in the HHC setting. This approach minimises the collective voices of patients, family members and formal caregivers, who may also have insights into the factors that shape infection risk within the HHC setting. Additional research in which HHC patients and caregivers are interviewed about the facilitators and barriers to infection prevention and control within the home environment could provide valuable data for the development of interventions aimed at preventing infections and associated healthcare outcomes.

What is known about this topic?

• Infections are a leading cause of hospitalisation among home healthcare (HHC) patients.

• Several biomedical factors have been found to contribute to infection risk among HHC patients, including chronic health conditions, wounds, and history of infection.

• Contamination in the home environment has been highlighted as a risk factor in infection.

What this paper adds

• Nurses viewed infection risk among HHC patients as shaped by multiple factors, including individual beliefs and behaviours, social and healthcare support, and the home environment.

• Patients were seen as having a reduced risk of infection when they were knowledgeable about hygiene practices and placed infection control as a high priority.

• Home healthcare nurses frequently encounter barriers to infection prevention and control in the home environment.