All healthcare organisations should adopt a single standardised approach to aseptic non-touch technique (ANTT) (Box 1) and review their policies, procedures, training and audit of practice in relation to aseptic technique (Public Health Wales, 2017). In 2015, the Welsh Government invested in a quality assured clinical practice framework in relation to ANTT with the aim of reducing inappropriate variation (Rowley and Clare, 2011a). All healthcare organisations were to adopt a single standardised approach to ANTT and review their policies, procedures, training and audit of practice in relation to aseptic technique (Public Health Wales, 2017). The Association of Safe Aseptic Practice pledged to work in partnership with healthcare organisations to significantly reduce healthcare-associated infections through standardising aseptic technique (Rowley and Clare, 2011b).
In order to discover whether healthcare workers are implementing the principles of ANTT within their daily practice, a focused ethnographic study was carried out in one institution within a paediatric setting.
Staff training commenced in April 2016. At the time of the study, all registered nurses had received the training. This involved an e-learning package and attendance at a study day in the local NHS health board. The study day included an ANTT presentation, knowledge assessment and simulated intravenous administration competency assessment involving standard ANTT using a direct observation of practice assessment pro forma. No additional equipment was required.
Methodology and methods
Aims
The aim of the study was to gain insight into the challenges faced by clinical staff within NHS child health services when adopting practices in relation to ANTT and intravenous therapy.
Research design
The use of qualitative research enables the identification of behavioural and cultural patterns regarding attitudes about infection prevention control practices (Shah et al, 2015). According to Burns and Grove (2011), qualitative research is a systematic subjective approach involving perceptual awareness to describe phenomena and interpret meaning. This research method is well suited to study human experience of health care as it aims to draw conclusions generated by the individuals living the experience (LoBiondo Wood and Haber (2006).
Ethnography, meaning ‘portrait of people’ was originally developed by anthropologists as a qualitative social research method to study cultures where the researcher is immersed in the culture (LoBiondo-Wood and Haber, 2006). Ethnography is perceived as both method and methodology—the process does not involve one particular means of data collection, but is a style of research enabling understanding of social meanings and activities of people in a specific area. The approach involves close association with and often participation in the setting (Brewer, 2000). The researcher (RI) is employed as a practice development nurse within the child health department of a Welsh NHS university health board trust. She was actively involved in ANTT training within the department and so acted as a participant observer as part of her researcher role.
Focused ethnography enables the researcher to apply ethnographic methods to a distinct issue or shared experience within cultural settings (Cruz and Higginbottom, 2013). Ethnographic workplace analysis allows for the possibility of full immersion through being a member of the workforce and personally sharing the experiences felt by colleagues (Tope et al, 2005). Therefore, in order to understand whether healthcare workers are implementing the principles of ANTT in their daily practice ethnography has the potential to explore current practice through immersion within the clinical environment.
Sampling
A convenience sample of 23 registered nurses who had received ANTT training in intravenous therapy were recruited to the study to be observed in practice. A purposive, stratified sample of six participants was selected for interview, comprising a ward manager, junior ward sister, three experienced registered nurses and one newly trained nurse in intravenous therapy. The sample inclusion criteria were registered nurses who were involved with intravenous therapy and who had received ANTT training and had undergone a direct observation of practical skill (DOPS) competency assessment. The exclusion criterion was staff who had not received ANTT training.
Data collection
Data collection included participant observation field notes, the ANTT audit questionnaire and semi-structured interviews. Data collection took place over 7.5 hours, working alongside clinical staff during their normal working time, taking field notes through participant observation for a period of six clinical shifts over 1 month. Following this period, the stratified purposive sample of six participants were invited to attend semi-structured interviews.
The study setting included both a medical and a surgical ward in the paediatric department on a single hospital site within the university health board trust. During field visits, reflective thoughts and observations were documented within the field notes. In addition, the ANTT audit questionnaire (the DOPS proforma) was used to observe practical skills directly. Semi-structured interviews were undertaken in an office within close proximity to the clinical environment. The six selected participants received a letter inviting them to attend an interview at a negotiated time convenient to them. Interviews lasted no longer than 20 minutes and were audio recorded and transcribed by the researcher.
Ethical considerations
Ethical approval was granted from the Swansea University ethics committee and the relevant NHS research and development ethics committee in October 2016, subsequently followed by ethical approval from the local university health board research and development department. The Director of Nursing Services and Director of Medical Services for the university health board granted permission to approach potential recruits for this study and approved access to two paediatric wards.
Data analysis
Processing the qualitative data was undertaken using the method adopted by Bryman (2015). The data were read case by case, and major themes were identified, including unusual issues and group cases. The data were then read again, the text was marked, and key words were highlighted. The text was coded, and theoretical ideas were then related to the text in order to interpret, interconnect, identify significance and relate the interpretation to the research question.
Brewer (2000) identified two steps for ethnographic coding; index coding and open coding. Table 1 represents codes as ‘descriptors’ identified from significant words or phrases transcribed in the field notes. An extract from the field notes was reviewed by an academic supervisor to help reduce the risk of researcher bias.
| Category | Descriptors |
|---|---|
| 1. Ward acuity |
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| 2. Position of researcher |
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| 3. Competent |
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| 4. Knowledge or skill deficit |
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| 5. Reaction to change |
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| 6. Challenges |
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| 7. Expectations |
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Coding of semi-structured interviews
The interviews were transcribed by the researcher and analysed using qualitative content analysis. To aid objectivity, a sample of the transcript was reviewed by the academic supervisor. During this process new descriptive codes and categories were developed.
Data were further analysed according to Wolcott's (1994) qualitative analysis process and emerging themes were reflected upon against the theoretical framework of Kirkpatrick's (1994) model of training evaluation, which adopts the characteristics of midrange theory and distinguishes four outcome levels:
Results
The following typologies were identified:
Further themes were derived from the interview data:
The findings from data analysis were reviewed against Kirkpatrick's (1994) evaluation theoretical framework for further confirmation and validation.
Level 1: reaction
This level acknowledges the effectiveness of training. When staff were asked what they thought of the way the ANTT training had been delivered, there was a positive response:
‘I think it was very good. It was informative and displayed appropriately. Yourself and your colleague have gone to the ward and introduced it. This was audited and assessed and it was done in a much-organised manner. I think overall it was very good and, obviously, we had the e-learning to do as well, ideally prior to attending the study day. It was very organised.’
An innovation is more likely to be accepted if is promoted by someone who shares a similar character and language with the target audience (Dulcan, 2005). Successful training should build upon learners' past experiences and connect learning to clinical practice (Knowles et al, 1998).
Level 2: learning
This level seeks to determine whether knowledge transfer, skill development/modification and attitudes were changed. Following data analysis, typologies were subsequently identified as: lack of knowledge, confused terminology, knowledge without skill and knowledge with skill.
Lack of knowledge
A lack of practitioner knowledge and understanding of key principles was observed.
Observed deviation from the taught technique identified unnecessary use of a sterile field, use of both sterile and non-sterile gloves and a potential failure to protect key parts of equipment. During one preparation phase the researcher was confident there had been no risk of contamination; however, in order to reach the patient the nurse being observed had to leave the treatment room and negotiate a corridor. The researcher therefore chose to intervene as key parts of the syringes were exposed. The researcher informed the nurse that she would need to protect the key parts before we could leave the treatment room. The nurse appeared to understand the reason why the researcher had intervened (Nurse R7, Ward A, extract from field visit 3).
Confused terminology
Despite undergoing training, some staff still appeared confused regarding the concept of asepsis. During observation, the researcher asked nurses what, in their view, was the aim of the technique. One said:
‘To be as close to clean and sterile as possible.’
Knowledge without skill
According to Harrison (2005), learning is a social process, influenced by everyday experiences, where a shift of control of learning to the learner develops. During field visits, the researcher became aware that although staff had received training some did not have the confidence or experience to practise the technique.
One nurse was asked her experience of using a standard ANTT with a central line:
‘To be honest, I haven't had much chance to practise the new technique as I haven't been on duty when I've needed to use it. I suppose it's like anything else, you just have to get used to it, although it's difficult, as I've been doing it another way for 10 years.’
If individuals do not value the content and are unable to apply it to the workplace, it is unlikely learning will be transferred successfully (Knowles et al, 1998).
Knowledge with skill
During field visits, 10 out of 12 staff directly observed administering intravenous therapy displayed the ability to perform to a specific standard in the clinical environment with appropriate knowledge, skill, behaviour and attitude (Franklin and Melville, 2015).
During a ward-based discussion with an experienced band 5 staff nurse, the researcher was informed:
‘Before I transferred to this ward I hadn't had much experience with central lines and I asked staff to show me how to use them until I was competent and felt safe, as I would never do anything I didn't feel safe to do. I have been shown a variety of ways until it was clarified exactly which way you do it. I am now confident with the technique.’
Jenner et al (2002) suggested that knowledge is achievable through training provision; however, that does not guarantee sustained behaviour change. Effective clinical practice is the result of a combination of knowledge, skills and attitude (Cooper, 2007). Throughout the field visits and interviews, it was evident that confusion existed regarding the terminology ‘aseptic’, ‘sterile’ and ‘clean’. The evaluation of learning provided examples of lack of knowledge, knowledge without skill, and knowledge and skill acquisition.
Level 3: behaviour
Behaviour can be defined as the extent to which change in behaviour has occurred as a result of receiving training (Kirkpatrick, 1994). Throughout the field visits, the researcher noticed there was a variance in the way staff performed ANTT. Although it is acknowledged that staff maintained asepsis while adapting ANTT, the researcher became aware that varying techniques can be confusing for teaching others such as parents and students. According to Ward (2013), the understanding of the reasons behind a particular behaviour is a key factor in promoting this behaviour. Interviewing participants provided an opportunity to explore this issue further:
‘I think it would be great if we could all do it the same way, especially now that we have the bigger blue trays. I notice more people are doing it the same way now. However, I think that it can be difficult to change practice when this is the way you have been doing ANTT throughout your career. I think as long as practice is safe and all key parts are protected then there is always going to be slight variation.’
Level 4: results
It was noted that, rather than fully employing standard ANTT, staff were adapting it by using a trolley rather than the blue tray provided to undertake intravenous therapy. Some nurses unnecessarily placed a sterile field on the trolley, while others managed the equipment in their packets or with caps on, either directly on the trolley or on a blue tray.
One of the principles of ANTT is to allow the nurse to risk assess how to achieve asepsis rather than dictate how clinical procedures should be performed (Rowley and Clare, 2011a). The researcher observed significant variation in the way that staff approached the technique with central lines. Risk assessments are subjective due to the principles of ANTT that permit the nurse to decide how they can manage the technique and minimise risk of contamination and introducing infection. This raises the question of whether this is better for the patient or whether clinical procedures should be standardised. One nurse commented:
‘I think, reflecting on my practice, the technique has changed based on what a certain area or ward sister likes to use. Things have come in and out of fashion and there have been different ways of doing it. Therefore, I think it would be a positive thing if we all sing from the same hymn book and use the same technique. As a mentor, I'm going to be teaching nurses of the future, and, if I teach them the way I used to before, they are going to get quite confused. It is better to have the one practice, and I would like all my students to learn the same way so that they are not confused.’
The principles of ANTT allow the healthcare worker to rationalise their behaviour based on the number and size of key parts.
Discussion
Challenges experienced by nurses with the introduction of ANTT
Iedema et al (2015) suggested that people are able to learn from scrutinising their own behaviour and habitual way of doing things. During participant observation, staff were asked whether they had experienced any challenges adopting ANTT. Some commented on the reaction of doctors; for example:
‘Medical staff have raised concerns about the technique. Parents are also taught a different way. I have seen people doing different versions of ANTT.’
De Bono et al (2014) stated that medical professionals often prefer to adhere to known practices rather than explore innovative methods. Significantly, although the paediatric consultant expressed concerns, he accepted the change of practice from a traditional aseptic technique to ANTT. Nurses voiced concerns regarding lack of clarity and standardisation of using ANTT. For example, one said:
‘I have observed some people doing a mix of the old [and new] technique. They still like to use sterile gloves and a sterile field but then manage the parts in their individual packets. Surely we should all be doing it the same way?’
McAteer et al (2014) suggested that implementation of interventions to change healthcare practice may be influenced by attributes of the intervention (e.g. the clarity of instructions for delivery) and psychological factors such as motivation and preference. This attitude was witnessed in both the study ward settings, but appeared prevalent in one ward more than the other due to a variance in the way staff chose to administer parenteral nutrition.
ANTT and application of Kirkpatrick's (1994) model of evaluation
Tarrant et al's (2016) ethnographic study suggests that when implementing staff training there is a need to go beyond focusing on individual behaviour change and to include an assessment of barriers and challenges to the implementation. The ANTT training provided was evaluated positively by the nurses and the researcher assumed that learning would follow, leading to positive organisational results (Reio et al, 2017). However, in order for learning to take place it requires a combination of attitude, knowledge and skill development.
This study found evidence of insufficient knowledge, and that staff were confused about clinical terminology and lacked the necessary skill to implement ANTT due to lack of confidence and lack of sufficient opportunities to practise. Staff who demonstrated competence with ANTT technique also acknowledged their difficulties ‘getting to grips’ with the technique, with some initially preferring to revert to the previous aseptic technique used.
Organisational cultural challenges
It is acknowledged that within the organisation a range of supra- and sub-cultures exist that influence and affect individual behaviour (Karahanna et al, 2005). According to Public Health Wales (2017), executive leadership is required to support the implementation of ANTT. Commitment requires a robust training and assessment programme, equipment and resources, raising the profile of ANTT and ensuring auditing and robust monitoring systems are in place. Across the organisation, there have been failures with engagement of other health professional groups including medical and allied health professionals.
In order to empower staff to provide high-quality care, it is essential to commit to a teaching and learning ethic, through the means of routine practice and innovation (Dixon-Woods et al, 2014). A culture change requires all those involved with the health service to open their minds and change their behaviours (Clark and Nath, 2014). However, achieving high levels of engagement is only realistic within positive cultures, where staff feel valued and where relationships are effective between managers, staff teams and departments (Dixon-Woods et al, 2014). The key to improving infection prevention control behaviour is motivation, education and system change—all of which are potentially influenced by cultural elements (Borg, 2014).
Conclusion
Limitations of the study
During the research period, which took place over 4 weeks in May 2017, the level of ward activity was comparatively lower than during typical winter months, leading to limited opportunities to observe nurses undertaking intravenous therapy. The follow-up interviews took place in June 2017. A longitudinal study, including night shifts and weekend working, might have provided additional insight. The researcher acknowledged that an outsider occasionally participating in a culture does not have the opportunity to systematically cultivate the collection of all kinds of information at all levels (Wilson, 1977) and future studies should take this into account.
Omitting patients and parents in the research process led to the exclusion of potentially valuable information and additional viewpoints. The value of patient and service user involvement has been acknowledged by National Institute of Health and Care Excellence (NICE), which suggested that involving patients and service users helps to focus on the humanity of the topic and orientation of patient experience, (NICE, 2013).
The disadvantages of participant observation are noted as the ‘Hawthorne’ effect. This effect threatens the validity of research as people may perform differently as a direct result of being observed, such as behaving in a way they believe is expected of them (Feist and Gorman, 2012). However, Cargan (2007) suggests that such altered behaviour is usually temporary and routine behaviour soon returns. Similarly, the interviewer effect can result in respondents failing to admit something or express an opinion, depending on their thoughts regarding the interviewer (Brewer, 2000).
Implications of this study
Changing behaviour and cultural norms at multiple levels of the organisation are key challenges of infection control practice (Pittet, 2004). The findings suggest that, in order to drive change, leadership is required at all levels of the NHS organisation, and this leadership should espouse the highest levels of knowledge, understanding and clinical evidence in practice. At the core of the organisation are its values, beliefs and rituals (De Bono et al, 2014) and some of these were evident here. The study identified the challenges faced by members of the organisation following the introduction of a mandatory training intervention, some of which were mediated through cultural understanding. Organisational culture is a significant modifier of healthcare worker behaviour, and therefore acknowledging organisational culture should influence infection and prevention control performance significantly (Borg et al, 2015). Future studies should focus on managing the culture change required to address habitual behaviours and any reasons for deviation from standard/best practice.
Modification of infection prevention practices are vital to improve patient care (Pittet, 2004). However it unusual for a single profession to deliver a complete episode of care in isolation (Reeves et al, 2010). Senior medical staff and ward managers are highly influential and maintain an important influence on organisational culture and barriers to improvement (Cooper, 2007). Significant factors to improve infection prevention control behaviour are effective education, motivation and system change (Borg, 2014). Edberg (2010) suggested that resources and opportunity are likely to dictate behavioural achievement.
The findings demonstrate that prior to introducing change, all levels of staff should be consulted and all staff should be trained. Evaluation of practice should take place regularly to address consistency and quality of care.
Relevance of findings to further research
Few studies have undertaken focused ethnography in the form of embedded research to study ANTT implementation in clinical practice. The data enabled evaluation on the effects of practice change, as perceived and experienced by the clinical staff concerned. This was a small-scale study; further studies should incorporate staff from different professions, service users and additional departments outside the specialty of child health across multiple sites in Wales.