REVISIONES

 

A challenge to professionals in infection control: nurse's lack of compliance with prevention and control measures

Um desafio para o controlador de infecção: falta de adesão da enfermagem às medidas de prevenção e controle

Un desafío para el controlador de la infección: falta de adhesión de la enfermería a las medidas de prevención y control

 

 

Ferreira Fernandes da Silva, Elisabete^*; Marinho Chrizostimo, Miriam^**; Lopes de Azevedo, Suely^**; Ferreira de Souza, Deise^**; de Souza Braga, André Luiz^** e Lima, Jorge Luiz^**

^*Enfermeira. Especializanda do Curso de Especialização em Controle de Infecção em Assistência a Saúde. E mail: elisabeteffsilva@hotmail.com
^**Enfermeiro. Mestre da Escola de Enfermagem Aurora de Afonso Costa/UFF. Docentes do Curso de Especialização em Controle de Infecção em Assistência a Saúde. Universidade Federal Fluminense (UFF). Brasil.

 

 

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ABSTRACT

Despite the knowledge on the nosocomial infection control and, mainly, on the prevention and control of general measures related to health assistance, a low adhesion of the nursing professionals to the preventive measures is frequently verified. This study was realized in 2012 and has as objectives: to understand the non-adhesion of the nursing professionals to the infection control and prevention measures; to identify the scientific works that discuss the reasons and, analyze the reasons of the nursing compliance to adhesion to the infection prevention and control measures.
The methodology utilized was the integrative revision, with qualitative approach. The categorization occurred through the theoretical Alfred Schutz. Sixteen articles from the databases of the Biblioteca Virtual em Saúde had been selected. The articles revision evidenced that the permanent education with the critical-reflexive pedagogy utilization favors the transformation of the being as professional in the environment in health, stimulating it to reflect and modify its actuation in the assistance to the patient, with the aim at disrupt the chain of nosocomial infection transmission.

Key words: Nosocomial infection prevention measures; Nursing; Permanent education in infection control; Adhesion.

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RESUMEN

A pesar del conocimiento sobre el concepto de infección hospitalaria y, en especial, de las medidas generales de prevención y control de las infecciones relacionadas con el cuidado de la salud, lo que ocurre a menudo, es la baja adhesión de los profesionales de enfermería a las medidas preventivas. Este estudio se llevó a cabo en 2012 y tiene como objetivos: comprender el incumplimiento por parte de los profesionales de enfermería de ls medidas de prevención y control de la infección; identificar los trabajos científicos que estudian estas causas y analizar la resistencia de la enfermería a la adhesión a las medidas de prevención y control de la infección.
La metodología se basó en una revisión integradora, con enfoque cualitativo. La clasificación se realizó con base en el teórico Alfred Schutz. Se seleccionaron 16 artículos en las bases de datos de la Biblioteca Virtual em Saúde. La revisión mostró que la educación permanente con el uso de la pedagogía crítica-reflexiva favorece la transformación del ser como profesional de la salud, estimulándolo a reflexionar y modificar su actuación en la atención al paciente, con el fin de romper la cadena de transmisión de la infección nosocomial.

Palabras clave: Medidas de prevención de infección hospitalaria; enfermería; Educación continuada em control de infección; adhesión.

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RESUMO

Apesar do conhecimento acerca do conceito de infecção hospitalar e, principalmente das medidas gerais de prevenção e controle das infecções relacionadas à assistência à saúde, o que freqüentemente se verifica, é a baixa adesão dos profissionais da enfermagem às medidas preventivas. Este estudo foi realizado em 2012 e tem como objetivos: compreender a não adesão dos profissionais de enfermagem às medidas de prevenção e controle de infecção; identificar as obras científicas que discutem os motivos e, analisar as razões da resistência da enfermagem a adesão às medidas de prevenção e controle de infecção.
A metodologia utilizada foi à revisão integrativa, com abordagem qualitativa. A categorização se deu através do teórico Alfred Schutz. Foram selecionados 16 artigos nas bases de dados da Biblioteca Virtual em Saúde. A revisão dos artigos evidenciou que a educação permanente com a utilização da pedagogia crítica-reflexiva favorece a transformação do ser como profissional no ambiente em saúde, estimulando-o a refletir e modificar a sua atuação na assistência ao paciente, com a finalidade de interromper a cadeia de transmissão de infecção hospitalar.

Palavras-chave: Medidas de prevenção de infecção hospitalar; enfermagem; Educação permanente em controle de infecção; adesão.

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Introduction

The assistance pattern of attention to health proposes to use standard operating procedures (POP) by the health professionals. However, over the professional practice, work processes that do not meet to proposal are identified, that makes the establishment of efficient and effective measures difficult for infection prevention and control.

In the work processes analysis with reading of scientific productions, it observes that three factors are necessary so that the infections transmission in the hospital environment can occur: patients, employees, visitants, inanimate objects, surfaces and equipments. The susceptible host is the patient, that has factors that makes it vulnerable to the microorganisms, mainly the immunossupressants like the newborns; patients in chemotherapy or bearers of immunodeficiencies. ⁽¹⁾

The microorganisms are transmitted through contact with droppings, airway, through a common vehicle or through vectors, thus, based on modes of agents transmission, specific precautions measures occur, that aims to reduce the risk of infectious diseases and standard precaution that aims to reduce the microorganisms transmission from known or not infection sources, must be used in all the patients. ⁽¹⁾

In case of the work process, it considers that the mode of the agents transmission occurs, mainly, through the health team, however, in this study the subject of this research is the nursing team that consists of nurse, technique and assistant.

The interruption of the transmission chain can occur by measures which have proven to be effective like the hands hygiene, articles and surfaces processing, use of individual equipments protection (EPI), in case of laboral risk and antiseptics measures. ⁽²⁾

Despite the knowledge on the nosocomial infection concept, its origins, factors related and mainly general infection prevention and control measures related to the health assistance, which frequently is verified, is the low adhesion of the nursing professionals to the preventive measures. ⁽³⁾

The adhesion means consent, approval and participation of an idea. Keeping adequate professional attitude with technical stimulus and knowledge means adhere to the infection prevention and control.

However, the behavior found among the professionals is different from the adhesion, despite the permanent education. The permanent education aims to the services restructuring, with transformation of the professional in subject, placing it in the centre of the learning-apprenticeship process. ⁽⁴⁾

This situation determined the choice of this thematic with the restlessness to describe why the non-adhesion of the nursing professionals to the infection control and prevention measures, through integrative research. Thus, the study object is the non-adhesion of the nursing professionals to the infection prevention and control, although it is aware of the existence of the adhesion to the prevention and control measures in the different settings of the assistance in health.

Thus, the question: which is the contribution of the scientific productions in the nursing area that make possible the understanding of the non-adhesion of the professionals to the infection prevention and control measures? The orienting questions are: Which are the nursing scientific productions that make possible the understanding of the non-adhesion of the professionals to the infection prevention and control measures? And, how the scientific productions in the nursing area contribute to the understanding of the non-adhesion of the professionals to the infection prevention and control measures?

It identifies that the objectives are: to understand the non-adhesion of the nursing professionals to the infection prevention and control measures through scientific productions; to identify the scientific productions that discuss the non-adhesion of the nursing professionals to the infection prevention and control measures; to discuss the reasons of nursing team compliance to adhesion to the prevention and control measures; and, to analyze the reasons of the nursing compliance to adhesion to the infection prevention and control measures.

Thus, the research justification is centered in the infection prevention and control assistance daily, in which the nursing team is inserted. As, the lack of adhesion to these measures needs the nurse manager's understanding of infection for effective and efficient intervention together with this team.

Therefore, the research relevance translates the human nature understanding, through scientific publications, with the identification of the reasons of the nursing team' s non-adhesion and analysis of the compliance reasons. Thus, it is the right strategy of approach and involvement of these professionals, with consequent, prevention and control measures implementation, such as: adequate professionals' hands hygiene, use of aseptic techniques before invasive procedures, precautions measures, among others.

The change of attitude allows the infection indexes reduction that is the aim of all Control Committee for Hospital Infection (CCIH). Thus, the client has a reduced hospital stay, costs are reduced and a high-quality pattern institution is guaranteed.

 

Methodology

The present work uses as research method, the integrative revision, with qualitative approach. The integrative revision that aims to analyze relevant researches, with the collection and synthesis of published studies synthesis. This process expands the knowledge about any theme and subsidies the health evidences incorporation. It allows, then, the improvement of the clinical practice and can identify the need of new studies. ⁽⁵⁾

The way to elaborate the integrative review begins with the choice of the specific objective, by the reviewer. That is, questions that still remain to be answered or hypothesis to be tested. The next step consists of the search to identify and collect as much as possible about relevant researches, in the inclusion and exclusion criteria, previously defined. ⁽⁶⁾ The inclusion criteria for the articles selection were: abstracts of the articles in Portuguese without repetition, published in the last 20 years, product in which it aimed to meet the research object and the descriptors combination.

The search for the literature review was done through the Virtual Health Library (BVS). It was used a combination among the following descriptors: "Prevention Measures of nosocomial infection", "Nursing", "Permanent education in "infection" and "Adhesion".

Through this research, the study sought to promote a discussion about the adhesion, to the preventive and infection control measures. The categorization occurred through Alfred Schütz' s theory.

Alfred Schütz, philosopher and sociologist. He was born in Vienna, Austria in 1899 and died in New York in 1959. Scholar of Law and Social Sciences. His first work was published in 1932. He emigrated to Paris in 1938. In 1939 he moved to the EUA, where published thirty-two titles. He dedicated to the social phenomenology. He studied the understanding sociology, the significant construction of the social world.

Schütz sought to establish the bases of a phenomenological sociology, a synthesis of Weber and Husserl's ideology, transforming both theories, in one self sufficient theory.

"The ideal of Alfred Schutz will be to establish philosophically the social sciences that seek to know what is the sociology in itself".⁽⁷⁾

Schutz constructed forty-eight concepts in relation to the man. It detaches the concepts that show the interaction among the natural attitude, the knowledge, the experience, the daily life world and the relevance and theirs influences on the man. From these concepts it concludes that the natural attitude, where the person acts spontaneously in its daily life world, the individual constructs its experiences, that in turn are limited by the objects, persons and events, to generate the knowledge. For him, what a person knows corresponds to its knowledge reserve. This knowledge will have different relevance aspects that would be: motivational relevance, thematic relevance and interpretational relevance. For Schutz, the daily life world is intersubjective, that is, we live new experiences and interpretations, generated from previous experiences. ⁽⁸⁾

For Schutz, in the interpersonal relation, the individual, invariably, brings to the relation its previous experiences rooted in its past and that will reflect in the present, in its conduct in the world. Each person has its own history. And the manner of acting or the social behavior is resulting from two different types of motives. The "because motive " or " in order to..." that comprehends the action to be realized, purpose to be achieved and the " because motive" or " in order to motive..." that reflects the individuals' s past, the previous experiences that will explain the present fact, and can be out of the conscience level. What differs them basically is that the "in order to motive" works with the subjectivity while the " because motive" with the objectivity.

"[...] the subjective notion must be understood as the relation action including the actor' s conscience. It is not therefore a notion that is nothing to do with the psychologist introspection. [...]. It is in this sense that Schutz emphasizes the subjectivity, having through this, that the aspects of that conscience can be described". ⁽⁷⁾

The search realized in the BVS with the descriptors use in an isolated way resulted in: "Nursing": 399.040 articles, "Adhesion": 368.215, "Nosocomial infection prevention measures": 60 and "Permanent education and infection control": 16 articles. Totaling 843.255 articles. In carrying out the 04 descriptors combination, no article has been found.

Then, it follows with the combination among the descriptors. First of all: nosocomial infection prevention measures and nursing that generated 16 productions. Subsequently, between the nosocomial infection prevention measures and permanent education: 01 article. In following with the combinations between nursing and permanent education in nosocomial infection control: 06 articles. At last: nosocomial infection prevention measures and adhesion: 01 article.

The combinations resulted in 24 articles in which, 02 articles repeated in three combinations, 04 articles were in English idiom and 01article published in 1984 exceeded the period required for the research (28 years) and 01 article was found with the same thesis title, being excluded following the inclusion criteria. Thus, 08 articles were excluded.

In this manner, the sample of this review consisted of 16 publications ^{(2-3, 9-22)} represented through the following tables. The table I present the specified scientific productions numbered of 01 to 08. The table II still present specifications of the scientific productions numbered of 09 to 16. This division was carried out to attend the table contents format.

 

 

Result

When considering as object and study problem the lack of adhesion of the nursing professionals to the infection prevention and control measures; the scientific productions contribution in the nursing area that make possible the non-adhesion of the professionals to the infection prevention and control measures; the objective that is to understand the non-adhesion of the nursing professionals to the infection prevention and control measures; to identify the scientific publications that discuss the motives and, to analyze the reasons of the nursing resistance to the adhesion to the infection prevention and control measures, it presents the result that brings the categorization according to Alfred Schutz.

The understanding of the human nature, through the scientific publications, seeks the correct strategy of the approach and control, in which the nursing team is inserted.

The lack of adhesion to these measures requires the infection manager nurse' s understanding for efficient and effective intervention along with this team.

The integrative review allowed the scientific productions analysis and gathered the results expected in this research in categories. Firstly the "in order to" motives are observed and after the "because" motives extracted from authors' s statements.

In this context, to address the "in order to" motives the categorization is revealed:

1. First category - The prevention measures in infection control.

1.1 The first subcategory is related to the nursing process.

[...] The importance of establishing methodologies which facilitate the IH control, pointing out that the Nursing Process use, as instrument, could result in great benefit, for the CCIH as well as the patient is evidenced ⁽²²⁾

1.2 The second subcategory refers to the reality transformation.

[...] Despite the directives existence, we believe that efforts must be addressed to the Professional formation and to permanent education programs, focusing on the critical awareness and ethical positioning for the reality transformation⁽⁹⁾

[...] It was observed the need for studies on the infection incidence in the critical patient [... ] in an attempt to establish causal relation and risk factors, with the aim of addressing adequate prevention and control measures ⁽¹¹⁾.

[...] The economic and social repercussion allows rethinking of the prevention measures just adopted and a deepening in the identification of other social determinants that are contributing to the accidents occurrence, prioritizing the nursing team ⁽¹⁷⁾.

[...] It notes that there are gaps in which refers to the knowledge and the practice regarding the studied infections control prevention and control measures [...] ⁽¹⁹⁾

1.3. The third subcategory refers to the prevention and control measures

[...] Challenge for the control teaching in the health area professionals formation and present some guiding presuppositions ⁽³⁾

[...] Beginning from the non-adhesion of the health area professionals to the prevention measures ⁽³⁾.

1.4. The four subcategory refers to the nursing team

[...] Thus, the authors propose a protocol to evaluate the actions carried out by the nursing team for venous catheters prevention and infection ⁽¹⁸⁾.

[...] We could see with this work that the preventive measures need to be taken together, in a complex of activities, founded in appropriate facilities and structure, developed by a joined professional team, in which all the members addressed to the same objectives. The effective prescriptions compliance will not occur if these measures are taken separately ⁽²⁰⁾ .

1.5. The fifth subcategory refers to the permanent education in infection control

[...] In spite of having directives, we believe that efforts should be addressed directly to the professional formation and to permanent education programs, emphasizing the critical awareness and ethical positioning for transformation of this reality ⁽⁹⁾ .

[...] It is noted the need of implementing activity of orientation able to make possible balance between the professionals' theory and practice regarding the IH prevention measures, aiming at improving the knowledge and behavior ⁽¹⁰⁾.

[...] Based on the results, it concludes that the nurse' s presence in the Radiology sector is essential to elaborate and implement programs about nosocomial infection prevention measures during radiological exams, aiming at the assistance quality ⁽¹²⁾.

[...] Thus, the objective is to identify the impeditive factors to the realization of the nosocomial infection control and to analyze the adhesion to these practices, making this infection control a step for the permanent education and reaching of assistance with quality ⁽¹³⁾.

[...] The study allowed identifying the nursing professionals' needs emphasized in the biosecurity aspects in relation to its practice performance, allowing formulating subsidies for the continued education service and Nosocomial Infection Control Service of the Institution ⁽¹⁵⁾.

[...] representing a challenge to the permanent education and of the infection control in the hospital in study ⁽¹⁴⁾ .

[...] It is evidenced the important nurse' s role in the infection prevention and control and the continued education as strategy of effective measures implementation of the care quality ⁽²⁾.

[...] The normalization process, as a participative movement, democratic, creative, motivating and systematized, respecting the individual differences and experiences of each nursing element, allowed reaching the values and attitudes consensus, normalizing the nursing procedures that represent nosocomial infection risk, transforming them in patterns that reduce the risk that the same represent ⁽²¹⁾.

In this context, it is necessary to assess the reasons "why" for the understanding of the lived come to the surface. Thus, continuing with the numbering for the category of the reasons "why".

Hence, the second category shows that the motives of the nursing team resistance to the adhesion to the infection prevention and control measures are related to practice factors in the daily. So that, the subcategories are:

2.1. The work process.

[...] Many obstacles were mentioned detaching the lack of resonance existent between the CCIH and the hospitalization units teams. [...] The problems identified in the operacionalization of the IH control are, in essence, of philosophical, educational or administrative character ⁽²²⁾

[...] The data reveal that measures addressed to infection prevention, in the parenteral drug administration route not always are adopted ⁽¹⁴⁾.

[...] The hemodialysis realization via short term central catheters was the main risk factor identified⁽¹¹⁾.

[...] However, I have observed that nursing team professionals, although showing attention and preoccupation with the patients, present actions that may spread microrganisms in the hospital environment ⁽¹⁶⁾.

2.2. The reality transformation

[...] Detect significant differences to improve the nursing professionals and assistants' knowledge and practice, when placed in different hospital groups, the questions analysis isolated not only distinguish, significantly the same groups ⁽¹⁹⁾ .

[...] Because of problems related to nosocomial infections found ⁽²⁰⁾.

2.3. The permanent education in infection control must meet the needs of the professionals' knowledge

[...] The lack of knowledge about how to deal with the patient and the type of care adopted [...] ⁽¹²⁾

[...] The data reveal that necessary measures to the infection prevention, in the parenteral drug administration route not always are adopted ⁽¹⁴⁾.

[...] This seems to represent the lack of knowledge, or the health professionals' indifference, to the risks of such procedures ⁽²¹⁾.

[...] The nursing professionals expressed their comprehension about the disease and their knowledge about protection measures in the care to the referred patients ⁽¹⁵⁾

 

Discussion

Through these categories we believe that the orienting questions were answered, having in view that the scientific productions allowed the understanding of the non-adhesion of the professionals to the infection prevention and control measures, according to authors who discuss the thematic.

Consequently, the scientific productions in the nursing area contribute to the professionals' non-adhesion to the infection prevention and control measures. These productions address work process aspects, the reality transformation and the permanent education in infection control. Therefore, the nursing professionals' non-adhesion comprehension to the infection prevention and control is centered in the daily practice factors.

 

Conclusion

The qualitative nature integrative review, using the keywords: "Nosocomial infection prevention measures", "Nursing", "Permanent education in infection control" and "Adhesion", discussed the this study thematic centered in the infection prevention and control assistance daily.

The assistance pattern of attention to health establishes the standard operational procedures (POP) by nursing professionals. For that reason, the lack of adhesion to these measures makes work processes does not meet the recommended measure, that makes difficult the efficient and effective measures implementation to the infection prevention and control. The nursing team resistance reasons to adhesion to the infection prevention and control measures are due to professional practice in the daily of the health service.

Thus, it emphasizes the work process, in which the integration between the Infection Committee and the nursing team is observed as disarticulated. Other aspect is the difference between the scientific knowledge and the practice, which makes difficult the POP'S implementation, the lack of knowledge in how to proceed in the situations before the client, even to the risks that the procedures mean for these clients.

There is a need for a change of attitude, to make possible the infection indexes reduction, in order to the Hospital Infection Control Committee' s objective is met. The clients must be guaranteed quality assistance without any risk for health-disease process that interferes in the hospitalization time. The institution needs to preserve its quality standard.

The Infection Committee has the responsibility under work process according to the infection prevention and control. The committee of this team, in which the infection controller nurse is executer member, needs to have efficient and effective intervention along with the nursing team.

Thus, the understanding about the non-adhesion to the infection prevention and control measures is of utmost importance, in order to reflect on the conduct to be adopted to reach a new reality.

In the reading of the scientific productions, it observes that prevention measures in infection control are related to the nursing process, as there is the importance of implementation of methodologies that control the infection to obtain transformation of reality. The adhesion to the prevention and control measures becomes a challenge for the CCIH with the nursing team, as the permanent education needs directives for formal and informal education with an emphasis on critical-reflective pedagogy.

Thus, the permanent education with the use of critical-reflective pedagogy favors the transformation of the environment as a professional in health, encouraging them to reflect on and modify their role in patient care, in order to break the chain of hospital infection transmission.

 

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