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首页> 外文期刊>BMC Health Services Research >The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians’ perceptions of professional and cultural factors that influence doctors’ attitudes and practices in a large Australian hospital
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The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians’ perceptions of professional and cultural factors that influence doctors’ attitudes and practices in a large Australian hospital

机译：医院感染防治的政治与伦理：高级临床医生的定性研究，从澳大利亚大型医院影响医生态度和实践的专业和文化因素的看法

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BackgroundIn high income countries, an estimated 4–8% of hospital inpatients develop healthcare-associated infections (HAIs) [1] and nosocomial transmission of multidrug resistant organisms (MRDO) is a major contributor to antimicrobial resistance (AMR) and its associated healthcare costs [2, 3]. It is estimated that 35–55%, or more, of HAIs are preventable [4, 5], although rates are highly variable, depending on how effectively IPC measures are implemented [6, 7]. Failures of routine hospital infection prevention and control (IPC) practices, in high income countries during this century, have resulted in devastating nosocomial outbreaks of exotic or emerging infections, such as severe acute respiratory syndrome (SARS) in Toronto, in 2003 [8] and Middle East respiratory syndrome (MERS) in Seoul in 2015 [9], causing preventable deaths and massive social and economic disruption.Hand hygiene is the most obvious, easily audited and, arguably, the most effective IPC practice [10, 11], Its efficacy has been recognised since at least the mid-nineteenth century, with numerous studies showing that significant reductions in pathogen transmission and HAI rates are temporally associated with improved hand hygiene compliance [12]. Nevertheless, the use of hand hygiene as a surrogate for IPC quality and the moral status of noncompliance have been questioned, largely as a consequence of ongoing controversy about auditing methods and plausible compliance targets [13,14,15]. Ethical considerations have particular salience in light of numerous studies reporting lower than average compliance with IPC policies among doctors, compared with other health professionals, albeit with wide variation [16,17,18]. Doctors’ attitudes and behaviours are important, because they disproportionately influence those of other hospital staff and doctors often overestimate their own knowledge and compliance [19, 20]. Yet their peripatetic clinical practice provides numerous opportunities to transmit pathogens [21] and to be pathogen “super-spreaders” [22, 23].Doctors retain considerable professional autonomy and power, despite repeated challenges from increased regulation, other health professions, evidence-based medicine and consumerism [24,25,26]. Despite recent attempts to redefine “medical professionalism”, a universally agreed definition remains elusive; but all versions include common commitments to e.g. patient welfare; maintenance of knowledge and skills; and securing public trust through professional self-regulation and avoidance of conflicts of interest [27,28,29]. How doctors interpret these commitments depends on how they perceive their professional identity [30]. In practice, their attitudes and practices are complex and sometimes perplexing. Assuming that patient welfare is doctors’ highest priority [31], one may reasonably ask why some would expose their patients to preventable infection risks by failing to observe well-established IPC rules [30, 32]?Previous qualitative and mixed methods studies of factors that affect adherence to IPC practices have generally involved mixed groups of healthcare workers and/or focused on particular institutional settings, such as intensive care units. While these studies have identified factors that contribute to IPC practices including: self-protection, role modelling, belief (or not) in the effectiveness of IPC, knowledge, communication and workload [11, 20, 33, 34] they have not, for the most part, explained why these factors are so influential. The aim of this study was to explore what factors affect doctors’ IPC practices and, more specifically, why they are so influential. It took the form of in-depth conversations between researchers and participants, all of whom were senior clinical leaders and or clinician-director/managers with many years’ experience. Our expectation was that the perspectives of both “insiders” [senior doctors] and more objective “outsiders” [senior nurses] would provide new insights to inform strategies to raise the priority of IPC within the medical community and limit harm from HAIs and AMR more effectively.Our research question was:What professional and cultural factors influence doctors’ attitudes to and practice of infection prevention and control?.
机译：背景技术高收入国家，估计4-8％的医院住院患者发展医疗相关的感染（HAIS）[1]，多药物抗性生物的医院传播（MRDO）是抗微生物抗性（AMR）及其相关的医疗保健费用的主要因素[2,3]。据估计，HAI的35-55％或更多可预防[4,5]，尽管速率是高度变化的，具体取决于有效的IPC措施[6,7]。在本世纪高收入国家的常规医院感染防治（IPC）实践的失败导致了2003年在多伦多的严重急性呼吸道综合征（SARS）的毁灭性的爆发了毁灭性的爆发或新兴感染，2003年[8]和中东呼吸综合征（MERS）在2015年首尔[9]，造成可预防的死亡和大规模的社会和经济中断。手卫生是最明显的，容易审计，可以是最有效的IPC实践[10,11]，自19世纪中期以来，其疗效得到了认可，众多研究表明，病原体传播和海率显着降低了随着改善的手工卫生顺应性问题[12]。然而，使用手工卫生作为IPC质量的代理人和不合规的道德地位受到质疑，主要是由于审计方法和合理的合规目标的持续争议[13,14,15]。与其他卫生专业人员相比，鉴于众多研究报告的伦理考虑众多，据报道，众多研究报告低于医生之间的IPC政策，虽然有宽的变化[16,17,18]。医生的态度和行为很重要，因为他们不成比例地影响其他医院工作人员的态度，医生经常高估自己的知识和遵守情况[19,20]。然而，他们的痛觉临床实践提供了众多机会传播病原体[21]并成为病原体“超级吊牌”[22,23]。尽管监管的增加，其他健康专业，证据 - 基于医学和消费主义[24,25,26]。尽管最近重新定义了“医疗专业主义”，但普遍商定的定义仍然难以捉摸;但所有版本都包括常见的承诺。病人福利;维护知识和技能;通过专业自我监管和避免利益冲突来保护公众信任[27,28,29]。医生如何解释这些承诺取决于他们如何察觉他们的专业身份[30]。在实践中，他们的态度和实践是复杂的，有时令人困惑。假设患者福利是医生的最高优先级[31]，可以合理地问为什么有些人会使患者暴露通过未能观察到善于熟悉的IPC规则[30,32]？以前的定性和混合方法研究因素影响遵守IPC实践的遵守通常涉及医疗保健工作者的混合组和/或专注于特定的机构设置，例如重症监护单位。虽然这些研究已经确定了有助于IPC实践的因素，包括：自我保护，角色建模，信仰（或不）在IPC，知识，沟通和工作量的有效性中，他们没有，因为最多的，解释了为什么这些因素是如此有影响力。本研究的目的是探讨如何影响医生的IPC实践的因素，更具体地说，为什么它们如此有影响力。它采用了研究人员和参与者之间的深入对话的形式，所有这些都是高级临床领导人和或临床医生主任/管理者，拥有多年的经验。我们的期望是，“内部人员”[高级医生]和更多客观“外人”的观点将提供新的见解，以告知策略，以便在医学界内提高IPC的优先事项，并限制HAI和AMR的危害有效。我们的研究问题是：专业和文化因素影响医生的态度和感染预防和控制的实践？

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