Introduction
Contamination in dental clinics is a global health matter that has made many public health authorities implement approaches to reduce the impact caused by unhealthy practices. The purpose of this change project is to ensure patient and staff safety by improving dental assistants’ knowledge and practice regarding decontamination in dental clinics using a behavioral change model. The main question addressed in this project was the following: Could multidimensional behavioral approaches in staff education improve infection control knowledge and practice?
The project team implemented a multidimensional educational program, which focused on educating and training dental assistants on 5 key indicators of good decontamination practices based on the Center for Disease Control and Prevention (CDC) standards. The project went through the gradual change of behavior using the Transtheoretical Model, which included the following five main stages: pre-contemplation, contemplation, preparation, action, and maintenance. Multiple approach activities were used to shift the participants from one stage to another.
This chapter will discuss the project findings presented in the evaluation chapter, and relate them to the literature review in chapter two. The discussion will be important because it will form the basis of the conclusion and recommendations.
The implication of the educational program on the knowledge of dental assistants regarding decontamination practices
The program results produced an improvement in knowledge following the attendance of an educational program on decontamination resulting in high post-test scores after the program. This indicates that the program was effective at improving participants’ knowledge and understanding in the area of decontamination. Statistically, the numbers showed an improvement in the overall passing score rates between pre-and post- implementation tests among dental assistants with an improvement percentage of 35.7%. This exceeds the team objective where the aim was to increase the knowledge of dental assistants to good decontamination practice by 20-25%. The results suggest that dental assistants could have had insufficient knowledge of infection control guidelines related to decontamination practices before the program. Insufficient decontamination knowledge could have been the main reason why there were many cases of contamination in dental clinics. Therefore, primary health care management might be needed to re-evaluate the way they educate and train on infection control practices. Relating the project results to literature, a study in the UK aimed at evaluating disinfection and decontamination among dental postgraduate courses. It showed a significant improvement in participants’ knowledge after conducting a pre-and-post course test (Pittet 2000). The results of the study showed an improvement percentage of 41.8% (Pittet 2000).
The results support the role of education in implementing improvement in knowledge, but as mentioned in the literature review, knowledge does not necessarily improve compliance with guidelines. Although the results suggest that educational programs have a positive impact on improving knowledge in infection control practices, they might not improve compliance with infection control guidelines. The literature review revealed that a poor infection control practice could be related to other factors like staff attitudes and established behaviors or shortage of resources or workload rather than lack of knowledge or education.
Further data analysis showed no significant differences in scores between participants of different ages or years of experience. This suggests that the program is suitable for dental assistants from all age groups and at all levels of experience. Participant A worked in a rural area and had the lowest pre-implementation test score, which reflects the fact that dental personnel in rural areas have less participation in educational courses because of their far location from the city where most of the educational activities occur.
There were different factors within the program that could be a possible cause to improve the staff knowledge. The multiple approach methods of the educational program, for example, self-learning, lectures, and practical demonstration could be a causative factor to improve knowledge among the staff. The finding correlates with findings from many studies that support the multidimensional interventions to improve infection control knowledge and practice (Bailey et al 2012; Maskerine & Loeb 2006)
Another possible factor that could have resulted in improving staff knowledge is the use of interactive techniques during the presentation of the educational program, such as using power-point presentations, videos, scenarios, and case studies. This is supported by some studies, which reveal that interactive techniques produce effective changing outcomes (Davis, O’Brien, Freemantle, Wolf, Mazmanian & Taylor-Vaisey1999).
In addition, the behavioral staged process that the project went through could be a cause of the improvement in knowledge. The dental personnel went through different stages in this project that transformed them from being reactive to becoming proactive. The use of adult learning and discussion groups made the staff feel that they were part of this change. The approach was supported by educators in literature by which they support engaging participants in education through adult learning and discussion (Stein, Makarawo & Ahmad 2003).
The implication of the change project on compliance to key indicators of good decontamination practice
The results show an improvement in staff compliance with the key indicators of good decontamination practices. The improvement percentage was about 43%, which is within the expected outcomes of the project. Some of the factors that were associated with the education program were found to affect the compliance of dental assistants with decontamination practice. The factors are discussed below.
Age
Older dental assistants showed less compliance with the guidelines in the pre-implementation stage (14.2% and 21.4%) compared with (64.2% and 78.6%) for relatively young health care providers working in dental clinics. That was in agreement with a survey conducted in Birmingham teaching hospitals, which concluded that older healthcare workers seem to be less compliant than younger workers. Another study conducted in Canada revealed that younger workers between the age of 19-29 years had better compliance with infection control practices than older workers above 50 years (Cheng, Su, Huang & Chuang 2012; Yassi et al 2007).
Site of practice
It was established that dental assistants working in rural areas had fewer compliance percentages compared with dental assistants working in urban areas. This was in agreement with a study in Taiwan that showed that dental settings located in rural areas less often adhere to infection control practice. The contributing factors could be that the personnel working in rural areas do not attend infection control courses and programs regularly because of the far distance to urban areas where most of these activities are conducted. In addition, dental health settings in rural areas suffer from a shortage of resources that could affect good infection control practices. Both human and financial resources are important in the implementation of many health programs across the world. In most cases, experienced health care providers do not work in rural health settings. Also, health settings are characterized by limited funds that are important in supporting critical health programs and initiatives (McCarthy, Koval, & MacDonald 1999).
Compliance with the first key indicator of good decontamination practice (Staff health & safety)
The baseline data revealed that 100% of the participants put on gloves, which is compared with 99% of the wearing gloves in Scotland (Yüzbasioglu, Saraç, D, Canbaz, Saraç & Cengiz, 2009). However, 80% of the participants did not wear eye protectors during the decontamination process compared with 51% not wearing eye protectors in Scotland and 18% of the dental staff in Canada not wearing eye-protective devices (McCarthy et al 1999). For the mask, only 40% of the staff wear a mask during decontamination procedures compared with 82% of the staff in Canada who wear masks. Post-intervention results, which were extracted from an external examiner observational visit, showed an increase in compliance. They showed that 100% of staff put on gloves and eye protectors, and 80% of the staff used masks. Two factors helped to increase the staff compliance with personal protective equipment (PPE) during decontamination practice. First, providing the staff with the required equipment was essential because all personnel could easily access the PPE. The implementation team succeeded in providing the participants with eye protectors that were initially available only for dentists. Another factor that helped in improving compliance is the educational program, which included some activities that emphasized the importance of wearing PPE in dental clinics.
Compliance with the second key indicator of good decontamination practice (Environment and workflow)
The baseline data showed that no dental clinic in PHC had a separated decontamination room from that of the treatment room compared with 80% of the dental clinics in Scotland which had no such separation. The separation of the two rooms in health care settings is important because it helps to significantly reduce the chances of contamination. In addition, all dental clinics did not show obvious workflow. The post-intervention data showed a problem in fulfilling the second key of good decontamination practice. Due to limitations in time and funds, the team could not separate the decontamination room from the treatment room. However, the team succeeded in implementing the workflow guidelines in 60% of the clinics. A recommendation was made to the senior managers to introduce a physical modification to dental clinics that could facilitate the decontamination practices according to the standards.
Compliance with the third key indicator of good decontamination practice (Equipment used for cleaning)
The baseline data showed that 40% of the staff used detergents or disinfectants according to the manufacturer’s instructions compared with 77.8 % of dental staff in Turkey (Yüzbasioglu et al 2009). Also, 20% of the staff used long-handled brushes to remove debris from instruments
The post-intervention data showed that 100% of the participants used detergents according to manufacturers’ instructions. In addition, 100% of the staff used the cleaning brush to remove debris. The significant improvement in compliance with the third key was as a result of training the staff on how to read manufacturers’ instructions and use measuring cups to produce the accurate mix of the disinfectant. Also, the team succeeded in providing the staff with the required equipment like the mixing cups, trays, and brushes that facilitated good dental practices.
Compliance with the fourth key indicator of good decontamination practice (Instrument inspection post-cleaning)
The baseline data showed that 40% of the staff routinely inspected instruments for cleanliness before packing compared with 85% in Scotland. However, none of the staff used a magnifier to inspect compared with only 1% of a dental personnel who used magnifiers for inspection in Scotland. Magnifiers are essential in inspecting for cleanness because they magnify the particles that could be a source of contamination.
Post-intervention data showed that 80% of the staff routinely inspected all instruments for cleanliness before packing using magnifiers, which were supplied in this project. The main factor that facilitated the compliance with the fourth key is that the dental assistants were given enough time to inspect the instruments.
Compliance with the fifth key indicator of good decontamination practices (sterilization of handpiece between patients)
The baseline data showed that 60% of the personnel were autoclaving hand equipment when handling many patients compared with 77% of the dental staff in Canada and 92.5 % in the USA. Some of the personnel were not sterilizing handpieces in between patients because they were practicing old guidelines, which considered disinfecting handpieces between patients an unacceptable practice, and were not updated. In addition, the staff thought that multiple sterilizations of handpieces would cause damage to the turbines.
Post-intervention results showed significant improvements in compliance with the fifth key indicator, where 100% of the participants sterilized handpieces between patients. That was a result of educating the staff about the risks associated with such practice on patient safety.
Other factors improved compliance with decontamination practice
The project revealed that implementing other factors in addition to education showed improvements in compliance with guidelines. Providing necessary recourses to achieve best practices during the project implementation increased compliance with the guidelines. Furthermore, providing enough time for the staff to practice good decontamination by allowing them to work only in dental clinics instead of doing other jobs improved the compliance. This was supported by the literature review. Some components of the review suggest that attention must be paid to some factors that might not be considered in the initial planning of educational programs intended to bring behavioral change. Some of the factors could be important in predisposing, enforcing, and/or enabling behavioral change (Creedon, SA, 2006).
Limitations of the project
Despite improvements in decontamination practices observed, a number of limitations were present in this study. First, due to limited time and budget, the study sample of dental assistants was small. This limited the power to make conclusions about the population. Second, a two-month follow-up period was not enough time to examine longer-term benefits. The sample was recruited from five dental assistants chosen for convenience. Thus, the findings cannot be generalized to all dental assistants working in PHC. Third, the method of measuring compliance was observing staff during practice. The effect of being monitored could improve compliance. However, the presence of the observer on a daily basis in the centers where the staff worked and conducting sudden several observational visits (3 to 4 visits) each visit with one-hour observation could overcome this limitation. Finally, because the intervention was multidimensional, it was difficult to assess the parts of the program that were the most effective.
To prevent a return to pre-intervention competency, the team will repeat the entire program at 6 -month intervals and administer it to new staff. In addition, the team will continue to monitor the staff compliance every month to identify any poor practices that would necessitate additional interventions.
Recommendations
Based on the findings of the project the following recommendations are made:
- It is important to consider the complexity of individuals and organizational factors when designing any intervention to improve infection control, realizing that a multidimensional intervention will have a greater impact on behavior
- There must be an adequate number of staff with appropriate training to execute good decontamination practices in dental clinics.
- Decontamination practices in the dental care settings must be monitored and feedback reported appropriately to become a part of the employee performance reviews.
- It is important to study other factors that may affect staff compliance with infection control practices like workload and shortage of resources.
- Improvement in the physical environment and adequate resources are important factors to allow good decontamination practices in dental clinics. Resources include both human and financial resources.
Conclusion
In conclusion, a multidimensional education program based on a behavioral change model resulted in significantly improved decontamination compliance. Changing behavior to achieve sustained compliance with infection control practice is a continuing challenge. The complexity of the change is a single intervention would fail in improving infection control practices. To improve compliance, it is recommended to implement staged behavioral change and multidisciplinary strategies. Several parameters were associated with the successful implementation of the educational program like leadership engagement and providing the staff with the necessary resources.
References
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