Translational Research for Practice and Populations

To address healthcare issues appropriately and with high quality, nurses should be aware of the latest therapeutic approaches, strategies, norms, and standards. In this regard, nursing evidence-based practices, which imply the application of the most current clinical research while making quality decisions to deliver sound patient care, are critical to excellent performance in healthcare. Therefore, this paper aims at identifying a current nursing practice that requires a change and the key stakeholders within healthcare setting, which participate in the changing process. Moreover, the paper will determine five sources from scholarly peer-reviewed journals and develop an evidence summary based on the findings from these sources. Finally, the paper will offer recommendations of a specific best practice based on the evidence summary and a practice change model that is appropriate for the proposed practice change.

Infection Control Practice

In every healthcare facility, infection control represents a significant issue that requires persistent and careful attention and considerable efforts in order to be addressed. According to the World Health Organization (WHO) (n.d.), every one out of ten hospitalized patients contracts at least one healthcare-associated infection (HAI). A patient acquiring an infection runs a high risk for a prolonged hospital stay or continued disability, severe illness, or even death. In hospitals, bacteria can spread in corridors, wards, offices, and also in the surgery and be transmitted by nurses, clinicians, consumers, visitors, and hospital-related works. One of the most critical concerns caused by infection is that many germs, Staphylococcus aureus and gram-negative bacilli, in particular, are resilient to most of the antibiotics. For example, approximately 50 percent of surgical-associated infections can be antibiotic-resistant (WHO, n.d.). In addition to harm to people, infection imposes a massive financial burden on a budget of consumers, their families, and the healthcare system.

In this regard, to prevent infection transmission, nurses, clinicians, consumers should adhere to precaution guidelines established by WHO, together with other organizations, such as the Centers for Disease Control and Prevention. These guidelines consist of standards and recommendations for hand and respiratory hygiene and cough etiquette, barrier protection, decontamination, antibiotic stewardship, environmental cleaning, and waste disposal, among others. Currently, as mentioned-above statistics show, most healthcare providers, especially in developing countries, fail to ensure precaution infection measures, which result in adverse consequences for patients and nation safety overall.

The Key Stakeholders in Infection Control

For the successful implementation of a change into existing nursing practice, there is a driving need to identify critical stakeholders of the infection control committee and determine their roles. The first stakeholder is the government of international, state, and regional levels, the primary functions of which are introducing nationwide and global policies and strategies guiding healthcare providers in preventing hospital-related infections. Besides, they are accountable for allocating financial and human resources. The second group of stakeholders includes hospital executives, board representatives, and managers that are responsible for establishing the organization’s guidelines and rules, required precaution measures, as well as planning and organizing organizational resources.

The last group of stakeholders comprises medical professionals such as physicians, clinical microbiologists, infection control specialists, and epidemiologists, nurses, and other hospital-allied staff, the central role of which is to follow infection-preventive norms and standards. Moreover, the tasks of microbiologists are to help in developing the infection control and the antimicrobial stewardship programs and deliver quality results of the tests. Infection control specialists and epidemiologists are accountable for controlling, monitoring, and reporting on the spread of infections and the epidemiological situation in the hospital.

Evidence Critique Table

Source Design type & level Level
Ho, J., Wong, S. H., Doddangoudar, V. C., Boost, M. V., Tse, G., & Ip, M. (2020). Regional differences in temporal incidence of Clostridium difficile infection: A systematic review and meta-analysis. American Journal of Infection Control, 48(1), 89-94. A systematic review and meta-analysis. Level I
Dingle, K. E., Didelot, X., Quan, T. P., Eyre, D. W., Stoesser, N., Golubchik, T., … Davies, J. (2017). Effects of control interventions on Clostridium difficile infection in England: An observational study. The Lancet Infectious Diseases, 17(4), 411–421. doi:10.1016/s1473-3099(16)30514-x A cohort study and case-control study. Level IV
Aliyu, S., Smaldone, A., & Larson, E. (2017). Prevalence of multidrug-resistant gram-negative bacteria among nursing home residents: A systematic review and meta-analysis. American Journal of Infection Control, 45(5), 512–518. doi:10.1016/j.ajic.2017.01.022 A systematic review and meta-analysis. Level I
Donkor, E. S., Jamrozy, D., Mills, R. O., Dankwah, T., Amoo, P. K., Egyir, B.,… & Bentley, S. D. (2018). A genomic infection control study for Staphylococcus aureus in two Ghanaian hospitals. Infection and Drug Resistance, 11, 1757. A case-control study. Level IV
Barker, A. K., Brown, K., Siraj, D., Ahsan, M., Sengupta, S., & Safdar, N. (2017). Barriers and facilitators to infection control at a hospital in northern India: A qualitative study. Antimicrobial Resistance & Infection Control, 6(1), 35. https://doi.org/10.1186/s13756-017-0189-9 A qualitative study Level VI

Evidence Summary

The study by Ho et al. (2020) aims at defining temporal tendencies in the C difficile infection’ cases across different geographic regions, including North America, Europe, Asia, the Caribbean, and Oceania. To achieve the purpose, the study analyses 83 research selected from the observed 3688 potentially eligible studies conducted between 1993 and 2015, which fulfill the predefined inclusion criteria. The examined data includes 10,887,050 patients with an average age of 65.28 years from over 12,188 hospitals and other facilities. The global incidence of C difficile has been assessed to be 50.42 per 100,000 person-years and 6.94 a 10,000 patient-days. Stratifying increasing incidences displayed that infection rates were more significant in developed countries compared to middle and lower-income countries on the same continent over the same period. In particular, the study has identified that C difficile infection is lower in Asia, but the infection rate in this area has increased from 1997 to 2015. It can be ascribed to the increased application of antibiotics. Thus, the research emphasizes the importance of the right system of successful antibiotic stewardship.

The cohort study by Dingle et al. (2017) is directed at investigating the impact of specific

public-health interventions on the England reduction in C difficile infection, which accounted for approximately 80% after 2006. The study observed regional, that is, in Oxfordshire and Leeds, and national data, that includes 4045 national and international C difficile isolates. The research has revealed that the decline in the use of fluoroquinolone in England was the leading source of the decrease in C difficile infection. Finally, the study indicates that antimicrobial stewardship should be a fundamental element of C difficile infection control programs.

The purpose of the systematic review and meta-analysis conducted by Aliyu et al. (2017) was to analytically review evidence of the prevalence of multidrug-resistant gram-negative bacteria (MR GNB) among nursing home residents. The study observed 327 articles for 2005-2016 years, out of which 12 articles were selected for the systematic review, and eight of 12 articles met the criteria for meta-analysis. The study utilized Downs and Black risk of bias criteria and a random-effects meta-analysis model. The majority of studies were conducted in the United States; the rest was done in Korea, Italy, Singapore, and German. The sample sizes of articles ranged from 51-1,221 participants. The study has discovered a higher occurrence of MR GNB colonization among NH residents and highlighted the necessity to improve policies for prevention and infection control in nursing homes.

The objective of the case-control study by Donkor et al. (2018) was to use Whole genome sequencing analysis (WGSA) to ascertain the potential transmission cases involved in two suspected Staphylococcus aureus hospital outbreaks in Ghana. The study was performed at Lekma Hospital (LH) and Korle-Bu Teaching Hospital (KBTH), where the epidemic occurred in 2015 and 2012, respectively. In particular, KBTH has 1500 beds, while LH has 100. The isolates were from three sources: carriage of patient’s disease, cases of patients, health workers and hospital visitors, and surfaces and equipment in the hospital wards. The study has revealed a high prevalence of pvl genes among the isolates and, thus, highlights the necessity of careful decontamination of environmental surfaces at hospitals.

The qualitative study carried out by Barker et al. (2017) aims at evaluating infection control policies at a tertiary care hospital in Haryana, northern India, based on the Systems Engineering Initiative for Patient Safety. The study design comprises 1250 bed tertiary care hospital; the study population involves twenty semi-structured interviews of nurses and physicians. Human and organizational level factors were the primary triggers and obstacles to infection control at the hospital. The main barriers included a high degree of nursing staff turnover, time wasted for training new staff, language competence, and excessive clinical workloads. A well-designed infection control team and corporate climate prioritizing infection control were prime helpers.

Recommendations for a Specific Best Practice

First, it should be indicated that many HAIs acquire immunity to most of the present antibiotics; moreover, many infection-related diseases, including those produced by C difficile, are caused by the use of antibiotics. Based on the evidence received from the articles mentioned above, it can be recommended that the international and national governments should focus on developing appropriate and valid antibiotic stewardship policies. These policies are to include norms and standards regarding antibiotic application and consumption. Second, Donkor et al. (2018) have manifested that the spread of infections, especially during outbreaks, is primarily caused by the lack of adherence to proper hygiene and disinfection of frequently touched surfaces. Thus, it is suggested to advocate for and advance practical hygiene and decontamination rules and strategies among healthcare providers and consumers. Finally, hospital executives should consider human-associated and organizational factors, such as clinical workloads, language competence, training new staff, among others, which can be both facilitators and obstacles to providing adherence to infection control policies.

Iowa Model of EBP

The Iowa Model can assist nurses, clinicians, and other healthcare stakeholders in introducing research findings into clinical practice to enhance outcomes for patients. To provide quality of practice change, the model consists of several steps, namely, identification of clinical question, a search of the literature, critical appraisal of evidence, implementation of practice change, and evaluation of results. In particular, the identified question can be problem-focused, that is, those issues deriving from financial or management, or health-related data, and knowledge-focused, which caused by a change in national or organizational guidelines, research, etcetera.

The Iowa Model has been chosen because it focuses on determining the problem that takes principal priority for medical organizations, departments, and individuals overall. Moreover, the model emphasizes the importance of evaluation of both the searched literature and outcomes of practice change, notably regarding infection control. For instance, before the implementation of practice change, healthcare providers would be concentrated on identifying the most critical problems; in the case of infection control, it is disinfection or antibiotic stewardship. Then, the model offers to begin searching the literature with a subsequent thorough analysis of it. Only after appraisal of evidence, the model recommends applying a change in clinical practice and policies, for example, the usage of new antibiotics or alteration concerning dose of a specific medicine. Finally, the evaluation of outcomes would warrant whether practice change is useful and effective in addressing a particular issue.

Barriers to Successful Implementation

First, one of the most significant barriers is the lack of time since the majority of nurses and clinicians have enormous medical and, sometimes, clinical workload. Thus, they cannot afford much time to search, read, review, and even discuss the literature. In addition, not all hospitals and medical organizations have access to resources and appropriate technical support. Moreover, to critically assess the material, clinical staff should possess somewhat understanding and skills about resources, and the hierarchy and strength of evidence. Finally, the most crucial obstacle on the way of implementation can appear to be resistance from health workers and providers since it can hinder both the beginning and the process of implementation.

Ethical Implications

The first fundamental provision is respect for human dignity and personal attributes of every person since, without valuing each person, it is impossible to consider all needs and details to provide quality treatment and service. This principle supports and directs the development of public healthcare policies that involve all individuals without prejudice. The second essential provision that supports the practice change is ‘nurse promotes, advocates for, and protects the rights, health, and

safety of the patient. In this context, the principle indicates that professional nursing is the process of constant education and training that includes the acquisition of sophisticated knowledge, skills, experience, and an in-depth understanding of the professional practice requirements.

References

Aliyu, S., Smaldone, A., & Larson, E. (2017). Prevalence of multidrug-resistant gram-negative bacteria among nursing home residents: A systematic review and meta-analysis. American Journal of Infection Control, 45(5), 512–518.

Barker, A. K., Brown, K., Siraj, D., Ahsan, M., Sengupta, S., & Safdar, N. (2017). Barriers and facilitators to infection control at a hospital in northern India: A qualitative study. Antimicrobial Resistance & Infection Control, 6(1), 35. Web.

Dingle, K. E., Didelot, X., Quan, T. P., Eyre, D. W., Stoesser, N., Golubchik, T., … Davies, J. (2017). Effects of control interventions on Clostridium difficile infection in England: An observational study. The Lancet Infectious Diseases, 17(4), 411–421.

Donkor, E. S., Jamrozy, D., Mills, R. O., Dankwah, T., Amoo, P. K., Egyir, B.,… & Bentley, S. D. (2018). A genomic infection control study for Staphylococcus aureus in two Ghanaian hospitals. Infection and Drug Resistance, 11, 1757.

Ho, J., Wong, S. H., Doddangoudar, V. C., Boost, M. V., Tse, G., & Ip, M. (2020). Regional differences in temporal incidence of Clostridium difficile infection: A systematic review and meta-analysis. American Journal of Infection Control, 48(1), 89-94.

Infection prevention and control (n.d.). WHO.