Patients receive healthcare in a variety of settings, including in their own homes. Hospitals are often considered when discussing cross-infection and healthcare-associated infection. However, the Royal College of Nursing (RCN) (2017) has stressed that such infections are not confined to hospitals, and that healthcare staff who practice in community settings have the same professional and clinical responsibilities as staff who work in hospitals to prevent opportunities for infection to occur.
The district nursing service provides nursing care and support for patients and their families and carers in homes and communities all across the UK. This service provides a range of elements of care and treatment including wound management, palliative care, continence and catheter care, tracheostomy care and medicines management. In all aspects of physical care, there are infection prevention and control (IPC) issues that need to be addressed and adhered to for safe and effective practice. This is increasingly so given the complexity of patients now being cared for outside the acute hospital setting, and there is an associated increased risk of infection.
Infection prevention and control came under the national and international spotlight during the COVID-19 pandemic. The main focus was on acute care, primarily in NHS hospitals, but community nurses are also practising in a setting which presents its own challenges for optimum IPC procedures – patients’ homes. Therefore, this article will focus on some of these challenges or barriers to applying IPC in patients’ own homes.
General barriers to infection prevention control
There has been a plethora of research around reason why staff do not or cannot carry out IPC procedures correctly. Barriers to compliance or reasons for non-compliance with IPC procedures can include:
- Lack of training
- Lack of leadership
- Workload
- Lack of facilities
- Skin reactions (gloves/hand hygiene)
- Lack of policies and guidelines
- Risk perception
- Access to facilities
- Lack of management support
- Staffing levels
- Lack of information
- Lack of positive role models
- Cost
- Lack of time
- Stress
- Conflicts of interest
- Manual dexterity (gloves)
- Patients being bothered by it
- Poor communication.
These tend to be around categories such as physical barriers, knowledge (Houben et al, 2022), support and work pressure issues. Barriers highlighted in previous research include a lack of access to items such as personal protective equipment (Brooks et al, 2021) or alcohol handrub, workload or lack of time, lack of management support (Sugg et al, 2023) or positive role models (Driscoll et al, 2022), and lack of knowledge and training about what the correct procedures are (Donati et al, 2019). A Cochrane database systematic review highlighted issues such as access to local guidance and constantly changing guidance, workload and fatigue, levels of support and communication, a lack of training, and a lack of space and facilities as the main barriers to healthcare staff adhering to IPC guidelines (Houghton et al, 2020). Much of this research, however, has been carried out in hospital settings. Peoples’ homes present a different set of challenges which require staff to adopt a risk assessment/management approach in order to address them.
The patient's home as a barrier
Primarily, district nurses can consider practical barriers such as what is available in patients’ homes, in particular for hand hygiene. Payne and Peache (2021), for example, highlighted the lack of compliance with guidance of handbasins/sinks in people's houses and the cleanliness of sinks as barriers. Dowding et al (2020) also discussed cleanliness as a potential barrier. In patients’ homes, community nurses are working in an environment that they have little control over, as opposed to areas such as hospitals and clinics which are set up for clinical practice. Nazarko (2016) further identifies that nurses may not even have access to running water in some homes. This means that they have to use a risk management approach to IPC in addition to other aspects of care. Murphy (2023) states that nurses will often lack the appropriate resources when visiting patients in their homes; this means that they need to apply the principles of IPC in problematic settings, using a variety of strategies such as the use of alcohol handrubs and wet wipes. Community nurses, as identified, have to regularly deal with the fact that they are working in an environment over which they have little or no control over (Higginson, 2018).
Additional barriers to effective IPC practices in patients’ homes that have been identified are clutter and environmental cleanliness (Adams et al, 2021). These are a particular challenge as these patients live their lives this way and nurses have to demonstrate a non-judgemental approach to care while also minimising the risk of infection to both staff and patients. Nurses need to adapt clinical procedures, such as wound dressings, to apply the principles of asepsis in an environment which is not always ideal and which might, for example, increase the risk of the patient acquiring a wound infection.
Policies, knowledge and education
Felembam et al (2012), in their observational study of hand hygiene in community nurses, highlighted poor compliance, identifying several reasons for this including a need for training of staff concerning hand hygiene in their everyday practice. While a lack of knowledge and training has been identified in a variety of settings as a barrier to optimum application of IPC processes, there can be particular challenges in community nursing in that usual training content may not be applicable to patients’ houses and may not focus on the risk management approaches that are required in many cases. Ensuring that education provided to staff who care for patients in their own homes takes into consideration the challenges in this setting and provides advice and tips on how some of these can be overcome will assist staff to achieve better compliance with procedures. Education may also be an issue as it relates to relatives and carers; McDonald et al (2020) identified that there were limits to what nursing staff could do with regard to their patients’ general level of cleanliness and their home environment. They highlighted that it was easier to provide education to patients and their families than it might be to try and alter the cleanliness of that environment. Shang et al (2020) emphasised the importance of this in their conclusion that providing carers with appropriate IPC education reduces the risk of infection to the patient. It is also worth considering in light of the previously mentioned barrier of levels of cleanliness in some homes.
A previously identified issue related to IPC compliance (Houghton et al, 2020) is the availability of IPC policies and guidance. Of particular importance in community nursing is the applicability of such policies to community practice. The use of hospital-based policies and procedures can lead to confusion about appropriate practice when the settings are not comparable. This can result in frustration with what can be considered to be unrealistic expectations in a person's home environment, as opposed to a clinical environment. This could potentially lead to poor practice as staff interpret the policies in different ways in terms of applying them to their setting. The approach needed will differ between houses and this needs to be reflected in IPC policies and guidance.
Leadership, management and role models
In general research around non-compliance, a lack of leadership within a team, a lack of management support and a lack of positive role models have all been identified as barriers to optimum IPC practice. Pogorzelska-Maziarz et al (2020) identified the need for a leadership focus on quality and a coordinated approach to care in ensuring success and innovation in IPC in community care. If the leaders and managers of a team do not consider IPC to be a priority, this message will be transferred to frontline staff and will adversely affect standards of practice. While there is a lot of emphasis in the media and in IPC research on acute settings, this will continue to reflect a message that IPC is not necessarily relevant to community care. Therefore, it is the role of managers and leaders to highlight the need for good practice and to role model good practice, given the increasing complexity of community-based patients. Community care leaders have a major role to play in supporting their staff to apply good practice in all settings and to highlight the importance of the prevention of infection and cross-infection in their patients.
Summary
Patient care is carried out in a variety of settings, including in their own homes, and this can present challenges to IPC for community nursing services. Available facilities, cleanliness, knowledge and training of both staff and family/carers, applicability of IPC policies and guidance to the home setting and management/leadership issues can all act as barriers to good practice. Ensuring a risk management approach to care, that policies and training are applicable to patients’ homes and that managers emphasise the importance of IPC processes in the provision of safe, quality care can assist in addressing these barriers so that both staff and patients are at much lower risk of infection.