Patricia Beryl Marck

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections

BACKGROUNDnThe objectives of this integrative review were to critically examine the overall state of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections (HCAIs) in acute care and long-term care settings, and offer recommendations for future directions in the field based on our findings.nnnMETHODSnWe searched for original research and reviews of research published between January 1, 1996, and July 31, 2006. Studies were identified through the electronic databases Medline, CINAHL, EMBASE, PUBMED, the Cochrane Library, and through expert consultation. Our comprehensive search strategy included all English articles for which hand hygiene or handwashing-related terms were combined with HCAIs. All studies that investigated a relationship between hand hygiene practices and HCAIs in acute care facilities were considered. These hand hygiene practices included the initiation of multimodal hand hygiene initiatives, the introduction of alcohol sanitizers, the implementation or changes of the infection control practices or infection control policies, and other organizational interventions. Studies only examining hand hygiene compliance, efficacy of alcohol hand gels, plain soap, and antimicrobial soap in reducing bacteria count recovered from hands were excluded.nnnRESULTSnOf the 1120 articles retrieved, 35 publications, including 4 reviews of research discussed at the outset of this article, met our inclusion criteria. The remaining 31 eligible original studies included 18 (58.07%) before and after studies without control groups, 4 (12.90%) before and after studies with a control group, 3 (9.68%) cohort studies with no control group, 4 (12.90%) cohort studies with a control group, and 2 (6.45%) randomized trials. Over 50% (16 or 31) of the studies were conducted in the U.S. Two independent reviewers conducted independent evaluations of all eligible studies, critiquing and scoring each study using a rating scale for examining the fatal flaws of quasi-experimental and before and after studies.nnnCONCLUSIONSnThere is a lack of rigorous evidence linking specific hand hygiene interventions with the prevention of HCAIs. The varied nature of the interventions used and the diverse factors affecting the acquisition of HCAIs make it difficult to show the specific effect of hand hygiene alone. The most frequent methodologies currently used in this research area are before and after observational studies without a control comparison group. Based on these findings, we recommend that researchers used a modified version of Larsons 2005 criteria to guide the design and conduct of future before and after observational studies in this area. We also argue that as we accumulate stronger evidence of which interventions are most effective, we need to develop additional research approaches to study how organizations succeed and fail in fostering the uptake of evidence-based hand hygiene interventions.

Medication administration technologies and patient safety: a mixed‐method systematic review

BACKGROUNDnHealthcare leaders need evidence-based information on nursing medication administration technologies to guide the design of improvements to patient safety.nnnAIMnThe aim of this study was to evaluate the research evidence on relationships between the use of medication administration technologies and incidence of medication administration incidents and preventable adverse drug events to inform decision-making about existing technology options.nnnDATA SOURCESnThirteen electronic databases and seven relevant patient safety websites were searched for the years 1980-2009.nnnREVIEW METHODSnA mixed-method systematic literature review of research on medication administration technologies and associated links to patient safety, operationalized as medication administration incidents and preventable adverse drug events, was conducted.nnnRESULTSnTwelve studies (two qualitative, five pre- and postinterventions and five correlational) met the inclusion criteria. All were assessed as medium quality with low generalizability of study findings. Only two studies sampled more than one hospital and none of the studies was driven by an explicit theoretical framework. The studies included in this review are generally positive towards medication administration technologies and their potential benefits, yet the level of evidence overall is equivocal. The majority of studies pointed to the development of workarounds by nurses following medication administration technology implementation that could compromise patient safety.nnnCONCLUSIONnMore theoretically driven research is needed to determine which medication administration technologies should be implemented in what ways to most effectively reduce medication administration incidents and preventable adverse drug events and minimize the development of potentially unsafe workarounds. Further evidence is required to accurately assess the actual contribution of medication administration technologies for improving patient safety.

Engaging with nature to promote health: new directions for nursing research.

AIMnThe aim of this paper is to offer a conceptual framework for nature-based health promotion in nursing and provide related recommendations for future nursing research.nnnBACKGROUNDnEmpirical data suggest that interaction with nature has direct health benefits. When people attend to outdoor habitats, gardens and other forms of nature, they are more likely to engage in physical activity and other behaviours that improve health. Engaging with nature can even cultivate ecological sensibilities that motivate us to protect the health of our planet.nnnDATA SOURCESnMultidisciplinary theoretical and research publications from 1985 to 2008 were examined in the development of the framework.nnnDISCUSSIONnAs the health of our planet continues to deteriorate, there is a pressing need for theoretically informed, ethical, sustainable ways of engaging with nature to promote human and environmental health. We adapt principles and socio-ecological thinking from the fields of nursing, health promotion and ecological restoration to delineate the essential elements of the proposed framework. Implications for nursing. Although evidence-based knowledge about nature-based health promotion is not readily used in nursing and health care, its development and application are critical to designing effective strategies to strengthen both human and environmental health.nnnCONCLUSIONnNurses can use nature-based health promotion concepts to work with citizens, health practitioners and policymakers to explore and optimize reciprocal, health promoting relationships among humans and the natural environment. To the extent that nurses integrate nature-based health promotion into their research efforts, we can expect to contribute meaningfully to both environmental and human health in communities across the globe.

An integrative review of infection prevention and control programs for multidrug-resistant organisms in acute care hospitals: A socio-ecological perspective

BACKGROUNDnThe infection rates of multidrug-resistant organisms (MDRO) are increasing in Canada and the United States. The prevention and control of MDRO infections remain an important issue in acute care hospitals. Although comprehensive infection prevention and control programs have been recommended, there is little evidence to date of their effectiveness or of what aspects are most important.nnnOBJECTIVESnOur objectives were to review and critique the literature on the relationship between an MDRO infection and control program and MDRO rates in acute care hospitals.nnnMETHODSnStudies including original research published between January 1, 1998, and May 14, 2009, were identified through MEDLINE, CINAHL, EMBASE, PUBMED, The Cochrane Library, and expert consultation. A comprehensive search strategy was developed with a librarian to find studies that covered the main subject areas of this integrative review.nnnRESULTSnOf the 1,382 papers retrieved, 47 were reviewed, and 32 studies met the inclusion criteria. The interventions in the included studies were assessed using the tier 1/tier 2 framework. A total of 18 (56.25%) studies had an administrative measure as an intervention; 20 (62.5%) studies had education and training of health care personnel; 8 (25.0%) studies had judicious use of antimicrobial agents; 17 (53.1%) studies used surveillance; 24 (75.0%) studies had infection control precautions to prevent transmission; 7 studies (21.9%) introduced environmental measures; and 9 (28.1%) studies used patient decolonization. Although all the 32 studies were quasiexperimental studies, only 2 (5.9%) studies provided sample size calculations, and only 5 studies reported confounding factors. Whereas 27 used an interrupted time series design and 2 were controlled pre- and post-intervention designs, 3xa0were pre- and post-intervention without control groups.nnnCONCLUSIONnThis integrative review demonstrated that the evidence of the relationship between MDRO infection prevention and control programs and the rates of MDRO is weak. Although major methodologic weaknesses exist in the published literature making it not possible to exclude other plausible explanations for the reduction of the acquisition of MDRO, the overall evidence does support the use of multiple interventions to reduce the rates of MDRO in acute care hospitals. Whereas it is unclear which bundles of interventions are effective, there is a clear suggestion that multiple simultaneous interventions can be effective in reducing MDRO infections. In addition, despite the limitations of interrupted time series, multiple studies employing active surveillance cultures were associated with reduced MDRO infections. Future individual reports of outbreaks and intervention studies should be written in a standardized manner using the recommended Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) guidelines. Further research is needed on the proposed tier 1/tier 2 framework clearly indicating all the interventions implemented.

Nursing Care and Patient Safety: Visualizing Medication Organization, Storage and Distribution with Photographic Research Methods

Neste estudo qualitativo, adaptou-se o metodo de pesquisa fotografica de estudos anteriores, para identificar fatores relacionados a organizacao, acondicionamento e distribuicao que poderiam levar a erros na selecao, preparo e administracao de medicamentos. O recorte da pesquisa apresentado foi desenvolvido em unidade de clinica medica de um hospital publico, Brasil. Os participantes da pesquisa foram enfermeiros que trabalhavam naquela unidade e academicos dos dois ultimos semestres do curso de graduacao em Enfermagem. Obtiveram-se fotografias digitais do sistema de medicacao e, subsequentemente, utilizou-se a elicitacao das fotos para rever imagens com os participantes da pesquisa, a fim de obter suas percepcoes e narrativas a respeito do trabalho com medicamentos, naquela unidade. Apresenta-se uma selecao dos principais achados da pesquisa sobre organizacao, acondicionamento e distribuicao de medicamentos, indicando que ha espaco para melhorar a seguranca do sistema de medicacao.In this qualitative study, we adapted photographic research methods from earlier nursing research to identify factors related to organization, storage and distribution that could lead to errors in the selection, preparation and administration of medications. The research excerpt presented here was developed in a clinical unit of an urban Brazilian public hospital. The research participants were nurses working at that unit and students from the two final semesters of the Undergraduate Nursing Course. We collected digital photographs of the medication system and subsequently used photo elicitation to review the images with research participants, so as to obtain their perceptions and narratives of working with medications in the unit. We report selected findings here on the organization, storage and distribution of medications, which indicate there is room to improve the safety of the medication system.

Strengthening access to restorative places: findings from a participatory study on engaging with nature in the promotion of health.

In this paper, we examine selected research findings from a community-based study on engaging with nature to promote health. Combining participatory photographic research methods with an iterative process of dialectical analysis, we explored nature-based health promotion with community citizens, practitioners, and decision-makers from various sectors to examine the complexities of connecting with natural outdoor places in local contexts. Participants identified an array of barriers to and opportunities for everyday access to restorative outdoor places. The findings suggest that inter-sectoral governance with active citizen engagement in research, decision-making, and action may be essential to develop the ecological citizenship and communal norms and strategies that promote the health of people and their shared restorative places.

Teorizando sobre sistemas: uma tarefa ecológica para as pesquisas na área de segurança do paciente

Com o movimento global atual sobre seguranca na area da saude, pesquisadores tem chamado a atencao para o referencial da abordagem do sistema como um meio de melhorar a seguranca dos ambientes e pacientes. Entretanto, quais tipos de teorias do sistema devem guiar as pesquisas sobre a seguranca de pacientes? Nesse artigo, argumenta-se que enfermeiros e outros profissionais podem usar as teorias e principios da restauracao ecologica, ou seja da reparacao de ecossistemas danificados, para estudar e fortalecer a seguranca de ambientes. Usando a ciencia da restauracao para teorizar sobre sistemas de saude, serao desenvolvidas habilidades para pensar ecologicamente sobre nossas relacoes com o outro e com os ambientes que dividimos, entre eles o ambiente hospitalar. A aplicacao do conhecimento da ciencia da restauracao em conjunto ao da enfermagem e area da saude, pode fortalecer a criacao de sistemas seguros para todos a custos adequados.As a global safety movement gathers momentum, experts call for a systems approach to improve the safety of todays health care environments. Yet, what kinds of systems theories should guide the field of patient safety research? In this paper, it is argued that nurses and other health professionals can use theory and principles from the field of ecological restoration, which is the repair of damaged ecosystems, to study and strengthen the safety of health care environments around the world. When we use restoration science to theorize about health care systems, we develop the ability to think ecologically about our relations with each other and with the environments we share. As we integrate knowledge of restoration science with nurses knowledge and other knowledge in health care, we may actually create safer health care systems for all at a human and material cost that we are able and willing to pay.

Cuidados de enfermagem e segurança do paciente: visualizando a organização, acondicionamento e distribuição de medicamentos com método de pesquisa fotográfica

Neste estudo qualitativo, adaptou-se o metodo de pesquisa fotografica de estudos anteriores, para identificar fatores relacionados a organizacao, acondicionamento e distribuicao que poderiam levar a erros na selecao, preparo e administracao de medicamentos. O recorte da pesquisa apresentado foi desenvolvido em unidade de clinica medica de um hospital publico, Brasil. Os participantes da pesquisa foram enfermeiros que trabalhavam naquela unidade e academicos dos dois ultimos semestres do curso de graduacao em Enfermagem. Obtiveram-se fotografias digitais do sistema de medicacao e, subsequentemente, utilizou-se a elicitacao das fotos para rever imagens com os participantes da pesquisa, a fim de obter suas percepcoes e narrativas a respeito do trabalho com medicamentos, naquela unidade. Apresenta-se uma selecao dos principais achados da pesquisa sobre organizacao, acondicionamento e distribuicao de medicamentos, indicando que ha espaco para melhorar a seguranca do sistema de medicacao.In this qualitative study, we adapted photographic research methods from earlier nursing research to identify factors related to organization, storage and distribution that could lead to errors in the selection, preparation and administration of medications. The research excerpt presented here was developed in a clinical unit of an urban Brazilian public hospital. The research participants were nurses working at that unit and students from the two final semesters of the Undergraduate Nursing Course. We collected digital photographs of the medication system and subsequently used photo elicitation to review the images with research participants, so as to obtain their perceptions and narratives of working with medications in the unit. We report selected findings here on the organization, storage and distribution of medications, which indicate there is room to improve the safety of the medication system.

Cuidado de enfermería y seguridad del paciente: visualizando la organización, acondicionamiento y distribución de medicamentos con método de investigación fotográfica

Neste estudo qualitativo, adaptou-se o metodo de pesquisa fotografica de estudos anteriores, para identificar fatores relacionados a organizacao, acondicionamento e distribuicao que poderiam levar a erros na selecao, preparo e administracao de medicamentos. O recorte da pesquisa apresentado foi desenvolvido em unidade de clinica medica de um hospital publico, Brasil. Os participantes da pesquisa foram enfermeiros que trabalhavam naquela unidade e academicos dos dois ultimos semestres do curso de graduacao em Enfermagem. Obtiveram-se fotografias digitais do sistema de medicacao e, subsequentemente, utilizou-se a elicitacao das fotos para rever imagens com os participantes da pesquisa, a fim de obter suas percepcoes e narrativas a respeito do trabalho com medicamentos, naquela unidade. Apresenta-se uma selecao dos principais achados da pesquisa sobre organizacao, acondicionamento e distribuicao de medicamentos, indicando que ha espaco para melhorar a seguranca do sistema de medicacao.In this qualitative study, we adapted photographic research methods from earlier nursing research to identify factors related to organization, storage and distribution that could lead to errors in the selection, preparation and administration of medications. The research excerpt presented here was developed in a clinical unit of an urban Brazilian public hospital. The research participants were nurses working at that unit and students from the two final semesters of the Undergraduate Nursing Course. We collected digital photographs of the medication system and subsequently used photo elicitation to review the images with research participants, so as to obtain their perceptions and narratives of working with medications in the unit. We report selected findings here on the organization, storage and distribution of medications, which indicate there is room to improve the safety of the medication system.

Theorizing about systems: an ecological task for patient safety research

Com o movimento global atual sobre seguranca na area da saude, pesquisadores tem chamado a atencao para o referencial da abordagem do sistema como um meio de melhorar a seguranca dos ambientes e pacientes. Entretanto, quais tipos de teorias do sistema devem guiar as pesquisas sobre a seguranca de pacientes? Nesse artigo, argumenta-se que enfermeiros e outros profissionais podem usar as teorias e principios da restauracao ecologica, ou seja da reparacao de ecossistemas danificados, para estudar e fortalecer a seguranca de ambientes. Usando a ciencia da restauracao para teorizar sobre sistemas de saude, serao desenvolvidas habilidades para pensar ecologicamente sobre nossas relacoes com o outro e com os ambientes que dividimos, entre eles o ambiente hospitalar. A aplicacao do conhecimento da ciencia da restauracao em conjunto ao da enfermagem e area da saude, pode fortalecer a criacao de sistemas seguros para todos a custos adequados.As a global safety movement gathers momentum, experts call for a systems approach to improve the safety of todays health care environments. Yet, what kinds of systems theories should guide the field of patient safety research? In this paper, it is argued that nurses and other health professionals can use theory and principles from the field of ecological restoration, which is the repair of damaged ecosystems, to study and strengthen the safety of health care environments around the world. When we use restoration science to theorize about health care systems, we develop the ability to think ecologically about our relations with each other and with the environments we share. As we integrate knowledge of restoration science with nurses knowledge and other knowledge in health care, we may actually create safer health care systems for all at a human and material cost that we are able and willing to pay.