Demographic characteristics of the participants
Majority of the nurses were aged between 30-39 years. Level of training in nursing ranged from diploma to master’s degree with more than half having attained a diploma. There were more degree holders in the private hospital than in the public and faith based.
Nearly half of the nurses had spent more than 10 years in their current facility, although majority were from the public hospital. Regarding years of experience as a newborn nurse, only one had more than 10 years with majority of the nurses having spent between one and six years. The characteristics of the interviewed nurses are summarised in table 1.0.
Table 1.o Demographic characteristics of participants
The findings are presented in two sections. The first section presents the IPC norms in each hospital while the second section focusses how local contexts create emergent properties within nurses’ practice that are an important influence on quality of care (QoC). I present how nurses negotiate the different healthcare contexts resulting in practical norms.
Infection prevention and control and its contribution to quality care
All nurses were cognizant of how infection prevention and control was a key process that contributes to quality care. In this regard, an IPC plan was in place in three hospitals. There were posters and other laminated materials on how health care workers, parents and visitors to the newborn unit (NBU) ought to conduct themselves in regard to IPC. The public and private hospitals also had an isolation room for babies referred from outside the hospital and for babies with a contagious disease respectively. Each hospital-specific measures to address IPC are described and compared across three hospitals followed by how nurses negotiate their practice within these contexts and their perceptions of these negotiated practice.
IPC protocols
All three hospitals controlled entry for nurses, mothers and visitors to the ward. There were instructions at the entrance on changing their home clothes and shoes for clean disinfected hospital shoes for all, and for hospital gowns for mothers and into clean nursing uniforms for nurse. Table 2.0 shows that similarities and differences in IPC norms across three hospitals.
Although visitors were allowed in the NBUs, they were however required to remove any extra clothing such as sweaters and jackets, and to fold long sleeved shirts or blouses. They were in addition instructed to wash their hands with soap and water or apply an alcohol based hand rub. All hospitals had water and soap for hand washing as well as alcohol based hand rubs visibly displayed in the NBUs, although water supply was irregular in the public.
Table 2.0 Similarities and differences in what IPC norms in the three hospitals.
There were observed differences across the hospitals in terms of controlling for visitors; availability of an isolation room as well availability of water as well adherence to handwashing. In this regard, only the private hospital expressly indicated that they allowed visitors into the ward. Moreover, only the faith-based hospital did not have an isolation room in the newborn ward. Although a 24- hour supply of water was a challenge in the public hospital, even in situations accessions when water and soap as well as the alcohol based hand rubs were available, there were no visible or verbal instructions for their use for all who entered the ward to use them. From my observations, it was noteworthy that these norms were not fully implemented across the newborn wards.
In the next section, I present these observations and what nurses said influenced their practices.
Practical implementation of the IPC protocols
Table 3.0: Practical implementation of IPC across hospitals
From the table 3.0 there are changes on what was in table 2.0 as described below.
Public hospital
Whereas, the public hospital had indicated that no visitors were allowed in the newborn unit, in practice, visitors could be seen on the ward. Reasons given by nurses in the public hospital, were poor physical layout, understaffing, lack of enforcement to protocols uninformed mothers, insufficient gowns and sandals.
Regarding poor physical layout, the nurses at the station or in other rooms where babies are admitted, could not see the entrance and some mothers took advantage of this to sneak in relatives.
“…You see when we are seated at the nurse station, you can’t see the entrance…the other problem is visitors, although we have written no visitors allowed they are sneaked in when we are busy attending to babies in either side or gone to the KMC section... and there we are failing…” Public 06
It is lunch time in public NBU, Public 04 and Public 07 are at the nurse station going through the handover process. While this is going on, relatives keep walking in and out of the NBU. Whenever Public 04 noticed strange people walking in, she would warn the mothers that visitors were not allowed in the unit due to low immunity of the babies.
Although the mothers seemed to be aware of this requirement, they just ignored it. The mothers cited the long distances their relatives had travelled to check on them and their babies while nurses thought this was a sign of low value placed on adherence to IPC.
Observation notes Public 10.02.2018
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Uunderstaffing on the ward created opportunities that mothers seized to bypass the IPC requirements. The text box below describes how the only nurse on the previous shift in the public hospital is conducting a handover to an incoming nurse and literally this means the ward is unattended to, and how mothers exploit this shortcoming to sneak in their relatives.
Resource scarcity in the public such as clean hospital provided gowns and sandals led to mothers entering the ward with their own ‘sanitized sandal’. A nurse explains the danger in doing so.
“… Mothers are supposed to change their home clothes and shoes, but we don’t have enough for all of them. They end up with their slippers in the ward and yet they have been walking everywhere with them…” Public 02
There was a lack of observation of hand hygiene procedures by mothers and visitors. I observed that the location of the sink in the room that housed babies that were classified as critical as opposed to it being located for example at the entrance contributed to this of practice. Secondly, I did not hear any verbal instructions given to the visitors or mothers to observed hand hygiene before entering the ward or holding the baby as there was no personnel to enforce and monitor visitors’ and mothers’ adherence to the instructions.
Although there was an isolation room in the public hospital, I observed that babies whose condition deteriorated and needed resuscitation were shifted to the critical babies’ room where the resuscitation equipment was available. Although this was in direct contravening of the isolation policy, nurses considered saving the baby’s life more important.
“…This baby needs oxygen which is only available in this room, so I had to bring her in here... so, we try to avoid mortality that is what we don’t want to happen to these babies…” Public 07
Faith based hospital
IPC practices in the faith based hospital were implemented according to the norms. Cognizant of resource shortages in terms of adequacy of staffing, physical space and lack of isolation room, the hospital policy allowed only babies born in the hospital to be admitted into their NBU. To control for visitors, the NBU was located at the end of the ward in a corner with two doors controlling entry. The nursing desk was located directly facing the entrance to allow the nurse to enforce handwashing instructions, removal of extra clothes and change of sandals into clean sanitised NBU sandals.
The NBU was also out of bounds for casual workers employed by the hospital to carry out cleaning, but instead nurses took upon themselves cleaning roles.
“…We try and limit traffic by only allowing in mothers, controlling for infection, not admitting babies born at home or those we have discharged and have come back. In addition, we do the cleaning of the incubators, the shoes, and the floor. The support staff don’t move close to the cleaning in here. Every day (morning) we clean at least two incubators, dust the others and by the end of three days, we have cleaned all the incubators…” Faith based 01
To allow for relatives to see the babies in the NBU, the inside facing wall was made out of glass so that at the request of a mother, the curtain covering the glass wall could be folded for them to have a glimpse of the baby.
Private hospital
In the private hospital, systems of IPC control went beyond the nurses to involve the security guard who was aware as well as in-charge of enforcing the norms. I observed a very strict adherence to hand washing as well as folding of long-sleeved clothes and taking off of extra clothing such as sweaters and jackets for consultants and visitors. The following is a description by a nurse of the hospital’s elaborate IPC procedures.
“…we have infection control programs – the greatest challenge for neonates is that they are prone to infections. The fact that they are born premature is a direct exposure that makes them susceptible to infections. Handwashing and sanitizing our hands in this unit must be followed strictly. There are sanitizers on the incubators of every baby – you must have noticed that outside every door there is a sanitizer. Inside the room, there is a sink, a sanitizer and a --hand scrub. For neonates, Infection is likely to be from patient to patient and the only way that the care giver can almost prevent contact infection will be proper handwashing so that an infection is not picked from one patient to another. Visitors to the unit are restricted – the doors have a “STOP” sign, and instructions to remove your coat in order not to transfer infections from other external sources, because this is a sensitive unit. Here, everyone is very keen because you do not want to be the one responsible for spreading infections – but it has happened…” Private 09
The hospital also preferred the use disposable cups for those cup feeding to avoid contamination that could result from improper disinfection. Although visitors were allowed into the neonatal intensive unit, they were not allowed to touch the babies, instead they were allowed to see them in their incubators. However, for the parents or family designated next of kin of the babies in the neonatal high dependency unit, they were required to change into clean provided hospital gowns so they could hold the babies as well as practice kangaroo care.
From these findings, it emerges that nurses across the three hospital sectors are aware that IPC is very important in their quest to provide quality inpatient care. However, they also recognised that their work environment is important in facilitating their ability to practice IPC. How the different hospitals are physically designed and staffed either facilitated or hindered nurses IPC practices. This led to nurses in this study negotiated their practices differently, with the public hospital nurses acknowledging their failure to control for visitors. Whereas, the private hospital had put in place simple interventions such as hiring a security guard to control for visitors as well as ensuring adherence to hand washing norms, the absence of such in the public led to uncontrolled inflow of visitors. The lack of isolation room in the faith based caused the hospital to admit only in-house born babies.