Rasmussen, Julie (2012) Exploring the use of protocols and guidelines in the management of healthcare-associated infection : a case study. PhD thesis, University of Warwick.

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Abstract

Implementation of protocols and guidelines is an important strategy used by
hospitals in their fight against healthcare-associated infections (Pratt et al., 2007),
yet their use remains a challenge (Boaz et al., 2011; Grimshaw et al., 2001). This
thesis addresses the topic of behavioural change through exploring how protocols
and guidelines are used on hospital wards to manage the risk from Clostridium
difficile infection, the difficulties ward staff faced with their use and what
happened in practice as difficulties were experienced.
A qualitative study was conducted using a single case study methodology (Yin,
2009) with one acute NHS hospital in the UK. Methods used included nonparticipant
observation (184 hours), informal conversation, interviews (49) and
document review. An adapted version of the topic guide developed by Michie et
al. (2005) based on their theoretical framework of behavioural change was used in
the interviews. Data collected was analysed inductively using NVivo 8 and
compared against Michie et al’s (2005) framework.
The findings illustrate that nurses and doctors were detached from protocols and
guidelines. Instead they relied heavily on informal sources of knowledge to guide
their practice. Examples include experiential knowledge, common sense,
intuition, ‘‘rules of thumb’’ and “mind lines’’ (Gabbay and le May, 2004, 2011).
They also took account of preferences, their perceptions of risk, social norms and
other contextual issues. Four emergent themes illustrate the complexity of factors
hindering and assisting the use of protocols and guidelines into practice. These
are ambiguity, organisational issues, professional frustrations and perceptions of
contamination. Variations in practice were widespread as protocols and
guidelines were ‘worked around’ and improvisations were made as ward staff
struggled against a tide of organisational constraints, unrealistic conflicting
priorities and difficulties with protocol ambiguity. The way that difficulties were
being solved on the ward means that the underlying causes were not being
addressed as concerns were not brought to the surface. Professional frustrations
such as feeling overwhelmed and powerless acted as barriers to nurses’ reflection.
The study has empirically expanded Michie et al’s (2005) behavioural framework
whilst exploring the dynamics and complexity of categories influencing the use of
protocols and guidelines through a ‘thick’ description of the study findings. This
study has made a conceptual contribution to the literature by identifying that
Michie et al’s (2005) framework does not seem to take into account tacit and
experiential knowledge, professional knowledge, how sense is made of
information from the local context or the process of reflection as part of learning.
Recommendations are made to address the findings from this study.

Item Type:	Thesis or Dissertation (PhD)
Subjects:	R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine R Medicine > RC Internal medicine
Library of Congress Subject Headings (LCSH):	Nosocomial infections, Nosocomial infections -- Prevention -- Standards, Medical protocols
Official Date:	October 2012
Dates:	Date Event October 2012 Submitted
Institution:	University of Warwick
Theses Department:	School of Health and Social Studies
Thesis Type:	PhD
Publication Status:	Unpublished
Supervisor(s)/Advisor:	Seers, Kate ; Hundt, Gillian
Sponsors:	NHS Institute for Innovation and Improvement (Great Britain)
Extent:	xix, 506 pages.
Language:	eng

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