NTARY

ml ethics for infection control: The than he infection control practitioner

K~th@~ine Hill Chavigny, Ph.D., FACE Chicago, lflinois

Infection control practice is a relatively new specialty area. In keeping with the rapid evo- lution of events typical of a modern technolog- ical age, infection control has reached its ma- turity after only 20 years of independent exis- tence in the United States. More than this, infection control has become a professional ac- tivity in its own right; however, professionalism demands the assumption of ethical responsi- bilities that exemplify professional status.’ This article will discuss three major hallmarks of professionalism essential to infection control practice; these hallmarks are autonomy, au- thority, and accountability. These three attri- butes will become moral imperatives to guide the direction and quality of practice in the future.

Professionalism has evolved as a naturally oc- curring process. Most people consider the 1960s as the time when programs for infection control were established in North America. In the 1970s leaders in infection control grouped to form professional organizations to voice the needs of practitioners for education and standards of practice. APIC was born in this era and, a de- cade later, the Society for Hospital Epidemiol- ogists of America.’ Recently, certification to confirm the knowledge base of practitioners has been established”

From the Office of Related Health Professions, Department of Medical Education and Science Policy of the American Medical Association.

Presented in part as the keynote address at the Fourth Biannual Symposium on Infection Control, APIC, September 1984, Al- bany, New York.

Reprint requests: Katherine H. Chavigny, Ph.D., FACE, Amer- ican Medical Association, 535 N. Dearborn St., Chicago, IL 60610.

The activities of the past 20 years illustrate the ability of infection control practice to dis- play autonomy, defined as professional self-de- termination and self-direction on professional matters.4 The second attribute of professional- ism is authority, the ability of a profession to make the right decisions. Authority is based on education and its method of affirmation, cre- dentialling. Accountability, the third attribute of professionalism, is the acceptance of respon- sibility to adhere to standards and codes of practice. Accountability depends on a thorough understanding of the scope of the responsibili- ties involved in the role of the ICP. Titles play an important part in accountability because they imply that the underlying authority or knowledge indicated in the title has been at- tained. We have reason to be pleased with our accomplishments to date. We have struggled to accept the responsibilities of infection control practice and to increase its effectiveness, but the future will demand more from us in terms of autonomy or self-direction, more in terms of authority or scientific knowledge and more, much more, in terms of accountability, the ac- ceptance of responsibility for practice.

In order to discuss self-direction, knowledge, and acceptance of responsibility, let us review the present scope of practice of infection control and the educational preparation that is needed to maintain standards of care. What is the role of the ICP? There has been lively and often con- troversial discussion for many years about the scope of the responsibilities of practitioners in the field. A traditional approach to defining a role has been to discover what the majority of professionals are doing in their practice set- tings.5-8 This approach was used to define the curriculum for certification in the handbook on

1 Chavigny Amertcan Journal of

iNFECTION CONTROL

ig. 1 e Model of the role of the ICP. Functional descrip- tion of practice: surveillance, teaching hospital person- nel, consultation, developing policies and procedures, and investigation of epidemics.

Follow-up in Corn

Public health model of the role of the nurse epidemiologist. Functional description of practice: anal- ysis of infection control data, research, problem solving (for example, mini epidemic outbreak).

infection control CertificationP A functional de- scription is to be found in the same text, de- scribing the role as “surveillance, teaching hos- pital personnel, and consulting about infection control.” It includes “developing policies and procedures, and investigating epidemics.” An- other approach used to define role responsibil- ities is to inspect curriculum content and ex- trapolate activities associated with practice. The Certification Board of Infection Control (CBIC) lists curriculum content required to pass the certification examination A model has been derived from inspection of this curriculum to describe the areas of responsibility of the ICP (Fig. 1). The model shows six areas for practice consistent with the handbook’s description of

the ICP, and uses terms taken directly from the examination content and the C of the role.

It is useful to compare the model for the ICP with a similar model concerning the role of the nurse epidemiologist developed in 1975 (Fig. 2). Originally this model was also based on tasks performed in practice.” It was presented to practitioners at a conference in Ottowa and has been used to teach epidemiology for infection control at the Centers for Disease Control (CDC) in Atlanta. It includes some basic principles of public health such as primary, secondary, and tertiary prevention essential to effective prac- tice.” Additionally, there is a special reference to the interface between the hospital and the extramural community exemplified by the out- patient clinic. The model is well integrated- but a functional description similar model can be noted. In this model, the nurse epidemiologist is described as the surveillance and analysis of infection control data,12 research, and the follow-up needed to control epidemics.

A comparison of the two models shows some differences between the role of the ICP and the role of the nurse epidemiologist, sumrnarized as follows: the nurse epidemiologist’s practice is based on philosophical principles of public health. This role accentuates epidemiologic methods to prevent and control infectious dis- eases in institutions. The responsibilities for de- veloping policies and procedures as well as en- vironmental maintenance is whereas the responsibility for tion plays an important part in the role of the ICP. Furthermore, the concern of the nurse ep- idemiologist is the group, the total hospital community; the ICP relates more to the pro- cedures for the care of the individual patient. The reason for the difference between the two roles may be the inclusion of “epidemiology” in ,the title and its application to infection con- trol. Examination of the role of the hospital ep- idemiologist will assist us in understanding this implication.

The role of the hospital epidemiologist is still relatively underdeveloped. Curriculum to edu- cate physicians in this specialty is being iden- tified, but it is di&ult to define curriculum con-

Volume 13 Number 4

Augusr, 1985 Commentary 1

tent that has general acceptability. It was, therefore, impossible to develop another model from curriculum content for comparative pur- poses; however, a functional description of the role can be found in the literature. The Survey of the Efficacy of Infection Control (SENIC)13 described the hospital epidemiologist’s respon- sibilities as follows: (1) the supervision and evaluation of the collection of infection control data, (2) research, (3) liaison between the med- ical staff and the infection control program, and (4) the supervision of the infection control nurse. The bospital epidemiologist was referred to exclusively as a physician and the description used in SENIC emphasized supervision respon- sibilities. Despite this difference from the func- tional description of the nurse-epidemiologist, the nurses’ role aligns well with the description of the role of the hospital epidemiologist re- gardless of the difference in licensure. Addi- tionally, evidence to support this view is pro- vided by Hierholzer.2 He recognizes that all ep- idemiologists, regardless of their discipline, apply the principles of epidemiology in its broadest sense. He states that specialization is indicated by the setting or the area of common interest. For example, he states that an interest in the control of nosocomial infection is the sa- lient factor indicating specialization in hospital epidemiology. It is obvious from the literature that epidemiology crosses all boundaries of dis- ciplines and is practiced in several settings.14-17 It can be applied to pharmacy and anesthe- siology as appropriately as to chronic disease or acute infectious disease. The common factor is the application of principles and methods of epidemiology. These commonalities are impor- tant and give the authority-the knowledge base-for the use of the title “epidemiologist.”

We have just reviewed two roles, both of which use the name “epidemiologist” to de- scribe practice responsibilities. The difference between them seems to lie in the nature of their basic licensure, nurse or physician, rather than the application of epidemiology to infection concerns. ut a review and comparison of the two models of the ICP and the epidemiologist who is a nurse shows that their scope of practice has some fundamental differences. The roles are not quite the same. True, they overlap; but this

overlap is due to the ubiquitous nature of epi- demiology and not to the similarity of practice responsibilities. Surely this does not, de facto, make the ICP a qualified epidemiologist, nor does it justify the use of the title.

Many disciplines with many different titles are eligible for certification, such as “infection control coordinator, ” “infection control nurse,” or “environmental surveillance officer.” Up to now the title has been inconsequential as long as there is a special interest in infection control in the hospital. This policy is not necessarily wrong. It has been inclusive perhaps to fulfill an urgent need to provide certification as an umbrella under which all health disciplines are authorized to enter the field. But the choice and use of a title after certification may be mislead- ing. The title “infection control practitioner” correctly identifies the interest in a highly fo- cussed area of professional practice; however, within infection control the ICP can be appro- priately viewed as a generalist. A title repre- senting additional specialization within infec- tion control is specific and must be earned. Cer- tification of the ICP has identified a knowledge base encompassing an extensive variety of spe- cialty areas used in the field. Thus the authority to make the right decision is based on several basic and social sciences; and importantly, the accountability of the practitioner for standards of care has its foundation in an extensive range of information and scholarship.

The wide variety of organizations interested in promoting and monitoring standards ofprac- tice in infection control testifies to the need for many specialists to become involved in the safety of the hospital environment. In the field of occupational health diverse titles describe different roles and educational preparation. For instance, experts in occupational health are also industrial hygienists, industrial toxicolo- gists, safety officers, and radiation health spe- cialists, to mention just a few.“, l9 Valenti” ap- propriately calls the occupational health nurse the employee health practitioner. Physicians in- terested in this area practice occupational med- icine. The National Institute of Occupational Safety and Health (NIOSH) is the mecca for occupational health specialists and provides guidelines for standards of care for health per-

Arneman Journal of

‘NFECTION CONTROL

Less than a year ago, the American Occupational Medical Association (AQUA) also published its guidelines for em- ployee health services in the hospitals.Z2

Another area of special knowledge required for hospital infection control practice is envi- ronmental science. 23 The literature in infection control shows an increasing awareness of the need for the safe disposal of hazardous waste. In the hospital setting, waste contains a large proportion of infectious and biologic materials as well as chemical and radioactive effluent. It remains waste, however, and the special prob- lems of the hospital only serves to accentuate the need for highly trained personnel. Some of the standards for practice affecting environ- mental maintenance are set by the Environ- mental Protection Agency (EPA).

We already referred to epidemiology as a spe- cialty area required for infection control, but we also need to mention acute infectious dis- eases and the microbiology on which it de- pends. The Centers for Disease Control (CDC) are the bastions for epidemiology and infectious diseases24 and have played a pioneering role in education for ICPs. In 1983, CDC published guidelines for programs for infection control and also published guidelines in several areas of concern including infection control in hos- pital personne125 and hospital environmental control .26

It is obvious that infection control practice has engaged the interest of many prominent, powerful organizations. These professional es- tablishments are striving to provide criteria for standards of care for which we, the practitio- ners, are publicly accountable through the Joint Commission of Accreditation of Hospitals. It would seem that the reason for so much na- tional involvement is related to the complexity of the problem and the many areas of special- ization required to meet the needs of the hos- pital population. High expectations are im- posed on ICPs to be proficient in all areas of knowledge and accountable for all standards of patient safety. Perhaps we should emphasize the referral and coordination role of the prac- titioner, thereby increasing the accountability and credibility of the profession.

Autonomy, authority, and accountability in-

volve future needs as well as present concerns. To date, we have accomplished what has been feasible and practical. We have developed cer- tification from tasks performed in practice. The future demands that we guide the profession in directions based on scientific k~owle$ge and philosophical conviction, rather than follow practices already in place. The autonomy of the profession refers to the self-determination to identify trends and counsel accordingly. In this way the profession will be ethically responsible to prepare and guide practitioners for impend- ing change.

EickhofP7 in 1980 identified future problems in infection control practice as he saw it. He stated that we have failed in a most important mission. We have failed to provide clear evi- dence of effectiveness of most of our recom- mendations for infection control. A year later, Shands et a1.28 supported Eickhoff by saying that many recommendations or guidelines for infection control have little basis in scientific fact. This lack of “authority” challenges the credibility of infection control, which is now being labelled by some as “a small lily, heavily gilded.” Yet others point to the field as a morass of regulations full of medical-legal pitfalls and claim that we have sensationalized a monster who is out of control. We have a moral obli- gation not only to define our roles in relation to areas of specialization utilized in practice, but to increase our credibility by specifying with greater precision the basis of knowledge from which we derive our authority to make recommendations. If we are unable to meet this challenge, we will find that future events will deprive us of autonomy, the professional right to determine and influence our own destiny.

Since the 1980s there have been social and political changes affecting the total health care system. Cost-containment is not merely a by- word, it is a matter of survival.“‘, 3o Care will shift in the coming decade into the community. The frail elderly, the terminal cancer victim, and the chronically ill will be maintained as much as possible outside institutions. Many hospitals may close. Length of stay, an impor- tant predictor of hospital acquired infection, will be curtailed as far as possible. Patients who remain in the hospital will be acutely, seriously,

Vo!ume 13 Number 4

August, 1985

ill and will represent a cohort at high risk of nosocomial disease. A surplus of physicians will occur and physicians who receive special edu- cation in infection control practice will be more available. Closure of hospitals will make the distribution of nurses more equitable and choice of hire will depend more and more, not on availability, but on preparation and knowl- edge of the job. Shared resources will be the organizational model of the future. Specialists will be hired who serve several hospitals and health facilities for a fixed salary. Accreditation will require the consultation of industrial hy- gienists and environmental health specialists and, in certain circumstances, epidemiologists, who will be a.ccountable in several settings for standards of care related to their fields. These are the practical considerations behind the moral imperatives for autonomy, authority, and accountability.

Rielly4 has said that nurses wish to be all things to all people. We can apply this to infec- tion control and say that practice is all inclusive and that practitioners wish to be accountable in several complex areas of specialization. It is an admirable goal, but it stretches credibility to impractical limits. If the ICP continues to be a generalist in nature, then the major function of the role is coordination and management of infection control policies for quality assurance rather than specialization in epidemiology or environmental maintenance. Titles should re- flect the authority-the educational preparation of the user; titles carry the responsibility to per- form the role that they describe.

In conclusion, professionalism brings ethical responsibilities to infection control practice that are unavoidable if we are to survive the economic constraints of the future. We have made gallant progress; but the field must dem- onstrate its autonomy and guide the profession towards standards for patient care that have scientific value and tangible effectiveness for quality control. Authority must be derived from a knowledge base in infection control practice that is consistent with the responsibilities im- plied by the title used by the practitioner. We must be accountable not only for codes of prac- tice in our own discipline, but also for the re- sponsibility to recognize and consult with spe-

cialists in associated fields. These moral im- peratives, when fulfilled, will bring us the credibility we need to survive. Infection control will be respected as a professional practice and acknowledged as an indispensable part of qual- ity assurance for patient care in institutions.

References

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11

12

13.

14.

15.

16.

17.

18.

19.

Etzioni A: Modern organizations. New Jersey, 1964, Prentiss Hall Inc, pp 77-88. Hierholzer WJ: The practice of hospital epidemiology. Yale J Biol Med 55:223-230, 1982. Shannon RJ: Certification for infection control practi- tioners: The time is now (Editorial). Infect Control 2:8- 20, 1981. Rielly DE: Why objectives? Relationship to occupa- tional health nursing practice. Occup Health Nurs 29:7- 11, 1981. Booth AL, Weeks RM, Hutcherson RR Jr, Schaffner W: A statewide characterization of hospital infection con- trol practices and practitioners. Infect Control I:227- 232, 1981. McArthur BJ, Pugliese G, Weinstein S, Shannon R, Lynch P, Jackson MM, Tsinzo M, Serkey J, McGuire N: A national task analysis of infection control practitio- ners, 1982. Part one: methodology and demography. AM J INFECT CONTROL 1288-95, 1984. Cox AR: AAOHN education survey. Occup Health Nurs 31:28, 1983. Silverstone R: The role and educational needs of OH nurses, 3. Role overlap. Occup Heaith (Land) 34:559- 563, 1982. CBIC Certification Board of Infection Control: Hand- book for Candidates, Cleveland, Ohio, Psychological Corp. Chavigny KH: Nurse epidemiologist in the hospital. Am J Nurs 75:638-642, 1975. Burton LE, Smith H: Public health and community medicine, ed 3. Baltimore, 1980, Williams and Wilkins. Kaiser DL: Data analysis vs. data examination. Infect Control 3:85-86, 1982. Haley RW: The hospital epidemiologist: In U.S. Hos- pitals, 197677: A description of the head of the infec- tion surveillance and control program report from the SENIC project. Infect Control 1:21-32, 1980. Zelis R, Borhani N: The need for training cardiovas- cular disease epidemiologist. Clin Res X3:65-67, 1975. Fonaroff A: Epidemiological implications of pharmacy practice. Am J Pharma Educ 39:605-607, Peterson HB, Rubin GL, Tyler Cw Jr: The need for anesthesiologists trained in epidemiology (Letter). Anesthesiology 53~263, 1980. Friedman C, Hazuka BT: Basic epidemiology for oc- cupational health nurses. Occup Health Nurs 29:7-l 1, 1981. Dees J: Conceptual model for nursing practice in oc- cupational health. Occup Health Nurs X2:137-140, 1984. Pope R: Control and prevention in occupational health: The nurse’s role. Occup Health Nurs 29:12-14, 1981.

1 Chavigny American Journal of

INFECTION CONTROL

20. Vaienti WM: Infection control and employee health. Infect Control 9:192-195, 1984.

21. CDC, NIQSH Personnel health guidelines expected in 1983. Hosp Employee Health 1:157-160, 1980.

22. Brown TC: ALMA unveils minimum EH standards for hospitals (Interviews). Hosp Employee Health 1:73-76, 1982.

23. Roberts FJ: The logic of routine environmental sur- veillance. AM J INFECT CUNTROL 11:74-75, 1983.

24. Langmuir AD: The epidemic intelligence service of the Centers for Disease Control. Public Health Rep 95:470- 477, 1980.

25. Williams WW: CDC guidelines for the prevention and control of nonsocomial infections. Guidelines for infec- tion control in hospital personnel. AM J INFECT CONTROL E2:34-63, 1984.

26. Simmons BP: CDC guidelines for the prevention and control of nosocomial infections. Guidelines for hos- pital environmental control. AM f INFECT CONTROL 11: 97-120, 1983.

27. Eickhoff TC: Nosocomial infections-A 1980 view: Progress, priorities and prognosis. Am J Med 70:381- 388,1981.

28. Shands JW Jr., Wenzel RP, Wolff SM, Eickhoff TC, Fields BN, Jackson GG: From the Infectious Diseases Society of America. Hospital epidemiology and infec- tion control: The changing role of the speciaiist in in- fectious diseases. J Infect Dis 144:609-613, 1981.

29. Daschner FD: Practical aspects for cost reduction in hospital infection control. Infect Control 5:32-35, 1984.

30. Kirkman-Liff B, Danday S: Hepatitis: What price ex- posure? Am J Nurs 84:988-990, 1984.

Classified advertising

The American Journal of Infection Control offers a classified advertising section in each issue. It lists positions available and positions desired. Rates for announcements of JO words or less are $60.00 for one insertion and $48.00 for three or more insertions. Each additional word is $1.20 and $1.05, respectively. There is a $6.00 charge for box service for the first insertion only. Payment must accompany insertion orders. Send classified ads to the Journal Advertising Department, American Journal of Infection Control, The C. V. Mosby Company, 11830 Westline Industrial Drive, St. Louis, MO 63146.