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American Journal of Infection Control 41 (2013) 971-5

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American Journal of Infection Control

journal homepage: www.aj ic journal .org

American Journal of Infection Control

Major article

“Recognizing rapport”: Health professionals’ lived experience of caringfor patients under transmission-based precautions in an Australian healthcare setting

Mary-Rose Godsell RGON GDipHSM, MAdvPrac(Infection Prev & Con), Hons AFAAQHC a,*,Ramon Z. Shaban RN, CICP, PhD, FACN, FCENA b,Jenny Gamble RN, RM, DAppSc(NursEd), BN, MHlth(Research), PhD(Midwifery) b

aWestern Australia Country Health Services, Bunbury, AustraliabCentre for Health Practice Innovation, Griffith Health Institute and School of Nursing and Midwifery, Griffith University, Nathan, Australia

Key Words:Transmission-based precautionsPatient safetyInfection preventionInfection control

* Address correspondence to Mary-Rose Godsell,(Infection Prev & Con), Hons AFAAQHC, Nurse ConsuControl, South West Region, Western Australia Countr4th floor, 61 Victoria St, Bunbury, WA 6230, Australia

E-mail address: maryroseg@hotmail.com (M.-R. GThis research was funded in part by the Unive

Midwifery through a postgraduate student research gConflict of interest: None to report.

0196-6553/$36.00 - Copyright � 2013 by the Associahttp://dx.doi.org/10.1016/j.ajic.2013.05.022

Background: Preventing health careeassociated infections is essential to the safety and quality of healthcare. Although patients’ experience of care under isolation is well established, little is known of healthcare workers’ experiences when providing such care. This study explored the health professionals; livedexperience of caring for patients under transmission-based precautions.Methods: Interpretive phenomenology was used to examine 12 health care professionals’ lived experi-ence of providing care under transmission-based precautions in 3 health care facilities in Australia. Datawere obtained from in-depth interviews and observations of health professionals.Findings: The essential phenomena of “recognizing rapport” represented the health professionals’ livedexperience. Three themes emerged starting with (1) relationships with others, their rapport andcommunication with patients, patients’ families and visitors, and colleagues. These relationships areinfluenced by (2) barriers to practice, such as personal level of comfort whenwearing personal protectiveequipment, physical limitations of the environment, and management of workload and resources. Suchbarriers influence (3) patient outcomes, namely the quality of the care provided and adverse events.Conclusion: In the context of caring for patients under transmission-based precautions, the relationshipsbetween health professionals and their patients are critical to the quality and safety of health care withrespect to infection prevention and control.

Copyright � 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved.

Despite recent advances in treatment of disease, health care-associated infections are a continuing global burden. Patientsacquire these infections during the course of treatment for otherconditions within a health care setting. Infection and colonizationby multidrug-resistant organisms (MDROs), such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistantenterococci (VRE), and gram-negative bacteria, are endemic andubiquitous in health care settings.1,2 Approximately 200,000 health

RGON GDipHSM, MAdvPracltant, Infection Prevention &y Health Services, The Tower,.odsell).rsity School of Nursing andrant.

tion for Professionals in Infection C

careeassociated infections occur each year in Australia, resulting inincreased morbidity and mortality, patient length of stay, and costto the health system.3,4

The importance of preventing and controlling health careeassociated infection is well established.4 In Australia, as in mostdeveloped countries, infection prevention and control is animportant element of clinical governance frameworks in contem-porary health care settings. In 2008, the Australian Commissionon Safety and Quality in Health Care developed a national safetyand quality framework, which includes the program “reducingharm to patients from health care associated infection: the role ofsurveillance.” This framework underpins facility-based infectionprevention and control programs to prevent health careeassociated infections and mitigate risks through effective workpractices.5

Transmission-based precautions are work practices carried outin addition to standard precautions for patients with known or

ontrol and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

M.-R. Godsell et al. / American Journal of Infection Control 41 (2013) 971-5972

suspected infection or colonization with infectious agents thatare not contained by standard precautions alone.1 The use oftransmission-based precautions is associated with both positiveand negative patient outcomes. Previous studies have reported thathealth professionals are less likely to visit or interact with patientsreceiving transmission-based precautions compared with otherpatients, leading to reduced documentation of care and increasednumbers of preventable adverse events.6-8 Furthermore, thepsychological effects, such as sensory deprivation9 and ethicalconcerns in providing rehabilitation treatment for patients withMRSA,10 also affect the quality of care.

Although much is known about the patients’ perspectives andexperiences of receiving care under transmission-based precau-tions, little is known about health care workers’ experiences whenproviding such care. Understanding the experiences of health careworkers may help realize efforts to mitigate the negative effects oftransmission-based precautions and improve the quality and safetyof health care.11 The aim of this study was to explore healthprofessionals’ lived experience of caring for patients undertransmission-based precautions.

METHODS

Study design

This study used an interpretive phenomenology approachderived from the hermeneutic philosophy of Heidegger.12 Thisapproach enabled examination of the phenomena from the healthprofessional’s perspective, providing insight into the meaning ofthose lived experiences rather than simply describing the experi-ences of caring for patients under transmission-based precautions.The methodology was a good conceptual fit because it took intoaccount a pre-understanding of theirworkplace, the culture, and thelanguage within it. Human Research Ethics Committee approvalswere obtained from the participating health care service.

Participants and setting

The research was conducted in 3 district hospitals in WesternAustralia. A purposive sample of 12 health professionals wasrecruited to the study to amass information on the researchphenomena. All 12 had both experience in and knowledge ofpracticing transmission-based precautions and the opportunity tocarry out these practices during the study as part of their dailywork practice. The criterion sample included nurses, medicalofficers, physiotherapist, and an occupational therapist currentlyworking in 1 of the 3 health care facilities. Nine registered nurses,2 medical doctors (interns), and 1 physiotherapist participated inthe study, with half (n ¼ 6) of the participants working in allhealth care areas and the remainder working in the medical andpediatric wards, and on a day stay unit. Ten of the 12 healthprofessionals were interviewed, 1 of whom was also observedcaring for a patient under transmission-based precautions.The other 2 health professionals were observed practicingtransmission-based precautions but not interviewed owing tounavailability. Informed consent was obtained from all partici-pants and the patients cared for by the health professionals duringobservations.

Data collection and analysis

There were 2 sources of data for the study: individual inter-views and observation field notes, both recorded by a singleresearcher (M.-R.G.). In-depth, semistructured interviews with

each participant were the primary form of data collection.13 Thisenabled an exploratory form of inquiry suited to the methodologywhen nonassisted responses and nonverbal indicators wereinterpreted through the interview questions,14 and providedrichly detailed information.15 In addition to the interviews, fieldnotes were taken during observations. The duration of the inter-views averaged 30 minutes (range, 20-35 minutes) and wererecorded digitally and transcribed verbatim. Data were analyzedby the researcher by reflecting on the experience of healthprofessionals caring for patients under transmission-basedprecautions. Each interview text was read and reread thor-oughly, to allow analysis and interpretation to develop over timeuntil no new themes emerged, considered the point at which“thematic saturation” was achieved.16 Field notes were analyzedby linking the observations to the experiences expressed in theinterviews. Credibility and trustworthiness occurred throughmember checking the interview documentation12 and meticulousdata collection and documentation of the analysis process,methods, and assumptions.17 Ethical considerations for healthprofessionals were upheld, because individuals were not identi-fiable; anonymity was achieved through deidentification ofparticipant workplace through the inclusion of 3 health carefacilities.13

FINDINGS

For the participants in this study, the lived experience of caringfor patients under transmission-based precautions, revealed anoverall phenomena of “recognizing rapport” and 3 key themes: (1)relationships, (2) barriers to practice, and (3) patient outcomes.These themes reflect how the participants understand and inter-pret their experience of caring for patients under transmission-based precautions.

The phenomenon of recognizing rapport encapsulates rela-tionships with patients, colleagues, and family and visitors as a keyelement of patient care, and influences the quality and safety ofpatient care provided.

Recognizing rapport

Theme 1: RelationshipsFundamental to the lived experience of health professionals’

caring for patients under transmission-based precautions arerelationships. The health professionals’ actions were motivated bya sense of duty to their patients, their colleagues, and the patients’visitors and families. It emerged that building patient rapport wascentral to the health professionals’ experience.

Patient rapport. An essential aspect of health professionals’ practiceis patient rapport, which was evident when the transmission-basedprecautions created barriers, such as wearing personal protectiveequipment (PPE). One participant reported that not being able toput on and take off her reading glasses while wearing PPE createda barrier to establishing patient rapport, and was concerned thatthis may be perceived negatively by patients, affecting nonverbalcommunication:

“You don’t see things very well when you’re looking at things upclose you know...but you just have to look under them or overthem...and people say oh, you’re looking very stern.”

Similarly, many participants reported that wearing a maskprevents patients from seeing their facial expressions or hearingthem properly. This reduces the sense of personal connectionand impairs the therapeutic relationship with patients and

M.-R. Godsell et al. / American Journal of Infection Control 41 (2013) 971-5 973

represents one of the greatest challenges described. Participantsexpressed the belief that this alienates patients, which erodesattempts to develop trust and a good patient rapport as healthprofessionals:

“I know physically I’m doing all the things I need to do, but Ithink the therapeutic relationship is a big part of nursing, and Idon’t feel that we do that as well with precautions in place.”

Acknowledging the challenges of developing rapport, someparticipants attempt to counteract the effects of transmission-based precautions by using humor, apologies, and explanationswhen wearing PPE. They make an effort to speak with the patientsfor longer periods or more frequently. Even so, participants re-ported feeling able to give only limited psychological support topatients. One participant reported a similar concern regarding theimportance of connections with patients:

“Obviously, you’re trying not to catch what they’ve got...[how-ever, you don’t want to] make them feel like you don’t want togo near them.”

The theme of patient rapport highlights the relationshipsbetween health professionals and patients under transmission-based precautions.

Working with colleaguesRelationships with other health professionals feature strongly in

the lived experience of the participants in the study. Participantsexpressed that relationships are important to identifying andcommunicating the need for, and the type of, precautions requiredfor a patient as a priority. If this did not occur participants perceivedthat patient care was affected. One participant reported the expe-rience of communicating specific precautions and cleaningrequirements to a wide group of key stakeholders:

“As soon as we know that someone’s on the ward...underprecautions, I let the kitchen staff know, their supervisorknow...and I go through the precautions with nursing staff andget them to hand that on.”

If participants are engaged in providing care of a patient thattakes some time, they ensure that colleagues look after otherallocated patients:

“You actually had to manage your time differently, or obviouslyseek help from your colleagues...so it was just a matter ofmaking sure things were communicated well.”

Communicating with family and visitors. Communicating withpatients’ family members and visitors is significant to the partici-pants’ experience, as one participant recounted when it comes toeducating visitors about donning and removing PPE:

“You’re supposed to restrict the amount of visitors...and thentrying to educate the family about when they are actuallysupposed to de-robe...some are better on the uptake thanothers.”

As illustrated earlier, the health professionals in this study re-ported that there was little time to provide this education.

Participants reported that written guidelines and visualprompts aid them in this task, but believed that there are littleevidence to support these practices. As one participantcommented:

“I haven’t actually seen any data or studies that show that it hasdecreased transmission....from patient to patient, or frompatient to health care professional.”

This quote is an example of how participants question theevidence base and efficacy of formal guidelines relating to theirinfection prevention and control practices and required educationof visitors and family.

Theme 2: Barriers to practiceThe second theme, barriers to practice, highlights personal

comfort whenwearing PPE, the working physical environment, andworkload and resources in relation to caring for patients undertransmission-based precautions.

Personal comfort. One key feature is the participants’ level ofcomfort when wearing PPE and their perception of how thisaffects their ability to maintain transmission-based precautions.For many participants, wearing PPE is uncomfortable, claustro-phobic, restrictive, and hot:

“The worst aspect really for me is that you’ve got a gown on anda mask, and I think sometimes I feel a little bit claustrophobicwith having all that gear on as well. And it’s actually quite hotwearing all that gear.”

In contrast, some participants reported that PPE and surgicalmasks are quite comfortable. Regardless, participants expressed theimportance of wearing PPE in terms of their personal safety andwere happy to carry out transmission-based precautions to protectthemselves:

“I think when you’ve looked after those kind of patients thatyour awareness is definitely heightened. You know, maybe takethose few extra seconds to really make sure you’ve done a reallythorough job...there’s a chance that you’re going to catchsomething it does make it more meticulous.”

Some participants expressed concerns about the effectiveness ofPPE, noting that sometimes gowns do not protect against exposureto body fluids. Other participants conveyed concerns regardingemergency situation when there is insufficient time to don PPE.

Physical environment. The physical environment of a single roomfor patients under transmission-based precautions was cited bymany participants as a barrier to providing patient care. Partici-pants reported having to either leave the room to use the phone orto use the phone in the room while wearing PPE, which causesdifficulty in communication. Some reported being unable to usea fob watch for vital sign assessment because the gowns typicallycover it. The inability to access a pen towrite down data and havingto then remember the data to complete documentation onceoutside the roomwas reported. According to participants, wearinggloves reduces fine motor skills, and thus gloves are not alwaysused. Some participants found applying PPE frustrating in situa-tions requiring prompt access to patients, and noted that some-times precautions are not taken in an emergency.

The limited space of a single room restricts staff movement, aswas observed in practice. Two nurses carrying out contactprecautions for a patient while redressing several large woundswere observed having to dispose of numerous gowns and glovesbetween the dressings in the patient’s room. Given the spacerequired for other equipment and the dressing trolley, the recip-rocals were placed closest to the door to enable safe removal anddisposal before the next set of gown and gloves is donned. Thissituation highlights that practicing transmission-based precautionstakes extra time in a confined space, a challenge related to work-load and resources.

Workload and resources. Participants frequently described thetime-consuming nature of transmission-based precautions, yet

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expressed an understanding that these practices must be per-formed. The number of allocated patients, level of acuity, andconsecutive days of required transmission-based precautions wereidentified as important workload factors, as was the total numberof patients requiring a single room on a shift. One participantexpressed frustration at having to ask for help because it wastedtime:

“Even something as simple as somebody else to come into theroom to help you lift the patient off the bed...you would...comeout of the room, disrobe, get clean, get help, get back within thespace of 5 minutes, and it’s just so frustrating. It’s like wastingeverybody’s time.”

Implementing transmission-based precautions was also viewedas a strain on nursing resources in addition to the usual staffingshortages:

“It can be quite demanding on nursing resources, nursing timewhen we’re all so time- starved, with staffing shortages. It putsa lot of extra strain on the nurses by having to put additionalprecautions in place.”

Observation of nurses performing several largewound dressingson a patient under contact precautions reinforced the extrademands on nursing time and staff. This increases the workloadowing to the lack of available equipment in the room. Any forgottenequipment must be retrieved and extra time taken to clean it afterpatient use, which is connectedwith perceived or real effects on thequality of patient care.

Theme 3: Patient outcomesAll participants described some aspect related to intended

patient outcomes through the standard of care given and potentialor actual adverse events.

Level of care: The standard. Some participants reported thatpatients under transmission-based precautions do not receive thesame level of care as patients not under such precautions, owing toless human interaction. One participant, a doctor, suggested thatnot being able to readily access patients because of precautionsinfluences the quality of patient care:

“A patient with precautions, it’s so much effort to go in and outof the room each time, you don’t do it...you read back throughthe notes...they don’t see us as often if I was to be honest.”

Patients under transmission-based precautions are reported tohave fewer visitors. In addition, transmission-based precautionscan create a delay in services provided, such as the collection andtesting of blood samples. Other participants suggested that patient-dedicated stethoscopes were inferior in quality to their personalstethoscope, influencing the standard of care provided. Participantsexpressed concerns about the variations in level of patient care, butdid not always express negative outcomes as a consequence;however, adverse events were identified in some circumstances.

Adverse events. Participants reported that some patients undertransmission-based precautions are at greater risk of adverseevents. For example, it was suggested that some patients do notreceive insulin on time or at all, whereas other patients do not haveclinical observations recorded. In other instances, some treatments(eg, physiotherapy) were abridged owing to a lack of space. Mostparticipants reported patient safety as the rationale for wearingPPE, which they noted is important for protecting vulnerablepatients.

Potential adverse events were also related to the applicationor omission of transmission-based precautions. One participant

reported that daily safety checks of equipment are not always donein the room of patients under transmission-based precautions:

“When you’re doing your checking of all your equipment andthat sort of thing, I couldn’t say that really happens veryoften...I mean, I certainly haven’t done those checks unlessthey’re actually using oxygen or suction.”

The availability of medical staff during the admission was citedas a potential problem. If a doctor is not available, then the patientis admitted without a diagnosis, which is problematic if the patientpresents with confirmed or suspected communicable disease,because it delays the instigation of transmission-based precautionsand thus puts staff and patients at risk.

DISCUSSION

Research shows that transmission-based precautions andcomparable infection control practices have a major effect on thepsychological well-being of patients.6,18,19 For example, the use ofa gown and a pair of gloves may be a barrier to providing healthcare. The present study shows that health professionals areconscious of such effects and actively search for ways to developpatient rapport. Participants also reported concerns that thephysical barriers of PPE and personal spectacles carry negativeconnotations and create a barrier to patient rapport. This raisesquestions regarding the nature of relationships, power, andauthority between patients and the health professionals caring forthem. Participants assigned equal importance to protecting them-selves by wearing PPE and promoting psychological care bydeveloping patient rapport when carrying out transmission-basedprecautions.

The literature provides evidence that health professionals spendless time with patients under transmission-based precautions.Caring for multiple patients under contact precautions is time-consuming for health professionals.20 Our present findings areconsistent with this, and emphasize how human and physicalresource allocation in clinical settings is a significant factor in thequality of patient care. Reasons specific to the participants in thisstudy included workload, number of patients requiring a singleroom on the ward in a shift, demands of patient acuity level,number of consecutive days of transmission-based precautions,staff shortages, and the need to take extra time to ask for help fromcolleagues. It was also reported that several health professionals areoften required to care for a single patient under transmission-basedprecautions for certain procedures.

The participants noted that in some instances, the level of caregiven to these patients can lead to adverse events. They reportedthat the level of care provided to patients under transmission-based precautions differs compared with that for patients notunder precautions. What is not examined in the literature,however, is how this variation in level of care may lead to potentialor near-misses rather than actual adverse events. PPE was cited asa barrier to providing the standard of care required, as reportedpreviously,6 Restrictive and uncomfortable PPE impedes the abilityto perform procedures, which threatens patient safety.

Our findings also provide insight into the interconnected natureof risk management and patient safety that do not feature promi-nently in previous research. Our participants perceive that extratime is needed to perform care under transmission-based precau-tions because of the physical environment. They reported thatrestricted movement in a confined space with limited accessand egress and hinders donning and disposing of PPE. Thechallenges of the physical environment faced by health profes-sionals are accentuated in emergency situations, with participantsreporting anxiety about having insufficient time to don PPE and

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provide the necessary patient care required, as well as concernsabout the risk of occupational exposure. The lack of access to andavailability of equipment and its quality also has consequences forthe standard and quality of care provided to patients.

Another factor integral to providing patients with safe andquality care is communication among health professionals. This iscritically related to the timing of placing patients in transmission-based precautions on admission and throughout the patientjourney. It is not always easy to identify the person responsible forspecifying the need for transmission-based precautions. Failure toso do potentially exposes other patients and staff to infection, and ifthis occurs unnecessarily, patients’ anxiety and psychological careis not addressed. Participants characterized working withcolleagues as essential; in situations when other allocated patientsneed attention, this can be given by their colleagues while they areengaged in providing care to patients under transmission-basedprecautions.

The study establishes that health professionals find it chal-lenging to instruct visitors about restricted access to patients andhave little time available for educating and monitoring the correctuse of PPE and other transmission-based precautions. These find-ings illustrate the importance of visitor education, although staffworkload must be taken into account. Health professionals reportbeing generally time- poor, and additional work will undoubtedlymake providing care even more challenging. For our participants,developing rapport with patients is an important aspect of patientcare. It is essential to understand the health professionals’perspective and the importance of striking a balance between theresponsibility to follow correct practices for patients undertransmission-based precautions, caring for these patients psycho-logically, and having an attitude that supports both.

Finally, our findings illustrate that health professionals are notalways clear about indications for the use of transmission-basedprecautions. This may be remedied by further education, but italso highlights the challenges associated with determining that theprecautions are indicated. This demonstrates that clear practiceinstructions are important for patient care, especially in ruralhealth care settings with fewer available resources.

This study has some limitations. The data are largely self-reported and thus might not reflect actual practice. In addition,our findings cannot be generalized to all health professionals’experience of caring for patients under transmission-basedprecautions, but are context-bound to a rural setting.

CONCLUSION

Health professionals are pivotal to patient safety and the qualityof health care. The findings of this study reinforce the interde-pendence of patients and health professionals in assuring safe,quality health care. The data connect patients’ and health profes-sionals’ perspectives with respect to health careeassociated infec-tions, and add to the evidence base of contemporary infectionprevention and control practice. They emphasize the importanceof building good rapport and well-balanced relationships withpatients and how this translates to improved patient care. They alsoreveal that understanding the significance of relationships withpatients and colleagues may improve both health professionals’

and patients’ experience of health care under transmission-basedprecautions. Education programs on transmission-based precau-tions should be provided to patients, families, and visitors inaddition to health professionals. Moreover, risk managementstrategies from the health professionals’ experience should beincluded in health care policy. Overall, our findings identify howhealth professionals’ experiences contribute to improving thequality and safety of health care for patients.

Acknowledgment

The authors thank the participants for their time and contri-butions that enabled this study.

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