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rev 2010-09-09
Research plan
Experiences in patients colonized with Methicillin Resistant Staphylococcus aureus
and knowledge, attitudes and behaviour of Health Care Workers
Maria Lindberg
Centre for Research and Development
Uppsala University/County Council of Gävleborg
SE 801 87 GÄVLE
Department of Public Health and Caring Sciences
Section for Caring Sciences
Uppsala University
Uppsala Science Park
Staphylococcus aureus (S. aureus) is a gram positive bacterium which normally can be
present on the skin, especially on warm and moist areas such as nasal mucosa, groin, axilla,
perineum and toe-web. Up to 50 % of the general population are nasal carriers of S. aureus.
This carriage is rarely a problem in healthy people, since S. aureus neither harm nor benefit its
host. But when a person becomes more vulnerable, e.g. elderly, hospitalized or immune
compromised, it is more likely to cause clinical disease (Cookson, 2005; Tarzi, Kennedy,
Stone, & Evans, 2001). S. aureus is the most commonly cause of skin and soft tissue
infections, pneumonia, post operative wound infections and blood stream infections (Doern,
Jones, Pfaller, Kugler, & Beach, 1999; Giacometti et al., 2000; Pfaller et al., 1999). A change
in the antimicrobial sensitivity of S. aureus was identified in the1960´s and became the gate
for methicillin resistant staphylococcus aureus (MRSA). This means that beta-lactamas, like
penicillin and ampicillin, are ineffective against most of the isolated strains, and this has
become a major problem in healthcare world wide (Bukhari et al., 2004; Cookson, 2005;
Hackbarth & Chambers, 1989; Tiemersma et al., 2004). MRSA and sensitive S. aureus occur
as asymptomatic colonisation which is far more common than infection. Colonisation may be
transient or persistent and last for years. Compared to the general population, higher rates of
colonisation are observed in healthcare workers (HCWs), intravenous drug users (IDU),
persons with insulin-dependent diabetes; dermatologic conditions; and long-term indwelling
intravascular catheters (Chambers, 2001).
In Europe there is a geographic variation of MRSA, with the lowest prevalence in the north
[Iceland, Denmark, Netherlands and Sweden] and highest prevalence in the south [Greece,
Malta, United Kingdom and Ireland] (Tiemersma et al., 2004). In the year of 2000 MRSA was
made a notifiable diagnosis in Sweden, and 325 cases were reported. The number of MRSA
cases rose to 544 in 2003. There are regional differences in MRSA-incidence and the most
cases are among those over the age of 60 (Stenhem et al., 2006). Although the prevalence of
MRSA in Sweden is less than 1%, the number of reported cases still increases, with 1479 new
cases in 2009 (Smittskyddsinstitutet, 2006a).
Interviews with MRSA-infected patients showed that fifteen patients perceived MRSA as an
infective agent, and six participants attributed the cause of their MRSA-infection as a direct
result of the hospital stay and treatment, but they were unclear about the exact mechanism of
transmission. MRSA was understood as a serious problem by seven participants and nine
thought it was not serious. Isolation in a side room was perceived to have both positive, e.g.
greater freedom from routine and greater privacy, and negative, e.g. lack of attention from
nursing staff and loneliness, aspects by participants (Newton, Constable, & Senior, 2001).
Fifty (44 %) out of 113 surgical out-patients had heard of MRSA; mainly via media (58 %) or
hospital staff (44 %). The possibility of acquiring MRSA revealed that 52 % of the patients
would feel afraid and 38 % would feel angry. Ten percent stated that they would not be
concerned and none would be ashamed (Hamour, O'Bichere, Peters, & McDonald, 2003).
Health care associated infections (HAI), including MRSA, are also known as nosocomial
infections or cross infections. A HAI is generally defined as “an infection occurring in a
patient in a hospital or other health care facility in whom the infection was not present or
incubating on admission to that hospital/facility” (Ducel, Fabry, & Nicolle, 2002, p. 1).
Hospitals are known as a source of the emergence, selection and spread of multidrug-resistant
bacteria that can cause severe clinical syndromes that are difficult and expensive to treat and
may even become incurable. HAI have a substantial impact on morbidity and mortality and
prolongs the duration of hospital stay, require additional diagnostic and therapeutic
interventions, and generate added costs to those already incurred (Pittet et al., 2005). In the
case of MRSA, patients with colonisation or infection are common sources of transmission.
However, MRSA is in general spread by HCWs contaminated hands (Hardy, Hawkey, Gao, &
Oppenheim, 2004). Infection control measures aim to prevent HAI caused by direct and
indirect spread of micro organisms. Direct contagion occurs from patients to HCWs or
contrary and indirect contagion is when transferred from a patient to another via the hands
and/or clothes of HCWs. In Swedish hospitals ethanol hand rub (rather than hand washing)
has been used as a standard for preventing HAI since the 1970s (Smittskyddsinstitutet,
2006b). Standard hygiene precautions include consistent hand hygiene with alcohol based
hand disinfection before clean and after dirty work even when pvc/latex gloves are used.
Aprons for single use or reuse and pvc/latex gloves must be used in work with possibilities for
body contact and/or body fluids and within areas around the patient (Socialstyrelsen, 2006).
Patterns of hand hygiene in the community and in healthcare settings represent a complex,
socially-entrenched and ritualistic behaviour (Whitby, McLaws, & Ross, 2006; Whitby et al.,
2007). Houang and Hurley (1997) describes a need to find ways to educate and motivate staff
to comply with infection control measures. A study on medical students showed that 58 % did
not know the correct indications for using alcoholic hand gel and 35 % did not know the
correct use of gloves (Mann & Wood, 2006). The importance of hand washing is understood
by HCWs, but they tend to overestimate their own compliance (Harris et al., 2000).
Compliance to hygiene precautions is described as low as 13 % (Karabey, Ay, Derbentli,
Nakipoglu, & Esen, 2002). Compliance with hand cleansing protocols has been most
frequently investigated in nurses because this group represents not only the majority of HCWs
in hospitals, but also the group of HCWs with the largest number of contacts with a need for
hand cleaning/disinfection during patient care. Factors associated with poor compliance to
hand hygiene include heavy workloads, performing activities with cross-transmission, glove
use and involvement in technical specialities (Pittet et al., 2000). A multi-modal campaign for
improvement of hand hygiene compliance showed an increase from 32% to 63%, with 74% of
staff reporting increased compliance throughout the campaign (Randle, Clarke, & Storr,
2006). The multi-modal campaign produces a sustained improvement in hand hygiene
compliance, with reduced rates of HAI and MRSA transmission (Pittet et al., 2000). When
using the theory of Planned Behaviour (TPB) to examine HCWs intention to hand washing
the results describes two distinct behavioural practices, inherent and elective hand washing,
and the model explains 64% and 76%, respectively, of the variance in behavioural intention
(Whitby et al., 2006).
It is a well known fact that the spread of antibiotic resistant bacteria’s, like MRSA, in
hospitals is facilitated by healthcare workers non-compliance to hygiene routines. To prevent
such spread, it is necessary to describe nurses’ attitudes in relation to care for patients with
multidrug-resistant bacteria. In addition, it is also valuable to obtain an understanding of
MRSA colonized patients perceptions of care and their daily life.
MRSA Colonization: The presence and multiplication of micro organisms without tissue
invasion or damage. MRSA should be laboratory-confirmed.
MRSA infection: The organism gets past the persons normal defences and becomes a
pathogen; examples include wound infections, pneumonia, urinary tract infections and blood
stream infections. Symptoms are present.
The overall topic is infection control from the perspective of nursing, with a specific focus on
perceptions and attitudes. The objective in the present thesis is to investigate patients’
experience of being colonised with MRSA and nurses attitudes toward patients with
multidrug-resistant bacteria. Moreover, the responsibility for adherence to hygiene routines
will be studied. Thus, patient safety is a keystone in nursing care.
Specific aims
Study I: The aim was to explore experiences and understandings of persons living with
methicillin resistant Staphylococcus aureus colonisation.
Study II: The aim was to develop and psychometrically evaluate a questionnaire designed to
measure nurses’ attitudes toward patients with multidrug-resistant bacteria. A secondary aim
was to describe these attitudes in hemodialysis nurses.
Study III: The aim is to investigate nurses’ opinions about responsibility for adherence to
infection control precautions in relation to their attitudes toward patients with multidrugresistant bacteria.
Study IV: The aim is to explore managers, healthcare workers and patients’ reflections about
the responsibility for adherence to infection control precautions to prevent spread of
multidrug-resistant bacteria.
Study descriptions
Study I
Design: explorative interview study
The objective was to explore individuals’ experiences and understandings of methicillin
resistant Staphylococcus aureus (MRSA) colonisation. Thirteen interviews were performed
and processed using content analysis, resulting in the theme “Invaded, insecure and alone”.
The participants experienced fears and limitations in everyday life and expressed a need to
protect others from contagion. Moreover, they experienced encounters with and information
from healthcare workers differently: Some were content whereas others were discontent. The
described fears, limitations and insufficient professional-patient relationship generated
unacceptable distress for MRSA colonised persons. Thus, the health care sector should
assume responsibility for managing MRSA, and healthcare workers must improve their
professionalism and information skills so as to better meet MRSA colonised persons’ needs.
Subjects and procedures
Approval to carry out the study was gained from the director of the involved medical
institution. A convenience sample of individuals with verified colonisation of MRSA, in the
County of Gävleborg, was achieved from the units’ register of diagnoses. Inclusion criteria for
participation in the study were age above 18 years and living in the county. An individual who
does not speak or understand Swedish or had a physical or psychological obstacle for
communication was excluded. Of the 61 persons in the register, 26 matched the inclusion
criteria. An information letter was sent home to the informants with a question of voluntary
participation in the study and a statement that their participation was guaranteed
confidentiality. The researcher phoned the informants one week after the letter was sent, time
and place for interview was booked with 17 individuals, although 3 of these did not come to
the interview. Individuals who could not be reached by telephone got a remind-letter after two
weeks, with an enquiry about participation, but none were sent back. Demographics (age,
gender and any spontaneously given reason for not participate) of non-participants were kept
in a record to describe attrition. Data collection was performed with a qualitative approach
using open-ended semi structured audio taped interviews. The use of the interview guide
ensured that all participants answered the two question areas “Impediments and influences in
life” and “Reception and information from health care”. Follow-up questions like “What do
you mean” or “Can you explore that” were applied when needed. The goal with this
procedure was to let the informants talk freely about the phenomenon. The interviews lasted
from 25 to 95 minutes, with the majority being between 35 and 60 minutes. The interview
setting was chosen by the participants; most commonly in the informant’s home, otherwise at
the hospital unit for infectious diseases or the informant’s workplace. Demographical data like
age, gender, educational level, work situation, marital status and time since MRSA diagnose
was gathered. One interview was lost due to a technical error.
Data management and analytical procedures
The interviews were transcribed verbatim and analysed using manifest and latent qualitative
content analysis. In manifest content analysis, i.e. answering the question “what”, the written
words are used as a basis for the analysis. In the latent content analysis, the aim is to find
underlying meanings in the text, i.e. answering the question “how” (Graneheim & Lundman,
2004; Krippendorff, 2004). To achieve an understanding of the text, the transcripts were read
and re-read whilst meaning units (words, sentences or paragraphs) corresponding to the study
aim were identified. The meaning units were condensed into a description of their manifest
content and given a code. The meaning units and the codes were consecutively compared to
establish concordance in the coding process. The codes were compared based on differences
and similarities and sorted into nine subcategories; the manifest analysis resulted in three
named categories. To discover the latent content of the text, the transcripts and meaning units
were re-read. The latent content was defined and abstracted to a theme, in accordance with the
meaning units. The codes, categories and theme were discussed by the co-authors until
agreement was reached. Concepts used in the analysis process were in accordance with those
suggested by Graneheim and Lundman (2004).
Study II
Design: cross sectional survey
The aim was to develop and psychometrically evaluate a questionnaire designed to measure
nurses’ attitudes toward patients with multidrug-resistant bacteria. A secondary aim was to
describe these attitudes in hemodialysis nurses.
Subjects and procedures
Approval to carry out the study was gathered from the director of the involved medical
institutions. The questionnaire consists of three conceptually distinct components; knowledge;
behaviour; and emotional response in accordance with the tripartite model (Pratkanis,
Breckler, & Greenwald, 1989) of what an attitude consist of. To derive items in each
component literature searches, discussions with experts in the field and an empirical
explorative investigation was performed, as recommended by Brink and Wood (1998). Eight
independent samples including 564 respondents were used in three phases to develop the
questionnaire. All subjects were recruited using a convenience sampling procedure. Two
samples were recruited in the construction phase; eight nurses from a unit for infection
diseases and six experts in infection control, respectively. During the development phase, two
samples were used for face validity assessments. These consisted of nine healthcare workers
(nurses, physiotherapists and occupational therapists), and four researchers (professors and
doctoral students), respectively. Further, the development phase included two samples used
for pre-tests of the questionnaire. These were composed of 13 nurses and 64 nursing students,
respectively. An additional pre-test was performed using a sample of 131 nursing students, in
their last semester, which ended the development phase. For the evaluation phase, 411
hemodialysis nurses at 19 dialysis units were eligible for participation and 329 (or 80%) gave
their informed consent. The head of respectively dialysis unit named a contact person who
distributed the questionnaire and performed reminders. Telephone calls were performed with
the contact persons for information about the study and procedures. Thereafter a summary of
the procedure, coded questionnaires and information-letters were mailed to the contact person.
The respondents themselves returned the questionnaire in a prepaid and addressed envelope.
Data management and analytical procedures
Item difficulty and plausibility of incorrect response alternatives (Strainer & Norman, 2008)
and possible discrimination using the top and bottom 27% of the distribution (Aiken, 1996;
Kline, 2005) were calculated in knowledge items. Frequencies and cross-tabulation were used
for examination of the data. A principal component analysis (PCA) with varimax rotation was
performed on emotional response items. Rejection of items was made on the following
criteria: 1) indistinct difference of vocabulary, 2) High inter-item correlation in the correlation
matrix, and 3) factor loadings less than 0.55 in the rotated factor loading matrix. Bartlett´s test
of sphericity and Kaiser-Meyer-Olkin´s (KMO) measure of sampling sufficiency were used to
consider the factorability of the correlation matrix. The results from Kaiser 1 (K1) and scree
test were taken into account in deciding the number of obtained factors. Internal consistency
reliability for the factors were calculated with Chronbach´s alpha, (Strainer & Norman, 2008).
When describing hemodialysis nurse’s attitudes to patients with multidrug-resistant bacteria,
their responses of knowledge and behaviour items were recoded into a dichotomous variable
(correct-not correct). The “don’t know” option and missing data were recoded as “not correct”
in knowledge items. Occasional missing values in behaviour items were handled by last value
carried forward when appropriate, i.e. when a hygiene precaution activity was (correctly) not
performed before the nursing measure it was plausible to assume that the precaution activity
neither was performed afterwards. The participants marked answers in the emotional response
component was transformed into a numerical scale from one to seven, after restructure so all
negative connotation correspond to one, and the positive correspond to seven.
To make the responses in each component comparable, the gained point in the knowledge and
behaviour components was transformed to values between 0-100 and in the emotional
response component 14-100 by dividing the summarised points with the maximum point and
then multiply with 100. Descriptive statistics were used for examination of the data. Pearson’s
correlation coefficient was computed to test independence among the three components. For
comparisons of means and demographics independent t-test or repeated measures of variance
(ANOVA) (Tabachnick & Fidell, 2007) was used. Bonferroni corrections were used to protect
from type I errors. All statistical analyses were conducted using PASW Statistics 18 for
Windows (SPSS Inc. an IBM Company, Chicago, IL, USA).
Study III
Design: comparative cross sectional survey
The aim is to investigate nurses’ opinions about responsibility for adherence to infection
control precautions in relation to their attitudes toward patients with multidrug-resistant
Subjects and procedures
The Swedish associations for haematology nurses [Föreningen för Hematologisjuksköterskor i
Sverige (HEMSIS)], district nurses [Distriktsjuksköterskeföreningen (DSF)] and infection
nurses [Intresseföreningen för infektionssjuksköterskor (IFIS)] will be used as cluster
selection. All members in HEMSIS (178) and IFIS (170) as well as every tenth member in
DSF (395) (Feb. 2010) will be asked for participation. Approval to carry out the study will be
gathered from the head of the involved associations, who also will have the role as a contact
person. Telephone calls and e-mail correspondences will be carried out to inform about the
study and procedures. Coded questionnaires and information-letters will be mailed to the
contact person, who will distribute them and perform reminders. The codes on the
questionnaires will only be used for reminders. Data will be collected with the questionnaire
developed in study II, which consists of three conceptually distinct components; knowledge;
behaviour; and emotional response in accordance with the tripartite model (Pratkanis et al.,
1989) of what an attitude consist of. For the two latter components a patient case provides the
base for answering the following items. Chronbach´s alpha coefficient for the three factors in
the emotional response component varied from 0.80 to 0.84, indicating good internal
consistency reliability. The respondents themselves will return the questionnaire in a prepaid
and addressed envelope. Returned questionnaires will be judged as the participants’ informed
Data management and analytical procedures
To describe the nurses’ attitudes towards patients with multidrug-resistant bacteria, the
responses on items in the knowledge and behaviour components will be recoded into a
dichotomous variable (correct/not correct). For knowledge items the “don’t know” option and
missing data will be recoded as “not correct”. The participants marked answers on the
emotional response component will be transformed into a numerical scale (from one to seven)
after restructure, so all negative connotation correspond to one and the positive correspond to
seven. To make the responses comparable, the gained points in the knowledge and behaviour
components will be transformed to values between 0-100, and for the emotional response
component 14-100. This will be expressed by dividing the summarized points by the
maximum number of points multiplied by 100.
For comparisons of the three associations’ appropriate statistics (for level of measurement and
the aim of the study) will be used, e.g. analysis of variance (ANOVA), multivariate analysis
of variance (MANOVA) or independent t-tests. Further, to investigate interactions between
the mean values of the three components, ANOVA will be used (Tabachnick and Fidell,
2007). All statistical analyses will be performed by using PASW Statistics 18.0 for Windows
(SPSS Inc. an IBM Company, Chicago, IL, USA).
Study IV
Design: explorative interview study
The aim is to explore managers, healthcare workers and patients’ reflections about the
responsibility for adherence to infection control precautions to prevent spread of multidrugresistant bacteria.
Subjects and procedures
Approval to carry out the study will be gathered from the head of the involved medical
institutions. A strategic sample of six patients with MRSA colonisation, six head of
departments, six doctors and six nurses will be carried out within the County of Gävleborg. In
total approximately 30 persons will be included in the study, in five separate interview
groups. An inclusion criterion for managers is experience from their assignment, doctors and
nurses must have at least six months work experience in their profession and experience of
caring for a patient with multidrug-resistant bacteria. Both males and females will be included
in the four interview groups with healthcare workers and one person will be representing the
following activities; primary health care, infection care, dialysis care, intensive care, surgical
care and orthopaedic care in the respectively group. Males and females over the age of 18
with a MRSA diagnosis from 2008 and later will be included in the patient group and they
will be achieved from the units’ register of diagnoses. An individual who does not speak or
understand Swedish or has a physical or psychological obstacle for communication will be
excluded. Responses from representatives will be accepted as the project leader can not
perform such judgement via telephone. Personal or telephone contact will be made with
HCWs and patients that fulfils the inclusion criterias. Persons will be asked for participation
until six informants are included in the respective group. A letter with the study aim,
voluntary participation and information about how to contact the project leader will be
distributed when asking about participation. Persons who want to participate in the study will
be asked to write down their telephone number and/or e-mail address in order to be contacted
during the autumn 2010 for scheduling time and place for the interview. Anonymous data
about gender, age, category of work profession/patient and any reason for not participate will
be registered in order to get a perception of potential attrition. Data will be collected using
focus group technique (Kitzinger, 2005), performed once with the respective group. Each
interview is estimated to take about one hour to perform, but the informants will be asked to
schedule two hours for their participation. During the interviews there will be an information
sheet available to the informants, which includes quotations from participants presented in
study I. Moreover, three main questions will be written down on this sheet, and used during
the interviews, concerning their responsibility to adherence of hygiene routines and
reflections towards the described quotations. Data about gender, age, level of education, work
situation, civil status and time for MRSA diagnosis will be collected.
Data management and analytical procedures
No specific analysis method is recommended when using focus group technique, although one
way of analysis is to let the researcher be guided by the data and that the analysis process
should be initiated during the interview phase. Data collection and data analysis is therefore a
parallel process (Kitzinger, 2005). The interviews in the present study will be analysed using
qualitative content analysis (Krippendorff, 2004).
The recorded interviews will be transcribed verbatim in connection to when it will be carried
out and the transcripts will be read and reread and simultaneously the field notes will be gone
thru, as described by Kitzinger (2005).
Different interpretations of the data will be possible to discus within the research group as
there always will be two researchers present at each group interview.
Ethical considerations
Approval to carry out the studies will be gathered from the director of each medical
institution/concerned authorities. The Regional Ethical Review Board has reviewed the ethics
in the project (Dnr 2007/068 and 2010/215). Participation in the studies is on a voluntary
basis and the participant can at any time during the studies, without motivation, withdraw
their participation. Informed consent from each participant will be obtained. Completion and
return of questionnaire will be judged as the participants’ tacit informed consent.
Plan for the research
Study I: Data was collected between October 2007 and April 2008. Data analysis was
conducted during 2008-2009. Published in J of Hosp Inf (2009) 73, 271-7.
Study II: Data was collected during 2007-2009. Data analysis was conducted during 20092010. Submitted 2010.
Study III: Data collection was initiated March 2010 and plans to end in October 2010. Data
analysis is planned to be conducted during 2010-2011.
Study IV: Data will be collected during November-December 2010. Data analysis is planned
to be conducted during 2011.
The research project will be carried out in part time studies, 50%.
Half-time control: 2010-02-11.
Disputation is planned 2012.
Importance of the project
If appropriate hand hygiene such as washing with soap and water or using an alcohol-based
hand sanitizer is not performed, MRSA can be spread when nurses touches other patients.
Such healthcare associated infections are preventable, and an important step to limit the
spread of MRSA is to receive knowledge of the daily living, in individuals with verified
MRSA colonization. Equally makes it as important to obtain understanding of nurses’
knowledge of, behaviour and attitudes for taking care of patients who are MRSA colonised.
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