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| PERSPECTIVE |
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| Year : 2022 | Volume
: 10
| Issue : 2 | Page : 54-56 |
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Link nursing programme in Indian hospitals: Are we overlooking the low-hanging fruit in infection control?
Saikat Mondal1, Nazneen Nahar Begam2, Rituparna Dasgupta3, Arghya Das4
1 Department of Medicine, All India Institute of Medical Sciences, Kalyani, India
2 Department of Internal Medicine, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India
3 Department of CTVS, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
4 Department of Microbiology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India
| Date of Submission | 04-Aug-2022 |
| Date of Acceptance | 04-Nov-2022 |
| Date of Web Publication | 01-Mar-2023 |
Correspondence Address:
Dr. Arghya Das
Department of Microbiology, National Cancer Institute, All India Institute of Medical Sciences, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpsic.jpsic_31_22
How to cite this article:
Mondal S, Begam NN, Dasgupta R, Das A. Link nursing programme in Indian hospitals: Are we overlooking the low-hanging fruit in infection control?. J Patient Saf Infect Control 2022;10:54-6 |
How to cite this URL:
Mondal S, Begam NN, Dasgupta R, Das A. Link nursing programme in Indian hospitals: Are we overlooking the low-hanging fruit in infection control?. J Patient Saf Infect Control [serial online] 2022 [cited 2023 Mar 30];10:54-6. Available from: https://www.jpsiconline.com/text.asp?2022/10/2/54/370885 |
It was in the mid-1950s when the need for nursing personnel was first perceived for institutional infection prevention and control (IPC) practices.[1] Since then, infection control nurses (ICNs) have become indispensable components of IPC programmes across hospitals in different countries. They were assigned responsibilities of carrying out an array of activities within the mandate of the hospital IPC programme, which include conducting IPC-related training, healthcare-associated infection (HCAI) surveillance, assessment of ongoing IPC practices, and many more. By conducting regular collaborative rounds and audits and collecting feedback from the clinical staff, they collect crucial information for planning, management and evaluation of the IPC programme. However, several impediments exist for ICNs in bridging the communication gap between the IPC and the clinical teams. For instance, the active involvement and presence of ICNs at the bedside is often regarded as an activity of an evaluator and leads to dissatisfaction among the clinical staff.[2] Under such circumstances, a genuine need appears for role models who actually can be entrusted as 'links' between local levels and specialist areas of IPC.
'Link Nursing' is not a new concept. In Western countries, this has been acknowledged as a useful strategy in different domains of healthcare, namely nutrition, pressure sore care, incontinence care, palliative care and so on.[3] The same concept has been applied in IPC programmes since the 1980s with the introduction of highly motivated and dedicated infection control link nurses (ICLNs).[4] They are the facilitators for cultural shifts and their roles should be recognised among the first steps for bringing IPC-related behavioural change among the clinical staff.
| Infection Control Link Nursing Programme In Indian Hospitals: From a Policy Perspective | |  |
The Ministry of Health and Family Welfare, Government of India has recommended that at least one full-time ICN should be appointed per 250 inpatient beds in hospitals.[5] However, the majority of Indian hospitals lack operational IPC programmes with guidelines implementable at local levels. ICNs are assigned tasks such as conducting management rounds and unit meetings, which are actually outside the purview of the hospital IPC programme. Undoubtedly, the ICNs are overburdened and their real responsibilities are overlooked and neglected. Thus, the role of ICNs has become a formality but not a well-perceived requirement for the hospital authority. However, a holistic approach to IPC with the inclusion of staff members from the clinical teams may bring a radical change to its implementation at the health-care delivery levels. The ICLNs may step forward to share the duties of ICNs. Their continuous presence within the wards, intensive care units, etc., brings unique opportunities in the clinical setup to spread awareness and promote scientifically proven practices simultaneously reducing the communication gaps between IPC and clinical teams [Figure 1]. From within the clinical milieu, they work as relationship nurturers and become the contact person for the IPC leadership for the implementation of IPC policies. | Figure 1: Infection control link nurse acting as a link between infection control and clinical teams
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An evidence-based argument in favour of the infection control link nurse programme
Data supporting the success of the ICLN programme have been sparsely mentioned in the medical literature. Nevertheless, the contributions of ICLNs are well evident in almost all aspects of an IPC programme. Working together with clinical team members, ICLNs not only help in developing opportunities to learn and adopt best IPC practices but also oppose the poor practice and encourage behavioural change. Seto et al. in their study have reported that despite aggressive promoting activities for hand hygiene for years, the compliance rate remained at a mere 50%.[6] However, with the involvement of ICLNs in both formulating and implementing strategies, the hand hygiene compliance rate was dramatically improved to 83%. In a similar context, Sopirala et al. also have demonstrated how the ICLN programme may facilitate the reduction of the HCAI rate, which is the ultimate goal for any institution-based IPC programme. While the healthcare-acquired methicillin- resistant staphylococcus aureus (MRSA) bacteraemia was reduced by 41% (improved from 0.18 to 0.10 cases per 1000 patient days), the overall healthcare-acquired MRSA infection was reduced by 28% (improved from 0.92 to 0.67 cases per 1000 patient days).[7] These success stories should be motivating for many hospitals in India. A recent study that included a total of 85 public and private hospitals in India has reported an overall hand hygiene compliance rate of only 23% in the newborn care units.[8] Furthermore, conducting audits and HCAI surveillance in health-care facilities catering to the need of 1.4 billion individuals with a high hospitalisation rate (according to a report in 2014, the annual hospitalisation rate in India was 37 per 1000 population) is an arduous task, especially when there is one designated ICN per 250 inpatients.[9] It seriously hinders the collection of surveillance data on a daily basis and leads to missing data, late entry, etc. ICLNs if properly trained may become immensely helpful in carrying out this activity from their respective workplaces. This strategy has also been proven time efficient. As ICLNs are aware of the infection status of their patients and well versed with the diagnostic and intervention-related data at their workplaces, it is easier for them to obtain and record data than for the ICNs. Thompson and Smyth reported that ICLNs took an average of 5.5 min per bed to collect HCAI data in contrast with an average of 13.3 min per bed taken by other members of the infection control team.[10]
Perceived hurdles in implementing the infection control link nurse programme
Although much promising the ICLN programme may seem to be, it becomes futile in the absence of proper benchmarking at the implementation level. Hospitals in India are overburdened with the low nurse-to-patient ratio. An enormous workload poses time constraints for the ICLNs to undergo regular training which is deemed necessary to ensure their optimal performance. With no defined criteria for the selection of ICLN, junior nurses are at times nominated from the clinical side. Challenging improper IPC practices by superiors or peers is difficult, especially for those lacking authority. Moreover, the entire foundation of the ICLN programme is based on the notion that IPC in a hospital is everyone's responsibility. However, in reality, a paradoxical situation unfolds when other members of the clinical team may think that the onus of the IPC implementation at the local level solely lies on the designated ICLN.
| Recommendations, Cautions, and Opportunities | | |
For the success of an ICLN programme, ICLN's unique contribution in imparting knowledge on IPC and promoting safe patient care practices must be first recognised by their colleagues and hospital administration. They should have the privilege to undergo IPC training during their duty hours. Providing financial incentives may not be feasible for all hospitals, especially those in the public sector for the lack of a defined role profile. Alternatively, appreciation by awarding titles such as 'clinical champion' and provision of duty leaves for undergoing specialised training will help to boost up their morale to perform additional tasks other than the expected clinical works. At the national level, competence-based role profiles need to be defined for the ICLNs. Although the nursing staffs have been traditionally assigned with the role of linking personnel in IPC activities, this policy is a matter of criticism in the modern-day context. With the multidisciplinary approach to the hospital IPC programme, the provision of an 'Infection Control Link Personnel' in lieu of ICLN may be made to include other health-care workers with different knowledge profiles and diverse skill sets.
As a note of caution, it needs to be emphasised that the participation of link personnel must be voluntary with the choice to opt-out. A programme running with personnel who lack interest and motivation will fail to demonstrate the diligence required to bring a behavioural change towards IPC practices among staff who are resistant to change. ICLNs should never be regarded as substitutes for ICNs. ICNs have a diverse set of responsibilities from which only a few can be shared with the ICLNs and they are expected to perform those specific ones for which they possess the required expertise. Responsibilities should be gradually shifted from ICNs to ICLNs. It will be prudent to identify and approach the enthusiastic and committed nursing personnel for their role as ICLNs during weekly/monthly meetings of IPC team with clinical teams. To start with they are entrusted with the role of an observer. They fill their daily observations on IPC practices in the provided checklists for hand hygiene audit, biomedical waste management, environmental cleaning and disinfection and care bundles. At the end of each month, the areas of concern based on the overall compliance on different IPC practices are addressed by the IPC team in a meeting with ICLNs.
While performing duties as ICLN, they also have the opportunity of not only gaining updated knowledge of IPC but also developing expertise in soft skills such as communication, writing, presentation, data management, planning, decision-making and problem-solving, which are desired in the future ICN. It is also useful for health-care setup to choose additional ICNs when needed from the pool of ICLNs. Finally, research within the ICLN programme should be welcomed as it provides the scope of generating an enormous amount of HCAI-related data that is otherwise missed or not reported from India. As with any programme, the success of this programme will ultimately be decided by commitment both at the individual and organisational levels. Further research on the planning and delivery of the programme will also assure its success and quality.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Quattrin R, Pecile A, Conzut L, Majori S, Brusaferro S, GISIO Group. Infection control nurse: A national survey. J Nurs Manag 2004;12:375-80.  |
| 2. | Siahaan M, Handiyani H, Nurdiana. Optimization of the roles and responsibilities of infection prevention and control nurse in hospital. IJNHS 2019;2:292-306. |
| 3. | Dawson SJ. The role of the infection control link nurse. J Hosp Infect 2003;54:251-7. |
| 4. | Royal College of Nursing (RCN). The Role of the Link Nurse in Infection Prevention and Control: Developing a Link Nurse Framework. London: Royal College of Nursing; 2021. |
| 5. | Ministry of Health and Family Welfare (MoHFW), Government of India. National Guidelines for Infection Prevention and Control in Healthcare Facilities. New Delhi: MoHFW; 2020. |
| 6. | Seto WH, Yuen SW, Cheung CW, Ching PT, Cowling BJ, Pittet D. Hand hygiene promotion and the participation of infection control link nurses: An effective innovation to overcome campaign fatigue. Am J Infect Control 2013;41:1281-3. |
| 7. | Sopirala MM, Yahle-Dunbar L, Smyer J, Wellington L, Dickman J, Zikri N, et al. Infection control link nurse program: An interdisciplinary approach in targeting health care-acquired infection. Am J Infect Control 2014;42:353-9. |
| 8. | Tyagi M, Hanson C, Schellenberg J, Chamarty S, Singh S. Hand hygiene in hospitals: An observational study in hospitals from two Southern States of India. BMC Public Health 2018;18:1299. |
| 9. | Pandey A, Ploubidis GB, Clarke L, Dandona L. Hospitalisation trends in India from serial cross-sectional nationwide surveys: 1995 to 2014. BMJ Open 2017;7:e014188. |
| 10. | Thompson IM, Smyth ET. The second national survey of infection in hospitals: Methods of data collection and overall impressions. J Hosp Infect 1996;32:57-60. |
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