Integrating patients' experiences, understandings and enactments of infection prevention and control into clinicians' everyday care : a video-­reflexive-­ethnographic exploratory intervention

This thesis is an experiment in asking patients, their visitors, healthcare professionals and researchers to talk about things that are not generally addressed in healthcare services research to discover how we can move forward 'together' to improve patient safety. In particular, the people with the most at stake - the patients ‚Äö- are positioned as central to the conversation. The conversations in this study are about healthcare-associated infections and infection prevention and control (IPC). Healthcare-associated infections, particularly those caused by multidrug-resistant organisms, represent an intractable issue causing significant, unnecessary suffering for patients and families and incurring escalating healthcare costs. Despite increasing standardisation and implementation of IPC strategies, healthcare-associated infections remain the most frequent adverse event experienced by patients worldwide. I argue that the less than optimal outcomes of current strategies for addressing healthcareassociated infection are in part a result of the failure to attend to the complexity of frontline work, and of an underestimation of patients' roles in IPC. In this research, I mobilised the interventionist methodology, video-reflexive ethnography, in new ways, to assist patients, clinicians and myself to explore the practical and relational complexities of patient involvement in IPC, and in healthcare-associated infection research. First, hospital inpatients were invited to scrutinise footage of their own clinical care to look for cross-contamination risks. The rationale for doing this was to acknowledge and respect patients' expertise and contributions to their own safety, and to ascertain whether this approach could have a transformative impact on patients, as it has for clinicians in previous video-reflexive ethnography research. Group reflexive sessions were then conducted with nurses in which footage of everyday patient care interactions were presented alongside patients' observations of the same events. The aim here was to explore whether such feedback might broaden nurses' understandings of infection risks and assist them to appreciate the productive possibilities of patient involvement. Invoking complexity and affect theories as analytical tools, this research demonstrates that using video-reflexive ethnography in this novel way created a 'safe space' for everyone to reflect on and reshape their assumptions, positions and practices: for the patients who developed a more critical attitude to infection risks and were able to develop new strategies for getting their infection prevention needs met; for the nurses whose often taken-for-granted practices were disrupted by seeing care through their own patients' eyes and were therefore enabled to consider patients as active participants in infection prevention; and for me who, by considering myself a research participant, was able to come to new understandings about my own infection control and research practices. The findings show that patients were actively contributing to IPC in ways that clinicians and researchers were not fully aware of. Some of the strategies were effective and some were counterproductive. Engaging with these contributions enabled the clinicians to understand how the quality of their patient-provider relationships and IPC conversations shaped patients' attentions and precautions around infection risks and behaviours and motivated clinicians to develop strategies to promote greater patient involvement. Two main conclusions emerge from this research. First, that patient involvement is an interpersonal, affective dynamic; the quality of which can strongly influence IPC behaviours. Second, that video footage can provide an important springboard for revealing and grappling with this affective dynamic. Viewing footage of their real-time care practices, in conjunction with patients' feedback on this care, can shrink the patient/clinician feedback loop: enabling clinicians to better understand how their own views about what constitutes good IPC aligns with the views of patients under their care; how mismatches between the two can impact upon patient safety issues like healthcare-associated infection; and to reflect on what could be done differently. Here, the importance of employing video footage is that it elicits more from patients than just memories and opinions about care. Rather, it allows patients to refer to specific aspects of care practices and relationships that clinicians can then focus on with an eye to practice change. Instead of calling for more standardised IPC strategies, we must ensure that all stakeholders be afforded the time and space to collaboratively examine the complexity of their in situ infection control activities, relationships and habituations so that together they can tackle the problem of healthcare-associated infection.