The ethics of contact precautions in hospital care : an interpretive description

Background A person with an infection is considered a reservoir for a pathogen and capable of facilitating its ongoing transmission to others. Within health ethics, an infected person is understood as posing a risk of harm to others whilst needing healthcare to protect their wellbeing. This creates a potential ethical discord if control measures are not proportional to the risk, or if harms outweigh benefits. Public health policymakers are committed to controlling incidence of antibiotic resistant pathogens in hospitals. Control measures (now known as Contact Precautions) were developed in the late 1970's however multi-resistant organisms (MROs) continue to occur in hospitals and antimicrobial resistance remains a global health risk. Negative consequences of Contact Precautions on patients, including psychological harm and compromised healthcare delivery, are recognised. Authors reporting these negative consequences have called for evidence-based change, but these appeals have been countered by researchers reporting conflicting findings. Evidence wars have resulted in an inertia of practice despite acknowledgement that the evidence supporting Contact Precautions efficacy is poorly constructed. The aim of this research was to explore the experience of Contact Precautions within a framework of bioethical principles which includes: respect for autonomy, justice, non-maleficence, and beneficence. The objectives were to understand the impact of Contact Precautions on patients and on health professionals, to discuss these findings within a bioethical framework with a view to exploring the ethical implications, and to make recommendations for an ethically sound framework for the management of hospital patients colonised with a multi-resistant organism (MRO). The research question asked: 'Are Contact Precautions ethically justifiable in contemporary hospital care?' Method Interpretive description, a methodological approach recognised as having practical application in improving nursing knowledge and practice, was used. The ethos of this qualitative approach mirrors recognised strengths of empirical ethical inquiry. Both have the power to discover the reality of a given situation, and to use the findings to develop insights into improved policy and practice. Theories of planned behaviour, principles of bioethics, and prior experience in infection prevention and control nursing provided the theoretical scaffold. The study was conducted in a publicly funded health system in regional Australia, with Human Research Ethics Committee (HREC) approval. Thirty-three participants (9 patients, 13 nurses, 7 doctors and 4 allied health professionals) were purposively recruited. Semi-structured interviews were recorded and transcribed for analysis. NVivo 12 was used to organise and manage the data. Data analysis of interview transcripts alongside research journal entries involved thematic and axial coding. Themed findings were explored in the context of the research question and theoretical scaffold alongside contemporary published research. Findings Four themes were identified, with sub-themes adding depth and texture. The first theme is 'Powerlessness moving to acceptance'. Contributory sub-themes are communication, and healthcare hierarchies. Patients are denied the opportunity to provide informed consent prior to diagnostic testing. Additionally, patients colonised with an MRO are inadequately informed about Contact Precautions and do not consider themselves active partners in decision-making. Health professionals trust Contact Precautions but hold concerns that they stifle their personal autonomy as a health professional. Neither group feels able to affect change despite feeling uncomfortable about policy requirements. They tolerate Contact Precautions as a necessary part of hospital life. The second theme 'You feel a bit of a pariah' describes staff reluctance to enter the rooms of patients when Contact Precautions are implemented, and patients' feelings of being untouchable. This was reinforced by staff wearing yellow gowns and other personal protective equipment (PPE), and signage displayed at doorways. Visual reminders of patient's contaminated status were reinforced by auditory messaging such as the use of words such as 'dirty'. The third theme is 'Others need protection, but I need looking after too'. Patients are committed to following the rules despite noticing their care being compromised. Health professionals also recognised patient care might be compromised by Contact Precautions but remained committed to the policy as a means of protecting themselves, their family, or their career. The fourth theme is 'Doing Contact Precautions is not easy'. Health professionals find Contact Precautions challenging because of confusing policy variations, and physical discomfort when wearing PPE. They experience negative emotions when balancing the need to follow a trusted policy with their professional and personal values when they notice associated harm for their patients, their workplace culture and professional relationships, or the environment. The findings corroborate other research reports, specifically those that describe the negative and harmful impact of Contact Precautions on hospital patients. Conflicts are identified with the bioethical principle of respect for personal and professional autonomy due to a lack of adherence to the requirements for informed consent, and sub-optimal communication to patients and health professionals. Patients are subjected to inequality of care provision and discriminatory practices, which breach the principle of justice. Contact Precautions potentially elicit stigma for patients, and moral distress and inter-personal conflict for staff, breaching the principle of non-maleficence. Under the principle of beneficence, a pluralistic cost‚Äö-benefit assessment of Contact Precautions situates them as a low-value practice. Health professionals require training to develop skills and confidence in discussing antimicrobial resistance and hospital infection prevention measures with patients, and to improve their practice from an ethical standpoint. Overt leadership that supports staff in speaking out when they observe patient safety risks, and role modelling of expected exemplary practice, would reduce the stress and harm experienced by health professionals in relation to Contact Precautions. Further research into health professionals' attitudes and beliefs around infection prevention policy, and the role of informed consent relating to clinical specimen collection and testing, would be beneficial. Conclusion Contact Precautions present a significant challenge to organisational culture, professional well-being, and the provision of person-centred ethical care. The identified negative impacts of Contact Precautions on patients and health professionals confirm they breach established ethical paradigms. The wider evidence base fails to confirm superiority of Contact Precautions over Standard Precautions in preventing MRO acquisition. In conclusion, the ethical costs of Contact Precautions outweigh the benefits, and Contact Precautions are confirmed as an example of low-value practice. It is time for the long-standing evidence wars to end as this study confirms that the use of Contact Precautions in the management of patients colonised with an MRO is not ethically justifiable in contemporary hospital care.