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The Department of Health stress that repeated instances of failure in healthcare could be avoided if the lessons of experience were properly learned (Department of Health, 2000b). Nutley and Davies (2001) define organisational learning as ‘‘the way organisations build and organise knowledge and routines and use the broad skills of their workforce to improve organisational performance’’.

Nicolini and Meznar (1995) argue that such definitions limit our understanding of organisational learning. They propose a wider framework built upon the work of other authors, which takes into account continuous cognitive change within an organisation. They recognise that the social construction of knowledge is deemed to be an important part of the learning process, and that there should be reflection on knowledge. They also suggest that new knowledge is created, it becomes normalised, and action is taken to put this new knowledge into practice. Fiol and Lyle (1985) conceptualised organisational learning as a two-staged cognitive process involving low-level (single-loop learning) and high-level (double-loop learning), based on the work of Argyris and Schon (1978) and Bateson (1972). Argyris and Schons’ (1978) conceptualisation of organisational learning involves single-loop learning, a process whereby workers detect and correct discrepancies within a system. It also involves double-loop learning which suggests that self- reflection must take place in association with error identification/correction. Bateson (1972) described organisational learning as a two-staged process,

learning skills within a context and learning how to learn (how to change the context).

Education is commonly used by organisations as a form of learning. Ward (2011) carried out a literature review to identify the role of education in the prevention and control of infection. The review focussed on the implementation of precautions laid down in infection control protocols and guidelines and the influence this had on infection rates. The author reported that education may increase knowledge, yet there was no rigorous, convincing evidence that education improved compliance with infection control precautions. The author acknowledged that the review was limited because only three databases were searched, therefore important studies may have been missed and only nursing students and midwives were included.

The use of ‘Communities of Practice’ described by Lave and Wenger (1991) as a form of organisational learning is something that has recently started to achieve increasing attention in the healthcare literature as a means of generating and sharing knowledge (Li et al., 2009; Ranmuthugala et al., 2011). Lave and Wenger (1991) proposed that most learning takes place within the workplace rather than in a classroom environment, and this is a central element of their theory of ‘situated learning’.

According to Li et al. (2009) labelling a group of people a learning community does not guarantee it will function as one. Tight bonds between members can become exclusive and present a barrier to newcomers, negatively influencing working relationships and the flow of information (Li, et al., 2009). A strong learning community based on trust and mutual respect creates a social structure for individuals to share conversations, stories, insights, improvisational skills and shared meaning that help people make sense of new knowledge (Lave and Wenger, 1991). Social and cultural influences within the environment in which communities operate are likely to influence the effectiveness of the group (Ranmuthugalaet al.,2011).

Gabbay and le May (2004, 2011) carried out an ethnographic study over two years to explore how primary care clinicians (general practitioners and practice nurses) used evidence in their day to day decision making at the individual and collective level. They reported that during their observations not once did they see participants read the many clinical guidelines available to them. Rather knowledge was used and implemented from ‘mindlines’ which the authors defined as:

‘‘collectively reinforced, internalised tacit guidelines. These were informed by brief reading, but mainly by their own and their colleagues’ experience, their interactions with each other and with opinion leaders, patients…and other sources of largely tacit knowledge’’(Gabbay and le May, 2004, p.1).

Tacit knowledge (‘knowing how knowledge’) has been described as an innate, unconscious practical wisdom, acquired through personal experience, shared across communities, dependent on the context and not readily accessed (Greenhalgh and Wieringa, 2011). This differs from the explicit knowledge, derived from written packaged information, such as protocols and guidelines that can be readily accessed and shared (Greenhalgh et al., 2008). Healthcare professionals may not be able to fully describe what they know, because this may relate to taken-for-granted assumptions about their work. The knowledge may only be revealed through the action itself (Greenhalghet al., 2008).

Greenhalgh and Wieringa (2011) have recently argued that the key to understanding how evidenced-based knowledge is taken and put into practice is by taking into account what Kemmis and Smith (2010) calls ‘personal praxis,’ that is, learning through experience, by reflecting on practice within a social group. Difficulties with the implementation of protocols and guidelines may be facilitated by discussions with colleagues or mentors or by observing others in practice and then trying out the knowledge for themselves (Liet al., 2009).

Prieto and Macleod Clark (2005) carried out a single case study to explore the perspectives of 19 nurses and healthcare assistants and the difficulties with implementing infection control practice. A secondary aim was to design an intervention to improve practice using facilitation and to determine the self- reported changes of participants in relation to their own practice. This was an

uncontrolled before and after study with no theoretical framework specified. The authors reported that nurses had uncertainty about the rationale for infection control practice and concerns about the risk to their own health from exposure to infection influenced their behaviour. These findings led to the development of new guidelines and supervision of practice so that questions could be answered as concerns arose. One of the limitations of this study is that observations were only made in relation to isolation practices. Although difficulties with hand hygiene were included in the study, environmental hygiene, including cleaning of equipment was not explored. One recommendation highlighted from the study was for further research to understand healthcare workers’ perspective of the problems associated with implementing infection control practice. Considering this finding, and that previous systematic reviews have identified that future research needs to consider how protocols and guidelines are used (Bick and Rycroft-Malone, 2010; Ilott et al., 2010) (See p.64), the following research question was devised to fill the gap:

How are protocols and guidelines being used on the hospital ward to manage the risk from Clostridium difficile infection?

Context has been identified as a factor that can influence organisational learning. Haddock reported being short staffed as a barrier to nurses reflecting and questioning their work routines (Haddock, 1997). A systematic review of the literature by Rashman et al. (2008) relating to organisational learning identified

that further research is needed to examine the learning processes within healthcare and how the context influences learning. This presents another gap in the literature which the current study aims to fill by asking the question:

What happens if difficulties are experienced when protocols and guidelines are put into practice?

In summary, protocols and guidelines have an important role to play in reducing healthcare-associated infection and standardising the care given by healthcare providers. The importance of the topic area of this study has been identified as a global concern. The literature review has identified that little is known about how robust knowledge contained within protocols and guidelines is used and put into practice to prevent and manage healthcare-associated infection. Context was identified as being important when considering how people make sense of explicit knowledge, and tacit knowledge was identified as a ‘way of knowing’ yet this type of knowledge may be difficult to access. The literature review has also identified that little is known about how learning is taking place within healthcare and how contextual factors may influence this process.

This thesis will therefore make an important contribution to the literature by using research questions to address gaps in the literature review through a case study of protocols and guidelines. This study aims to contribute to the literature by

exploring the use of infection control protocols and guidelines in practice from the perspective of nurses and doctors that are implementing them, exploring any difficulties they experience and examining what happens if difficulties occur.

The sections that follow discuss the factors that may influence the use of protocols and guidelines into practice.