Although some scholars advocate that communication means should be tailored to the norms and values inherent to the target group’s national culture (Marcus & Gould, 2000), we did not find major differences between HCWs from different countries in contrast to our expectations. Since the German culture is characterized by high degrees of uncertainty avoidance and power distance compared to the Netherlands (Hofstede, 1994), it was anticipated for German HCWs to hold more positive attitudes towards guideline adherence (see Chapter 1, section 1.2.1). In contrast to the national
level however, the cultural differences appeared to be on the occupational level. We therefore advocate dovetailing communication of infection control guidelines with the needs of various occupational groups rather than with the needs of HCWs from different countries. The absence of cultural differences on the national level increases the chance of success for a global health perspective on the control of health care- associated infections (see Chapter 2).
8.2. Theoretical implications
8.2.1. Shift in the function of guidelines as a communication
means
Infection control guidelines have two hardly reconcilable functions. They serve simultaneously as documentation of the health and safety policy of the healthcare institution (“regulation function”) and as a means of communication for individual HCWs (“communication function”). Since the first function prevails, the second function often plays a subordinate part, leading to HCWs who have to act upon their own insights, since the guidelines do not provide an answer to context-specific questions.
Feelings of annoyance and frustration towards guidelines with a “regulation function” can be prevented by putting more emphasis to the “communication function”, as was shown by this thesis’s research. In other words, the format (content, structure, and presentation) of guidelines should range somewhere between a rule-based protocol, which provides clarity about “do’s and don’ts,” and a knowledge-based protocol that can be used as a decision-making tool (Berg, 1997). Putting forward the “communication function” does not imply that the “regulation function” disappears. Instead, safety regulations and legislation are communicated to support the
guidelines, and do not longer function as the guidelines themselves.
Trying to change the focus of guidelines from the “regulation function” to the “communication function” is a challenge that also holds for other disciplines. In countless organizations, politicians, managers, safety officers, and work planners are involved in the control of safety by means of laws, rules, and instructions that are formalized means for the ultimate control of some hazardous process. They seek to motivate workers and operators, to educate them, to guide them, or to constrain their behavior by rules, so as to increase the safety of their performance. To be operational, the rules have to be interpreted and implemented in the context of the particular organizations, considering the work processes. However, the details drawn from local conditions and processes are often neglected in the communication of these rules, leading to unsafe situations (Rasmussen, 1997). Since situations are often dynamic, universal rules are inapplicable, and workers have to act upon their own insights. In order to prevent risky situations, it is of vital importance to tailor the communication of rules to the actual context in which they have to be adhered to. Guidelines that merely emphasize safety regulations are effective in industry but not
in health care. Safety in health care differs in two respects from safety in industry: (1) the patient is at the center of discussion instead of a product, and (2) HCWs are not steps along an assembly line or cogs in a machine producing a product; they are professionals who apply knowledge and adapt learned procedures. Particularly in the health care setting, situations are characterized by a context-specific nature, implying that the communication of rules and guidelines should enable HCWs to use judgment at each step of the care process. In order to ensure that guideline communication represents the context in which the safe work practices should be administered, HCWs have to be involved in the design process.
8.2.2. Involve HCWs in the design process
A plausible explanation of the poor performance of expert-driven guidelines is that in the process of development and implementation of the protocols, the authors did not sufficiently take into account the differences in knowledge and needs of the various groups of HCWs (see Chapters 2 to 4). These findings are not restricted to this thesis’s research: earlier research has already pointed out that protocols aimed at MRSA prevention and exposure to blood-borne pathogens were expert-driven (Van Gemert- Pijnen et al., 2005; Van Gemert-Pijnen et al., 2006).
In health care, the culture is still to implement single-faceted, expert-driven interventions rather than multi-faceted interventions that fit HCWs’ needs, often resulting in dissatisfaction and abandonment (Johnson et al., 2005; McCoy et al., 2001; Murphy 2002). Where previous studies only advocated the involvement of HCWs in the design process of guideline communication, they did not actually do so (Van Gemert- Pijnen, 2003; Grol, 2001; Gross et al., 2001). As far as we know, our study was one of the first attempts to actually employ a user-driven design process to design guideline communication, drawing causal links between the design approach, the quality of the guideline communication, and their efficiency and effectiveness. We showed, as in line with previous research, that user-driven design is important to create ownership and to foster the applicability of guidelines. Therefore, the development of means to communicate infection control guidelines should not be the exclusive responsibility of infection control professionals (Gross et al., 2001; McCoy et al., 2001; McGovern et al., 2000; Murphy, 2002). However, as we have claimed repeatedly during this thesis, medical microbiologists (experts) should always verify the guidelines’ clinical content.
8.2.3. Consider the context of use
Infection control guidelines themselves are hardly helpful in terms of stimulating guideline adherence (Elling, 1991; Van Gemert-Pijnen, 2003). More suitable means are organizational activities, such as management support, training, and communication. Organizational activities are crucial to ensure that HCWs become aware of the infection control guidelines and are ready and able to implement the required precautions (DeJoy, 2000). Generally, although a wide range of activities have been suggested to facilitate the implementation of infection control guidelines in practice, all that happens is that the protocol is brought to the attention of the users and a
and there is usually no specific plan for introducing the guidelines, despite such a plan being a requirement of the guideline development policy (Gross et al., 2001). Furthermore, training is usually content-driven instead of action-driven (Van Gemert- Pijnen, 2003).
The implementation of infection control guidelines should be a permanent feature in the hospital environment in order to ensure that HCWs behave in accordance with the required precautions and do not lapse into old routines. This thesis provides an intervention strategy to realize this (see Chapters 6 and 7 and section 8.2.).
We not only involved users in the design process but also asked them which factors affect a successful implementation process. This was found to be helpful, since users raised factors that differed from those stated by existing literature. Besides, by involving HCWs in the design and implementation process, safety awareness was created among HCWs, stimulating intensive discussion of safe behavior and thus guideline adherence. In this way, the research method in itself became an intervention strategy.
A theoretically guided approach can favorably influence implementation strategies. Therefore, we used the PRECEDE model to identify factors affecting successful implementation. Several other approaches to develop intervention strategies, such as Intervention Mapping or the Breakthrough Series Collaborative are available. Such approaches describe a user-involved methodology for the development of theory- and evidence-based health promotion programs, but they are not aimed particularly at the development and implementation of technology (Bartholomew et al., 1998; Cooper et al., 2005; Kok et al., 2004). Although these approaches have dramatic effects in the short term, it remains to be seen whether the changes reported will translate into long-term improvements (Glasgow et al., 2002). Furthermore, the approaches are particularly aimed at changing individual attitudes rather than creating organizational reinforcement.
8.2.4. Consider cultural differences between occupational
groups
Nearly each sample of the studies incorporated in this thesis’s research involved HCWs from two countries: Germany and the Netherlands. Given that the German culture is characterized as having a high degree of uncertainty avoidance compared to the Dutch culture (Hofstede, 1994), we anticipated detecting different needs toward guideline communication and a different degree of conformity with guidelines between Dutch and German HCWs (see Chapter 1, section 1.2.1). Cultures that score high in uncertainty avoidance prefer rules and structured circumstances, and these cultures try to minimize the possibility of unstructured, novel situations by strict laws and rules, safety, and security measures. It therefore was anticipated that German HCWs would revert themselves in safety rules and derive their behavior more from protocols and legislation to avoid uncertainty and justify their way of acting compared to Dutch HCWs. This expectation was strengthened by the findings reported in Chapter 2; the way in which national infection control guidelines were communicated differed
substantially between Germany and the Netherlands. Whereas the German guidelines emphasized the legislative and evidence-based aspects (“regulation function”), the Dutch guidelines incorporated more information- and communication-oriented elements such as decision trees (“communication function”).
However, in contrast to these expectations, no significant differences were detected on the national level, neither with regard to guideline adherence (Chapter 7). Also, we did not identify national cultural differences with regard to website evaluation (Chapters 3 to 6). Although previous research demonstrated that cultural background correlates with the preference for a particular website design (Marcus & Gould, 2000), Dutch and German respondents participating in this thesis’s research appeared to hold the same opinion regarding website design (Chapter 4), menu structure (Chapter 3), and website quality (Chapter 6). A possible explanation for the absence of cultural differences might be the cross-border region where (nearly) all studies were administered. In this region, many patients and HCWs cross the border daily to receive and provide health care (Friedrich et al., 2008). It might be that HCWs working in border regions hold values that diverge from what is typical for their country and rather embrace a cross-border mentality.
Although cultural differences on the national level remained absent, we detected “cultural differences” between occupational groups. Chapter 6 demonstrated that nurses were more willing to adopt the website in daily work practice compared to physicians and infection control professionals. Moreover, Chapter 7 reported on nurses’ stronger intention to adhere to infection control guidelines compared to physicians. Nursing staff might be more willing to conform to both website use as well as guideline adherence, as their views of professionalism are bound up with adherence to rules and guidelines, and they are therefore more inclined to change current routines than are physicians and infection control professionals. Physicians and infection control professionals, on the other hand, are trained to use clinical judgment and are encouraged to make decisions on a case-by-case basis. They therefore may perceive rules communicated on a website as a threat to professional autonomy (McDonald et al., 2005; Parker & Lawton, 2000). We therefore claim that interventions aimed at behavior change should be tailored not to the norms and values inherent to the target group’s national culture but to the occupational group to which they belong.