Are current infection prevention and control expectations fit for purpose? Interim results from an ethnographic study in South India

Abstract

Copyright © 2020 The Authors). Background: Carer involvement around the world has varied impact on infection prevention and control (IPC) practices in hospitals. We investigated the experiences of patients and carers in the surgical pathway of a tertiary hospital in south India, exploring their involvement in IPC and therapeutic decision-making along the patient pathway.

Methods and materials: Ethnographic study through observations from ward rounds, semi-structured interviews, in-depth case studies and documentary analysis. Field notes from observations and interview transcripts were subsequently coded using NVivo and analysed using grounded theory. Data collection and analysis were iterative, recursive and continued until thematic saturation was achieved.

Results: We conducted 48 interviews (44 healthcare professionals, 4 patients), over 100 hours of observations, and 2 in-depth case studies aided by documentary analysis of patient records. Institutional expectations of families are formalised in policies which demand that patients are accompanied by a relative at all times. Such intense presence embeds families in the care environment of the patients, as demonstrated by their high engagement not only in direct personal care (i.e. bathing patients) but also clinical tasks (i.e. wound care), hence playing an important yet implicit IPC role.

The informal carers actively discussed the patient's progress with healthcare workers, received post-discharge advice and, more often than not, decided on therapeutic options on behalf of patients. Such care leadership was assumed and accepted by patients (aware of such involvement in decision-making), healthcare workers and the institution (where policies about additional relatives staying in the ward were routinely ignored), reflecting a culture of communal and collective care.

For patients and relatives, infections were ‘brought in’ by other visitors, resulting in recently discharged patients being kept within the home, where the environment could be controlled and visitors restricted. This approach further highlights the importance of relatives as community carers and gatekeepers of care-related infection.

Conclusion: Applying the current worldwide IPC perspectives focused on patients as sole decision-makers in India may overlook the wider social-cultural context and the constellation of persons who play a role in care and by extension decisions about IPC. Culture-sensitive IPC policy which embrace the roles that informal carers play is urgently needed.