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Contents lists available at ScienceDirect

Collegian
journal homepage: www.elsevier.com/locate/colegn

Missed infection control care and healthcare associated infections: A

qualitative study
Kasia BAIL, PhD, RN a, Eileen WILLIS, PhD, M.Ed b,∗, Julie HENDERSON, PhD, BA (Hons) b,
Ian BLACKMAN, EDD, RN b, Claire VERRALL, MN, RN b, Allison RODERICK, RN, PhD c
a
Synergy Nursing and Midwifery Research Centre and Health Research Institute, University of Canberra, Australian Capital Territory, Australia
b
College of Nursing and Health Sciences, Flinders University, Australia
c
Clinical Educator, Sports Med, Stepney, Adelaide, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Research on missed nursing care reveals individual and systems failure. Research on infec-
Received 5 July 2020 tion control missed care is minimal.
Revised 20 November 2020
Accepted 29 November 2020 Aims: Investigate nurse perceptions of missed infection control.
Available online xxx
Design: Qualitative in-depth interviews with 11 Australian infection control nurse experts.
Keywords: Methods: Participants were asked whether nursing and hospital-wide care tasks fundamental to infection
Cascade iatrogenesis control were missed, and what were the underlying causes and contributing factors for these omissions.
infection control
Qualitative data was mapped against fundamental nursing practice and Australian infection control guide-
missed care
lines.
quality
risk Findings: Omission of infection control care occur at the individual clinician and organisational level.
safety Nurses describe failure to perform standard precautions as well as failure to perform basic care activities.
Participants identified a range of institutional and cultural factors which contributed to cascade iatroge-
nesis resulting in healthcare associated infections for patients. Some factors are outside nurses’ control
and include: environmental cleanliness; ward layout; ward culture; resourcing and staffing; integration
of infection control into clinical governance; action following audit results; and reviewing evidence base
of protocols.
Discussion: Care occurs in complex and conflicted settings, with prioritisation essential. Potentially harm-
ful practices are generally done with the intention of care. Nurses are key, but not sole performers in the
creation of quality infection control.
Conclusion: Mapping missed care related to infection control against standard frameworks of nursing
practice revealed “gaps in the chain of infection” that contribute to “cascade iatrogenesis” with negative
outcomes for patients.
© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

1. Introduction on patient quality and safety. This paper provides a brief overview
of the missed care literature before applying the theory of cascade
The last decade has seen a bourgeoning of research on missed, iatrogenesis to analysis the issue of missed infection control care
rationed or unfinished care (Jones, Hamilton, & Murray, 2015). in Australia.
While the missed care literature identifies systems issues beyond
the nurse, there is little research on the how missed nursing care,
or the nurse’s interactions with other health professionals, impacts 2. Literature Review

Underpinning missed care is the assumption that the ra-

∗
tioning of human and material resources means nurses priori-
Corresponding author at: Eileen WILLIS, PhD, M.Ed, College of Nursing and
Health Sciences, Sturt Campus, GPO Box 210 0, 50 01, Flinders University, Australia. tize some, usually medically ordered tasks, over other aspects of
Tel.: ±61 0447810441 care (Schubert et al., 2008). Similarly, Kalisch associates missed
E-mail address: Eileen.willis@flinders.edu.au (E. WILLIS). nursing care with three antecedents: human resources, material

https://doi.org/10.1016/j.colegn.2020.11.007
1322-7696/© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Please cite this article as: K. BAIL, E. WILLIS, J. HENDERSON et al., Missed infection control care and healthcare associated infections: A
qualitative study., Collegian, https://doi.org/10.1016/j.colegn.2020.11.007
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resources, and communication (Kalisch, Landstrom, & Hinshaw, in order to meet accreditation standards (Australian Commission
2009). Both Kalisch and Schubert have devised research surveys for Safety and Quality in Health Care, 2017). These frameworks of
to track missed or rationed care, however these tools also func- analysis allow for identification of missed care tasks beyond nurs-
tion to conceptually reduce care to simple tasks such as ambula- ing to include other health professionals and workers within the
tion or mouth care, without necessarily contextualizing the tasks system.
within the broader arena of patient care (Bragadottir, Kalisch, &
Brergthoora, 2016), although recent publications by the RANCARE 3. Methods
group have taken a broader approach drawing on systems the-
ories across a range of institutions including health and educa- Eleven infection control nurse experts were interviewed by au-
tion (Phelan & Kirwan, 2020). Phelan and Kirwan demonstrate that thors 2 and 3, both females, doctorally trained with over 20 years
nursing is more complex than isolated tasks (Kitson, Conroy, Ku- experience in qualitative interviews in 2018. The focus of the inter-
luski, Locock, & Lyons, 2013). For example, when a nurse responds views was to understand in more depth issues contributing to care
to a patient’s request for assistance in toileting, they must consider tasks missed that may result in a hospital acquired infections. Par-
patient safety and privacy, the management of various medical de- ticipants were informed that the interviews would form the basis
vices attached to the patient, along with infection control precau- of the development of a MissCare infection control survey that fol-
tions. But as Phelan and Kirwan (2020) note, this care may also be lowed the process outlined by Kalisch which involves interviewing
dependent on the quality of the education they received. experts to underpin the survey design (Kalisch & Williams, 2009).
No tool to date has been developed to capture the nuances of Participants were recruited through an expression of interest pub-
nursing work in relation to infection control, although a survey lished in the electronic newsletter of the Australian College of In-
tool has been devised by Lam to capture missed universal precau- fection and Prevention Control, enabling recruitment across a wide
tions (Lam, 2011). His work, while similar to that of Kalisch in that network of practitioners in all Australian states and territories. In-
it targets specific isolated tasks, considers all the procedures and dividual participants self-selected by contacting the researchers via
practices around standard precautions (Cruza et al., 2016). Find- email. Purposive sampling was chosen as it is viewed as a marker
ings from the Lam surveys suggest a correlation between nurses’ of rigor in qualitative research as participants are recuited for
years of experience, clinical grade and omissions, with higher edu- “the type of knowledge needed to understand the structures and
cated nurses less likely to omit standard precautions (Cruza et al., processes within which the individuals or situation are located”
2016). Nurses themselves identify resources and staffing as partly (Popay, Rogers, & Williams, 1998; p. 346). All participants had ex-
explaining why they omit some activities associated with universal pertise in infection control with eight currently employed in this
precautions (Luo, He, Zhou, & Luo, 2010). role. One respondent was male and 10 were female, six worked
Despite Lam identifying macro issues associated with quality in the public sector, four across multisites both public and private,
and safety including infrastructure deficits, the approach still iso- and one was based in a rural town.
lates nursing from the broader components of the hospital system Interviews were conducted via phone with an audio-recording
in that solutions focus on nursing behavior and education. This ap- made of the conversation. Interviews went for between one hour
proach fails to outline how other staff might contribute to nurse and 30 minutes and occurred either in the interviewees’ work-
omissions. Factors linked to resource allocation are also cited in place or home, with the interviewers noting responses and check-
the missed care literature (Kalisch & Kyung, 2010), however this is ing these out in subsequent interviews. All participants were given
rarely explored in depth or taken beyond the ward or the profes- a pseudomyn. The interviews were conducted using a guide gener-
sion of nursing, such as whether or not doctors and allied health ated by the research team as a starting point that addressed in-
workers also missed care, or what care tasks are rationed further fection control activities that participants believed were missed;
up or down the healthcare chain by funders, policy makers, man- the reasons why these activities were missed; nurses’ capacity to
agers, cleaners, or kitchen staff. This is even when a structural recognise the signs of infection; and other care activities which
analysis is provided that situates the problem in political decisions might contribute to development of infection. Lincoln and Guba
about funding or the shortage of support staff (Henderson et al., (1985, p.300) argues that rigor in qualitative research can be de-
2013). termined by the credibility, transferability, dependability, and con-
This paper explores the events which contribute to healthcare firmability of the findings. For Popay, Rogers, & Williams, (1998),
associated infections (HAI) using the concept of cascade iatro- rigor is reflected in the extent to which analysis reflects the mean-
genesis. Cascade iatrogenesis has been defined as the serial de- ings which participants attach to their behaviors and circum-
velopment of multiple medical complications that can be set in stances. In this study, transcipts were not returned to participants,
motion by a “seemingly innocuous first event” (Thornlow, Ander- but their feedback was sought on a survey design that was in-
son, & Oddone, 2009, p. 1528). Adverse events have been associ- formed by their interviews. This member checking through the sur-
ated with specific patient characteristics, such as age and fragility vey ensured credibility and confirmability, and enabled inclusion of
that make these patients vulnerable to an iatrogenic response. participant feedback on data analysis. Our analysis reflects the sub-
When these patient and particular system characteristics come to- sequent corrections provided. Subsequent papers have been shared
gether, they may predispose an individual to cascade iatrogenesis with the the Australian College of Infection and Prevention Control
(Thornlow Anderson, & Oddone, 2009). Bail and Grealish (Bail & as a further strategy to enhance valididty. Table 1, lists the partici-
Grealish, 2016, p. 148) have articulated the relationship between pant characteristics.
cascade iatrogenesis and care rationing or missed care for elderly
patients. They write; “It is not simply one injury, or a single, ad- 3.1. Analysis
verse ‘event’, but a series of mild cases of neglect, missed opportunities
and missed red flags that produce a cascade of iatrogenesis” One way To ensure the rigor of data analysis, the interviews were read
of exploring possible cascade events is to map practices against closely by three members of the research team (JH, CV, and KB)
the guiding principles for infection control employed in Australia working independently of each other. The first stage of analysis in-
and taught to all nurses as fundamental to care. These are; (i) volved the allocation of descriptive codes (free nodes). De Wet and
The Chain of Infection; (ii) Employing Standard and Transmission Erasmus (2005) argue for rigor through second level coding which
Precautions; (iii) The National Standards of Governance; and (iv) both identifies clusters within the data, and the complex relation-
and Evidence-based Practice, which all hospitals must adhere to ships, patterns and possible explanations. Second level coding in

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Table 1
Characteristics of interview participants.

Pseudonym Nursing role Workplace State

1 Alice Infection control/ quality assurance Multi-site/ multi state role South Australia
2 Bonnie Infection control (16 years)∗ Private sector New South Wales
3 Charlotte Perioperative / previous infection control and quality assurance role in theatre Private sector South Australia
4 Donna Clinical Nurse Manager (17 years) Public sector Victoria
5 Elise Infection control Rural public sector Victoria
6 Frances Infection control/ academic Multi-site New South Wales
7 Grant Academic /casual nursing work Multi-site Queensland
8 Harriet Infection control Public sector New South Wales
9 Isabelle Casual/ previous infection control role Multi-site Western Australia
10 Jenny Infection control Public sector Victoria
11 Kerry Infection control Public sector Australian Capital Territory
∗
Years in role documented if participants mentioned it, were not specifically asked

this study, involved drawing on the interview schedule to organize from coming in but if they’ve [got]two parents with their child al-
data into four major themes: infection control activities which are ready in the unit, they’re not going to leave a young child by them-
missed; the reason why they are missed; enablers of good infec- selves out in the waiting area. (Donna)
tion control practice; and strategies to improve infection control
From the reservoir, the micro-organism must have a mode of
practice. Data were then examined for (i) how nurses managed in-
escape in order to move to another host. This occurs through a
fection control and (ii) issues that captured hospital-wide factors
portal of exit. From this point the infection moves via the person
or involved other health professionals that might lead to hospital-
or instrument (mode of transmission) to the new host, and as the
acquired infection. These were collated and discussed within the
quote demonstrates via failing to perform the care task of mouth
research team and then inductively mapped against the guiding
care:
principles for infection control employed in Australia, which de-
veloped the thematic headings for tracing cascade iatrogenesis. It just made me cringe then because I have sent back so many
These are; (i) The Chain of Infection; (ii) Employing Standard and patients to the ward that I haven’t been able to see the teeth of
Transmission Precautions; (iii) The National Standards of Gover- the patient because there’s so much crud in their mouth…..because
nance; and 4. Evidence-based Practice. These themes provided in- we have to pass a tube down that throat. (Charlotte)
sight from the participant’s observations into how and why cas-
The micro-organism, now ensconced with the person or utensil,
cade iatrogenesis occurs. Mapping against these standard frame-
must have an entry portal. As Jenny notes this requires time to
works of practice revealed gaps in the chain of infection, where
clean which nurses believe they lack:
gaps in clinical governance aligned to create cascade iatrogene-
sis with negative outcomes for patients, in this case specifically I would say quite often … when people are in a hurry they’re more
hospital-acquired infection. likely to not clean equipment between patients. They’re more likely
to miss hand hygiene if they’re tired, if they’ve had to work a dou-
ble shift because of lack of staffing,if they’ve missed tea breaks and
4. Ethics
getting off late, if they’re short staffed… pretty much when staffing
is good and they’ve got the time, hand hygiene compliance is ex-
Ethical permission was obtained from the (inserted on accep-
cellent. (Jenny)
tance). Information about the study was conveyed through the pro-
fessional association and interested participants contacted the re- Likewise, the reservoir can harbour the micro-organism in
searchers via email. equipment or resources, especially where buildings are old:
The other thing is just the layout and physical design of the fa-
5. Findings cilities I work in in the public sector, they’re very old hospitals,
they’re not great layout and design. One of them has a [ward] and
The first event precipitating a possible iatrogenic cascade comes one of those rooms had ten beds in it, the other one had six, and
from a breach in the “chain of infection principle.” This is not lim- one had two…..and it has three shared bathrooms for all of those
ited to the ward or for that matter to clinical interventions; staff people...and it makes it quite difficult. (Bonnie)
from nonpatient areas can also be infectious agents, or as Elise be-
Or the reservoir can be the patients themselves:
low noted, the reservoir can arise from staff who come to work
sick simply because they do not want to let the team down; Quite often your canvas is not very clean and there are some facil-
ities that you can’t shower them prior to them coming through, so
The kitchen and cleaning staff are the same. “Oh, if I called in sick
you have to undertake a scrub on the table for them. (Charlotte)
today, they’ve got nobody to clean.” It’s like, yeah, but you just
spread your gastro…So it’s not just nurses. They’re all like that. Of course, not all hosts are susceptible to infection; some indi-
And it’s because they don’t want to let people down and they don’t viduals can fight it off, others, such as the frail elderly find it more
understand the ramifications of what they’ve done. (Elise) difficult and are a susceptible host to the cascade process. The cas-
cade process is outlined in Figure 1.
In the quote below, Donna identifies visitors as a potential
reservoir:
5.1. Employing standard and transmission-based principles of
I do see the visitors take it up [disinfectant] cos it’s right near infection control
the intercom, so … you do see them use it before they enter the
rooms… so that’s good….… .. you’ve got a lot of family and sibling As the chain of infection principle demonstrate, nurses, kitchen
visitors coming in. It is harder to manage all of them, particularly staff, visitors, and patients themselves as well as equipment can be
if they’ve got viruses, colds etc, you do tend to try and stop them vehicles for the spread of infections; the path can be circuitous or

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Fig. 1. Nurse participant examples related to the Chain of Infection.

straightforward, and is outlined in most hospital and health service start of the day, it’s hit and miss because I have to say… So I think
policies and procedures regarding standard and precaution mea- there is a lot of environmental issues and I sometimes question the
sures (SA Health, 2017). Staff other than clinicians are also impli- standards because I find we now have no, we don’t have covers
cated. What is also highlighted in these quotes is a failure to fully and we don’t have this, we have these pods and so forth; yeah
implement the principle of standard precautions for infection con- that’s fine, but who cleans them and that is – the cleaning sched-
trol including gaps in the implementation of hand hygiene; the use ules are just not there. (Charlotte)
of personal protective equipment; ensuring adequate environmen-
Grant notes that where a hospital has solid policies on infec-
tal controls; and transmission-based protocols and encouraging a
tion control, they may very well be undermined by staffing poli-
culture of safety within the ward or unit. The quotes below ad-
cies linked to productivity and efficiency, such as the use of casual
dress the challenges in meeting these standards in complex clinical
staff over permanent employees:
environments. Frances illustrates the lack of awareness on the part
of the nurse, patients and others: I suspect it’s occurring at a ward level….As an agency nurse, I
don’t have access to the hospital policy so I don’t know what the
In keeping … ..the sterile field, yeah, sterile. So inadvertently mis-
hospital policies are because they’re all electronic now and as an
placing …[items] onto the sterile field because the field is laid out
agency nurse, I actually don’t have any access. (Grant)
and then the nurse needs to leave to get more equipment, because
everything wasn’t assembled at the time, and that coming and go-
5.2. “Strengthening clinical governance” through resourcing and
ing, and then inadvertently not keeping the sterile field sterile…is
surveillance
most of an issue. (Frances)

The issue of clinical governance can be examined from two per-

The participants also commented on the laissez-faire approach
spectives; firstly, a whole of organisation model of infection con-
to the use of Personal Protective Equipment, and aseptic nontouch
trol needs to be in place and well-resourced, and secondly, there
techniques including practices in place for reprocessing of equip-
needs to be a systematic mode of surveillance to ensure ongo-
ment, the environmental controls covering cleaning and the man-
ing monitoring. Infection control governance is not solely the re-
agement of waste, respiratory etiquette, and linen management.
sponsibility of clinicians but is an organisation-wide task demand-
Charlotte reflects on cleaning practices, some of which are linked
ing strong leadership to drive the safety culture from senior man-
to changes in equipment and to failure to teach why certain clean-
agers and CEOs through to cleaners and ward staff. The quotes be-
ing tasks are performed:
low are mapped to the National Standards for Safety and Quality
It’s cleaning staff who perhaps may not be cleaning according to for Australia which all health services must meet for accredita-
their contract or their contract may not even be relevant to the tion, and they specify the components of the standards that must
needs of the area. You have nursing staff now in theatres, the nor- be met (Australian Commission on Safety and Quality in Health
mal practise is to damp dust your theatre before you start at the Care, 2017). The following standards are relevant to the discussion

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here: Action 3.1. Integrating clinical governance; Action 3.2 Apply- ing these in the light of evidence, and providing feedback: As Kerry
ing quality improvement systems; Action 3.3 Partnering with con- notes, policies are not always clearly defined:
sumers; and Action 3.4: Surveillance.
I had a Goth working for me at the time who had tattoos and
‘Integrating clinical governance’ is about implementing policies piercing all over him so he was a very good asset . So I said ..
and procedures, managing risks and identifying training re- “Should he be wearing them?” and I said “No it doesn’t comply
quirements. Alice identifies that leadership needs financial in- with the hospital policy of bare below the elbow therefore it will
centives and the ‘big stick’ of accreditation to recognise the attract bugs”. So my answer wasn’t good enough, had to ask the
value of infection control work: doctor didn’t they – so the doctor asked me what my thoughts
are so he wrote down what I said and said “This is what Wendy’s
…at one place that I worked, the accountant there, he had no idea
already stated and this is what it should be”. So then I got called to
at all, and it was something that, well because I’ve got no idea fig-
the chief nurse and the chief nurse said “Well I think that’s a silly
ures and numbers and things either. So it was a good thing, once I
policy”. So I then had to – then it had to go to the union and the
explained to him “Look you know we need to purchase this certain
government solicitor because I wanted him to remove them and/or
thing that’s going to cost $600” … “Because this is going to actu-
he had to have them covered at all times, right?
ally help us with our accreditation, it’s going to help us with our
education of blah, blah”. “This is going to reduce money because Nurse experts were clear about what the consequences for their
you’re not going to get HAI’s”. and that’s what it comes down to, patients were when the quality control gaps weren’t addressed:
you’ve got to say to them. (Alice)
Well, so first of all you, well you’re mainly an advocate for the
In regards to “Applying quality improvement systems” respon- patient, so you make sure that what they’re being prescribed, say
dents noted that it was difficult in the complex work environment, for example they’ve got a wound infection and then the doctor just
with a perception that cultural factors and logistic decision making sticks them on a broad spectrum antibiotic, is what they’ve done
had an impact on how the system functions. Alice provides an ex- for years. Part of what my job to do, was to do, was to actually
ample that even if a suitable protocol for escalation was in place, check the pathology results and make sure that the sensitivities
the cultural of the organisation is important in ensuring good prac- match to what the antibiotic was that they were given. (Isabelle)
tice:
It costs money to have an ICP champion, … people don’t usually 5.3. Integrating the components of evidence-based practice
put money into that resource. So that does make a difference be-
cause if the organisation hadn’t made a commitment to it wouldn’t Nurse clinicians are expected to work with evidence to meet
have happened. And also, I guess it’s their knowledge, …the organ- the needs of patients (Nursing and Midwifery Board of Aus-
isation is often management and bean counters who are not [from tralia, 2016). There is a natural tension in all clinical work where
a] clinical background. (Alice) the (i) research evidence needs to be combined with, (ii) the
clinician’s expertise and, (iii) the patient’s preferences in order
A second example of failed “quality improvement systems” was
to make decisions suited to the individuals and the situation
that if there is a lack of skill mix and experienced staff, then the
(Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996).
reporting and decision making and use of personal authority to
The first component, (i) ‘Research evidence’ that informs clini-
challenge poor infection control practice within a theatre will be
cian decision making is not an unequivocal truth: rather, it is em-
restricted:
bedded in the complexity of stages of science and peer review that
…there’s not the support and the mentoring of the staff and then is always changing, and interpreted differently, as one participant
you find that sometimes the most senior person is basically carry- highlighted:
ing everybody’s job and doing everything because the skill mix just
I think it would be good to have more of a consensus as to what
isn’t there to take any initiative. (Charlotte)
are the right ways to do things… that issue around research and
There is also a need to view patients as partners (3. ‘Partnering researching the information… you can have three doctors in the
with Consumers’) within this governance structure and to demon- room and four opinions. (Grant)
strate the importance of the systems and practices through regular
Additionally, there are many situations of clinical care delivery
monitoring and follow up (Australian Commission for Safety and
that have not had robust research conducted to support the prac-
Quality in Health Care, 2017).
tice, despite widespread expert recommendations. Charlotte de-
[The] understanding of a patient’s isolation status [can be lacking]. scribes:
So why …. are we using transmission based precautions? What is
[Some clinicians] don’t see the relevance that we turn our back to
the organism that the patient has? And is this information con-
a trolley or movement around a sterile field - those little practices
veyed to the patient? What is the patient’s perception of why they
that often don’t have robust evidence get ignored because people
are in isolation? (Harriet)
say ‘oh well, show me the evidence, where is it’. …that makes it
Education and training is organized around deficits that in turn, really hard to hold a discussion and argue for good commonsense
are exposed during regular and systematic audits, however, the practice because often the commonsense there may not be the ev-
value of audits and the standard requirement of “surveillance” were idence. (Charlotte)
questioned if there were limited resources to back up findings:
Elise expands to touch on how (ii) “Clinical expertise” needs
If you don’t have the auditing you can’t identify issues, you can’t to be used to interpret current evidence, for example there are
fix them up ….when …people do more hand hygiene but if they guidelines that are purportedly evidence-informed, but get out-
haven’t had the correct education they’re just do more incorrect dated while the next version is being prepared, and so clinicians
all the time. (Alice) make decisions:
It also points to the need to engage staff in infection control We’re technically going against the guidelines, but the guidelines
from within a culture that promotes safety. This means staff must need to be reviewed… so the bible that we all go by is the in-
be engaged in the regular review of protocols and policies, updat- fection control guidelines that are put out by the National Safety

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Council, yeah, that’s 2010, so they haven’t been updated since then clinicians to be more effective through resourcing, supportive edu-
and it’s eight years along. (Elise) cation and mentoring, and judicious and pragmatic decisions about
workable policies.
Conversely, Charlotte notes that a nurse’s clinical judgement is
no longer a strong voice, implying that guidelines have higher im-
pact than the clinician: Ethical statement

When I first started we were basically taught to have faith in our

The paper was submitted to the Flinders University Social and
judgement and if you could substantiate why you’re arguing for
Behavioural Science Ethics Committee on 14th June 2017.
the best for your patient that’s acceptable and your seniors would
There are not financial or personal matters that may pose a
stand behind you to do that. (Charlotte)
conflict of interest. Funding to conduct the research was received
from the Faculty of Medicine, Nursing and Health Sciences Seeding
6. Discussion grants ($18,0 0 0) in 2016.
Word length 4971. We note two different directions on word
This paper linked omission of care at the individual clinician length. One part of the guide to authors says 50 0 0, another says
and organisational level which may contribute to HIA. We argue 4500.
that adverse events arise from the failure to perform standard pre-
cautions but also from failure to perform basic care activities. We
further argue that it is often not a single event but a series of fail- Credit authorship statement
ures to perform activities that operate within standards which con-
verge to create cascade iatrogenesis and HAI and implicate staff be-
Conceptualisation Henderson, Blackman
yond the nurse. Participants identified a range of institutional and
Management of contact with Willis
cultural factors which contributed to cascade iatrogenesis many of participants and ethics
which are outside of nursing control. They include environmental Methodology Henderson and Willis
cleanliness, ward layout, ward culture and education and failure Conduct of interviews Henderson and Willis
to model appropriate practice, inadequate resourcing and staffing, Thematic analysis InVivo Bail and Henderson
Thematic analysis Henderson, Willis, Bail
lack of integration of infection control into clinical governance, fail- Drafting of paper Bail, Willis
ure to act upon audit results, and failure to review protocols in re- Conceptualisation of paper argument Bail
lation to the evidence base. Nursing was not the only profession Editing of paper and reviewing Verrall, Henderson, Bail, Blackman
implicated, and in some instances, practices were done with the
intention of care. Acknowledgments and Disclosure
Previous research on missed care has focused on individualized
nursing tasks such as hand washing, mouth care or patient am- (to be added on acceptance)
bulation. This approach continues despite most studies identifying
resourcing and systems issues as culpable (Schubert et al., 2013; References
Willis, Carryer, Harvey, Pearson, & Henderson, 2017). Similarly, in-
Australian Commission for Safety and Quality in Health Care. (2017). Australian
fection control studies attempt to move away from individual vic- Safety and Quality Framework for Health Care: Putting the framework into ac-
tim blaming to suggesting that the problem requires a whole of tion. Retrieved from Sydney https://www.safetyandquality.gov.au/wp-content/
organisation approach (Lam, 2011). Nurses who miss providing pa- uploads/2011/01/ASQFHC- Guide- Healthcare- team.pdf .
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