Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa.
Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa.
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DOI：
10.1371/journal.pgph.0000964
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发表时间：
2022
期刊：
影响因子：
--
通讯作者：
Kielmann, Karina
中科院分区：
文献类型：
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作者：
Arakelyan, Stella;MacGregor, Hayley;Voce, Anna S;Seeley, Janet;Grant, Alison D;Kielmann, Karina
针对空气传播感染的感染预防和控制 (IPC) 措施实施欠佳与医疗保健获得性感染的增加有关。对影响因素的研究往往侧重于基础设施薄弱或医护人员缺乏遵守建议的指南，而对实施 IPC 措施的工作环境考虑有限。我们使用临床民族志对南非结核病 (TB) 相关 IPC 进行分析，以阐明 TB-IPC 策略的有利环境。 2018 年 11 月至 2019 年 4 月，我们采用人种学方法，对南非夸祖鲁-纳塔尔省的六个初级卫生诊所的医护人员进行了观察、半结构化访谈和非正式对话。按照一个框架对定性数据和现场记录进行了演绎分析，该框架检查了影响 TB-IPC 实施的卫生系统“硬件”和“软件”问题之间的交叉点。诊所经理和一线工作人员在基础设施、资源和组织限制范围内协商并调整 TB-IPC 实践。工作人员对于 IPC 协议、IPC 委员会和 IPC 倡导者等管理监督措施的有效性持矛盾态度。实施分诊和筛查等行政措施的挑战与患者流程和信息组织效率低下以及政策指令不一致有关。环境控制的整合因物质基础设施和行为规范的限制而受到阻碍。尽管有个人防护措施，但由于感知风险有限以及缺乏围绕卫生工作者和患者安全的集体精神，并未始终如一地实施。在一家诊所，积极的组织文化提高了员工士气并促进了对 IPC 措施的遵守。 “硬件”和“软件”限制相互作用，对初级保健人员实施 TB-IPC 措施的能力产生负面影响。临床人种学允许对受损 TB-IPC 的“问题”进行多个切入点，强调了捕获“有利环境”维度的重要性，目前尚未在二元清单中进行评估。
Sub-optimal implementation of infection prevention and control (IPC) measures for airborne infections is associated with a rise in healthcare-acquired infections. Research examining contributing factors has tended to focus on poor infrastructure or lack of health care worker compliance with recommended guidelines, with limited consideration of the working environments within which IPC measures are implemented. Our analysis of compromised tuberculosis (TB)-related IPC in South Africa used clinic ethnography to elucidate the enabling environment for TB-IPC strategies. Using an ethnographic approach, we conducted observations, semi-structured interviews, and informal conversations with healthcare staff in six primary health clinics in KwaZulu-Natal, South Africa between November 2018 and April 2019. Qualitative data and fieldnotes were analysed deductively following a framework that examined the intersections between health systems ‘hardware’ and ‘software’ issues affecting the implementation of TB-IPC. Clinic managers and front-line staff negotiate and adapt TB-IPC practices within infrastructural, resource and organisational constraints. Staff were ambivalent about the usefulness of managerial oversight measures including IPC protocols, IPC committees and IPC champions. Challenges in implementing administrative measures including triaging and screening were related to the inefficient organisation of patient flow and information, as well as inconsistent policy directives. Integration of environmental controls was hindered by limitations in the material infrastructure and behavioural norms. Personal protective measures, though available, were not consistently applied due to limited perceived risk and the lack of a collective ethos around health worker and patient safety. In one clinic, positive organisational culture enhanced staff morale and adherence to IPC measures. ‘Hardware’ and ‘software’ constraints interact to impact negatively on the capacity of primary care staff to implement TB-IPC measures. Clinic ethnography allowed for multiple entry points to the ‘problematic’ of compromised TB-IPC, highlighting the importance of capturing dimensions of the ‘enabling environment’, currently not assessed in binary checklists.