Ensuring the survival of infection control nurses: an experienced infection control nurse looks at the education, knowledge, skills and relationships her professional peers need to ensure their unique role and scope of practice continues well into the 21st century.

When I was a student nurse in the late '80s, I never dreamed I would now be working in infection prevention and control. At the age of 18 I was the stereotypical naive nursing student--wanting to deliver babies in Third World countries! Had anyone told me I would one day work in infection prevention and control, I certainly would not have believed them. The infection control nurse in the hospital where I trained was an older woman, who seemed to be forever clattering up and down the corridors with yellow rubbish-bin stands for the HIV rooms. She would stand at the door, resplendent in theatre hat, boots, double gloves and a gown, while we, equally excessively attired, passed out the rubbish to be ceremoniously double-bagged. Not quite my ideal career mentor.

How things have changed! We now have a more rational science-based philosophy underpinning isolation practices, the cornerstone of which are standard precautions. But some things have not changed--handwashing remains the single most important means of infection prevention, just as it was in the days of infection control pioneer, Hungarian physician Ingaz Semmelweiss. And the basic principles of asepsis admonished by Florence Nightingale are still paramount. It is primarily the tools we use to accomplish these, and the new rationale behind the practices, that have changed. I have spent most of my nursing career in the prevention and control of health care-associated infections, primarily within the paediatric setting. The role of the infection control practitioner * is to assist other health care workers prevent patients from acquiring infections within health care settings, and, at times, the wider community. This is achieved by a number of methods, based on the five main tenets of infection control practice: education for all staff; provision of up-to-date advice; development and review of policies and guidelines, based on effective evidence; undertaking surveillance and research; and ongoing review of the programme based on quality principles and processes. The latter is important to ensure any interventions and changes implemented do not result in increased patient risk and/or harm.

As nurses we must be able to define what we do and articulate how we make a difference. Infection prevention and control is a field that tends itself well to evidence-based practice. Since well before the days of antibiotics, infections have been monitored and measured and the effects of interventions documented. We need to continue this with increasing scientific rigour. The infection control practitioner of the 21st century needs to be educated, not just in understanding the process of infectious diseases and basic microbiological concepts, but, more crucially, in epidemiology, research methodologies and the principles of public health. Our education should be at postgraduate level and specific to our specialty practice area. This will allow advanced development of the critical thinking skills required to develop and challenge clinical standards and evaluate health outcomes--not just in clinical terms, but also by ensuring other influences, such as the financial and resource impacts, are considered appropriately.

The role of the hospital infection control nurse was historically just that--hospital-based, located within nursing departments and focused on control of infection. Our role in the 21st century is much broader. We are not limited to acute hospital settings, but are active in primary care, community health, mental health, aged care, prisons, and rehabilitation, to name a few. Rather than attempting to control and contain infections after they have been identified, the role is now more prevention focused. Today's infection control practitioners work collaboratively across settings and within multidisciplinary environments, providing leadership and consultancy to all staff, not just fellow nurses. We practise autonomously, sometimes with little other than professional links with nursing. Expert infection control nurses are also involved with influencing development and maintenance of national and international policy and standards. Several countries have recognised the need for infection prevention and control roles within national government, particularly following expensive outbreaks of infectious diseases, published data relating to the cost of health care-associated infections and newly emerging diseases of global significance.

The role of medical microbiologists

I am concerned at the increasing number of medical microbiologists currently purporting to be experts in infection control. While a few may have undertaken specific, internationally-recognised training, the majority do not have the specific knowledge required to practise as infection control practitioners. I question why medical microbiology registrars and house officers are increasingly attending infection control committees and being involved in running infection control departments in some hospitals. Collaboration with medical colleagues is very important, and while acknowledging the inextricable links between the disciplines (particularly in hospitals), I believe each role is fundamentally different. The infection control practitioner operates within the paradigm of nursing, nursing theory and nursing research, practising a science that is more about prevention than cure. As infection control practitioners, we have our own unique body of knowledge gained from education, experience and research, and apply it from a nursing perspective. This forms the basis for our own unique scope of practice. This is one reason why medical microbiologists and infection control practitioners are not interchangeable. Each has specific knowledge that benefits the other and is useful to combine for the good of patients. But we need to maintain our differences and develop our different skills, so our collective expertise can be beneficial. I am concerned that infection prevention and control could potentially change from an autonomous role, that has historically had excellent collaboration with physicians and other health team members, to a role where practice is dictated by physicians. This could occur because of two things: microbiologists' increasing interest in infection prevention and control; and the inability of infection control practitioners themselves to value their skills and to gain further education that benefits their practice.

Just like all nurses, we need to be clear about our role and our specific scope of practice. It is extremely important to have a close collaborative relationship with the microbiology department, along with infectious disease physicians and occupational health specialists. But we all must recognise each other's unique role, specific expertise and defined scope of practice. Our medical colleagues have specific and valuable knowledge in their particular field, which is beneficial for the infection control practitioner to draw on, but at the end of the day, it is infection control nurses who must apply their own body of knowledge to answer the many queries they receive daily. It is the infection control nurse who will be called when the steriliser breaks down, who gives education to the new staff, who talks with the patient's family regarding isolation, who climbs up the air conditioning cooling tower, who observes handwashing techniques, who collects the data on intravenous infections in the intensive care unit, who searches the literature to inform policy change regarding urinary catheterisation in the community, who audits the hospital laundry, who inspects the bone-marrow transplant unit's hepa-filter with the hospital engineers, who answers the questions regarding the colour of the rubbish bags, who runs the evaluation process for alternative handwashing products, who assesses the practice of the mortuary staff, who answers the questions at certification time, who reports the surveillance figures to the quality committee, who communicates the outbreak to management, who prepares the audit documentation and such like. The knowledge to respond to such a broad range of queries and situations is based on education, experience and the application of theoretical nursing and public health concepts to daily practice.

And what of the future? A strategic review looking towards 2010 identified key skills and attributes for nurses of the future, including clinical inquiry, information technology, business and management skills, critical analysis of current knowledge and ability to influence health policy. (1) Infection control nurses of the future need to demonstrate these skills, possibly even more so than some of our nursing colleagues, due to our multi-disciplinary role and the increasing need to justify positions not involved with direct patient care.

Due to a number of factors, including the Health Practitioners Competence Assurance Act and the emphasis on increasing the effectiveness of service provision, we need to be more sure of our role than ever and be able to articulate our scope of practice. Otherwise, we will remain in the last century, white our colleagues in other fields and disciplines forge ahead and potentially take us over.

With moves towards nurse prescribing in New Zealand, infection control nurses are well placed to obtain limited prescribing rights. Currently many infection control practitioners dispense topical treatments for decolonisation of methicillin-resistant staphylococcus aureus, such as nasal mupiricin and chlorhexadine body washes. They are frequently asked for advice regarding antibiotic sensitivities and appropriate use of antibiotics. Larger hospitals tend to have excellent medical microbiology and infectious disease physician support and thus less need for nurses with education in prescribing, because the infection control practitioner's role has a broader focus than just the patient. But specific areas such as rural areas and groups of rest-homes would benefit from the work of nurses with a clinically-focused masters degree, with knowledge of pharmacology, physiology, chemistry, pathophysiology, pharmacokinetics and pharmacodynamics. Such infection control practitioners could align closely with public health services, as public health is concerned with disease prevention and incorporates many of the same principles the discipline of infection prevention and control is based upon--epidemiology, clinical epidemiology, health promotion/education, health service policy and health economics. Such a model may well lend itself to community-based nurse practitioners specialising in managing patients with specific infectious diseases.

Infection control nurses need to get back to our historical roots of basic hygiene and scientific principles and use this to underpin what is an evolving advanced practice area. We need to own our knowledge and specific scope and look outside the traditional hospital-based role. We need to undertake surveillance that results in meaningful data and analyse it in such a way that our results can be used to improve patient outcomes. We should undertake research that provides evidence of our effectiveness and communicate this in professional forums. We must further develop our critical thinking and reflection skills to ensure our advice and actions become more outcome-focused. And, as individual professionals, we need to be clear about our role and scope of practice in our particular multi-disciplinary work settings; we need to collaborate with other health professionals for the good of the patients/clients who are indirectly in our care, and we need to become more aware of who we are and what difference we make to those vulnerable individuals using our health care services.

* Note that the designation infection control practitioner is an internationally recognised term and is not linked with nurse practitioner[TM].

Reference

(1) Nursing Council of New Zealand (2001) KMPG Strategic Review of Undergraduate Nursing Education. Wellington: Nursing Council

Victoria Smith, RN, BN, MNS, PGDipPH, works as an infection control consultant in Michigan, United States (US). Before going to the US late last year, she worked part-time in paediatric infection control at Kidz First Children's Hospital and Community Health Services, Counties Manukau District Health Board, and ran a private infection control consultancy.