American Journal of Infection Control 42 (2014) 405-11

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American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

Preventing transmission of MRSA: A qualitative study of health care

workers’ attitudes and suggestions
Dorothy J. Seibert PhD, RN a, *, Karen Gabel Speroni PhD, RN b, Kyeung Mi Oh PhD, RN a,
Mary C. DeVoe BSN, RN b, Kathryn H. Jacobsen PhD c
a
School of Nursing, George Mason University, Fairfax, VA
b
Inova Fair Oaks Hospital, Fairfax, VA
c
Department of Global and Community Health, George Mason University, Fairfax, VA

Key Words: Background: Health care workers’ (HCWs) perceptions and attitudes affect implementation of pre-
Health personnel cautions to prevent transmission of drug-resistant pathogens such as methicillin-resistant Staphylococcus
Infection control aureus (MRSA). Identification of challenges and barriers to recommended practices is a critical compo-
Inpatients
nent of promoting a safe clinical environment of care.
Health care associated infection
Methods: Semistructured interviews addressed how MRSA affects HCWs, prevention of transmission,
Nursing personnel
and challenges and barriers HCWs experience when entering a MRSA isolation room and performing
appropriate hand hygiene.
Results: The purposive sample of 26 acute care HCWs (16 registered nurses; 1 physician; 6 allied health
professionals; and 3 support staff) self-selected from 276 responding to a questionnaire on MRSA.
Analysis identified 18 themes across seven categories. Most participants reported feeling responsible for
preventing transmission, and having the knowledge and desire to do so. However, many also reported
challenges to following consistent hand hygiene and use of contact precautions. Barriers included patient
care demands, equipment and environmental issues such as availability of sinks, time pressures, the
practices of other HCWs, and the need for additional signs indicating which patients require contact
precautions.
Conclusions: The HCWs reported a need for improved clarity of isolation protocols throughout patients’
hospital journey, additional rooms and staff for isolation patients, improved education and communi-
cation (including timely and appropriate signage), and an emphasis on involving all HCWs in reducing
contamination.
Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Recent qualitative studies in the United States provide insight
into developing strategies to successfully implement practices that
reduce health careeassociated infections (HAIs) related to medical
devices.1-3 However, only limited qualitative research has evaluated
health care worker (HCW) attitudes and reports of barriers to hand
hygiene and contact precaution adherence in acute care. Interna-
tional studies, mostly from Europe, have suggested that most HCWs
feel a strong responsibility to patients and a desire to prevent
* Address correspondence to Dorothy J. Seibert, PhD, RN, School of Nursing,
George Mason University, 4400 University Dr, MS 3C4, Fairfax, VA 22030-4444.
E-mail address: dseibert@gmu.edu (D.J. Seibert).
Supported by a grant from the Epsilon Zeta chapter of Sigma Theta Tau, the
Honor Society of Nursing.
Conflict of interest: None to report.
infections.4-7 They have also suggested that self-protectiondnot
patient protectiondis the primary cue to action for HCWs to
implement hand hygiene and contact precautions.4-8
Across studies, HCWs consistently report that barriers to
adherence include workloads and time pressures,4-7,9 as well as
insufficient access to appropriate facilities and protective equip-
ment.4,10-12 HCWs also report challenges in maintaining standards
during emergent clinical situations, because taking time for contact
precautions may compromise patient safety.4-6 The present study
builds on these previous qualitative studies by examining HCWs’
attitudes about methicillin-resistant Staphylococcus aureus (MRSA),
perceptions of challenges and barriers to MRSA prevention, and
suggestions for preventing the transmission of MRSA in acute
health care settings.

0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2013.10.008
406 D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 405-11
METHODS
Participants
This qualitative study is 1 of 3 components of a comprehensive
evaluation of MRSA prevention practices at an acute care hos-
pital that includes quantitative, qualitative, and direct observation
methods. The methods and results from the quantitative and direct
observation studies are reported elsewhere.13 A purposive sample
of 26 HCWs engaged in direct patient care or with jobs requiring
entry into patient care areas were recruited for interviews. Out of a
total of 276 HCW survey participants, 42 volunteered to be inter-
viewed for this study, and 26 completed the interview (24 females
and 2 males). The participants represented a variety of health care
fields (16 nurses, 1 physician, 6 allied health professionals, and 2
support staff), a wide age range (3 age 18-25 years, 6 age 26-35
years, 7 age 36-45 years, 4 age 46-55 years, and 6 age 56 years and
older), and varying employment status (22 full-time, 2 part-time,
and 2 as needed).
Interview methods
Semistructured interviews approximately 30 minutes in length
were completed in the hospital during September and October
2012. The following questions explored perceptions of MRSA and
challenges in reducing transmission in acute health care settings:
1. How do you feel MRSA affects you as a HCW?
2. What are suggestions of ways to prevent transmission of MRSA?
3. How are you challenged in your work task when you have to
enter an isolation room?
4. What are other barriers that prevent implementing isolation
precautions or appropriate hand hygiene?
Data analysis
Interviews were audio recorded and transcribed into 27 pages of
verbatim responses by the lead author (D.J.S.). Comments were
imported into Excel and sorted by theme. The lead author and 2
researchers (K.G.S. and M.C.D.) completed content analysis using a
directed approach with an open and selective method of coding.
Interviews were reviewed during transcription and categorization
to identify multiple unique elements from each conversation, and
comments were assigned to categories and themes.14 The reviewers
used an iterative process to refine categories and achieve consensus
on response categorization and theme coding. An a priori frame-
work focused on interview question objectives: perceptions or at-
titudes about MRSA prevention, challenges of adhering to contact
precautions for patients in isolation, and hand hygiene barriers. The
final categorization scheme also included time management,
knowledge or education about MRSA, communication (including
signage), and mechanisms of MRSA contamination (Table 1).
Within themes, keywords were identified and used as search
terms for a line-by-line analysis of interview transcripts (Table 2).15
The word processor “Find” function confirmed that all keywords
were identified and coded. Assignment of an observation was not
restricted to a single category; comments addressing multiple
themes were coded for relevant categories.
RESULTS
The final coding scheme consisted of 7 categories and 18 themes
(Table 2). Figure 1 shows each core category and theme. Here,
emergent themes from each of the 7 main categories are presented
in the words of the study participants.
Perceptions and attitudes
Figure 1 lists the participants’ positive and negative perceptions
about MRSA and its impact on their lives. The HCW’s responsibility
for patient care was a common positive attitude that promoted
MRSA prevention activities:
“First of all, I feel responsible for the person that I am dealing
with. That’s where it really impacts me. If I touch somebody and
I haven’t washed my hands properly, then I am going to be the
carrier and trigger for that MRSA to go forward. And to think
what happens to people! Especially, I work in joint replacement,
and if they have some kind of joint infection, it’s epic” (nurse).
“It requires that we be much more careful in our registrations.
Because.we’re responsible for alerting the clinical staff. So as
part of our job, we have to always be aware of an alert [and] to
pass the information on to the clinical staff” (support staff).
Negative prevention perceptions included concerns that per-
sonal protection may adversely affect patient care and inhibit
healing derived from physical contact with a caregiver:
“I think that at some point when a health care professional
knows that her patient is infectious, there is a barrier that
happens. A barrier to touch, just to provide comfort or a healing
touch or comfort touch.goes away when you have the barrier
of the PPE [personal protective equipment] and just the idea
that the patient is infectious then. You want to protect yourself
and of course when you go home, you want to protect your
family” (nurse).
“I feel like I don’t make a connection and a contact [with] my
patient that I normally would if somebody was not on iso-
lation...the gloved hands versus the skin-to-skin contact of
trying to make that connection with the patient” (nurse).
Some HCWs’ negative attitudes to contact precautions adher-
ence could have significant repercussions for patient safety:
“I think the biggest things are that people either think, ’Well I’m
only doing this one little task; it doesn’t matter,’ or ’I’m just
going to pop in the room, and I just need to get this one form
signedddo I really need to put on and use all the isolation or all
the preventive things I should?’” (support staff).
Contact precautions
Among the comments related to work practices and challenges in
work practice, 15 reflected adherence to recommended practices of
gloving, gowning, and hand hygiene and 13 reflected nonadherence.
Many participants expressed concern about nonadherence:
“My suggestion would be just better adherence to the system.
Maybe a more strict, straightforward way of having people look at
the signage and the carts and gowning up and gloves and every-
thing. I don’t feel like it is being adhered to as well” (allied health).
Adherence to contact precaution protocols raised concerns
about patient safety when time is critical. Donning and doffing
gowns and gloves is a challenge “when there’s a safety issue and
you can’t just run right in,” as reported by nurses concerned about
patients at risk for falling and injuring themselves, among other
possible threats to safety. Providing the same level of care to the
patient on isolation challenges the HCW who knows that “it just
 D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 405-11 407

Table 1
Definitions of categories by order of frequency

Category
Perceptions/attitudes (n ¼ 61)
Contact precautions (n ¼ 58)
Time (n ¼ 53)
Knowledge/education (n ¼ 41)
Communication (n ¼ 33)
Hand hygiene (n ¼ 28)
Contamination (n ¼ 22)
Definition
Positive comments such as responsibility in care, feelings, or opinions about awareness of MRSA, perceptions of barriers to patient care,
concern for MRSA transmission, and empowerment related to MRSA prevention; expression of negative perceptions, such as contact
precautions being barriers to healing touch and comfort, lack of awareness, fear of MRSA, and nonadherence to MRSA prevention
Challenges in the processes of caring for patients in isolation, equipment processing and cleaning, safety issues, barriers in gloving and
gowning, and adherence to practice standards
Time and contact precautions processes, time spent screening patients and researching patients’ MRSA histories, time caring for patients,
staffing issues, care planning and workflow, and planning assignments
Knowledge of MRSA, potential educational opportunities regarding MRSA, education about transporting patients and cleaning, methods
of education, and knowledge of patient MRSA status
Communication among HCWs and with patients, communication about MRSA status and MRSA screening, contact precautions signs for
patients with MRSA
Perceptions or attitudes about HCW adherence, responsibility for prevention, barriers related to facilities and equipment (eg, sinks,
dispensers, and alcohol rubs)
Contamination of the environment by MRSA, cross-contamination between patients and HCWs, contamination of equipment

takes more time to care for the patient” (nurse), but realizes that “I
don’t go into the patient’s [room] as frequently as I would nor-
mally go into a room because of having to gown up” (nurse). “To
come back to the room, regown, reglove, and go through the
whole thing is very time-consuming. So, I’ve noticed people who
take shortcuts” (allied health). Other HCWs identified concerns
related to contaminated charts, stethoscopes, wheels, other
equipment removed from isolation rooms, and the time element
involved in cleaning. An allied health HCW mentioned an addi-
tional barrier to use of contact precautions: “For one thing,
wearing the gowns can be little overheating if I’m doing a lot of
physical lifting of patients.”
Many HCWs questioned appropriate work environment pre-
cautions. A registration staff worker noted that “a big challenge
for us was [to determine] just what...we need to do.” According to
a presurgical HCW, “I’m challenged in terms of the extra work
that needs to be done to find out if they [patients] still need to be
kept on contact precautions when they come in for the surgery.”
A surgical HCW stated, “Bacteria, not only MRSA, are just
ubiquitous and everywhere. There is always a risk of cross-
contamination between patients, and any bacteria, not only
MRSA, can certainly complicate any surgical procedure and only
makes it worse...and without adequate staffing, the risk is
certainly increased.”
Time
entering and exiting isolation: “Getting gowned, gloved, washing
hands before and washing hands after, [and] cleaning my equip-
ment. So it definitely takes a lot of time.”
The HCWs acknowledged the challenges posed by the extra
time needed to provide care and a lack of support staff to provide
supplies and help with tasks. “Well, it definitely slows down the
process. If you have a patient with MRSA, sometimes you will see
that patient last versus seeing them first” (nurse). “An isolation
patient really requires 2 people to care for them together. You
have 1 considered contaminated and another clean” (nurse). As
for delays in getting assistance, “I find that the patient needs a new
brief or they need new linens and it’s getting someone else, calling
out of the room to get someone to bring in what we need” (allied
health).
Several participants who care for patients in isolation rooms
reported ways to minimize the time burden of caring for MRSA
patients and maximize patient safety: “Well, I don’t think it’s so
much of a challenge as remembering and positioning yourself in a
way that while you’re with a patient you don’t have to leave for
other supplies” (allied health). “We do make a really strong
conscious effort [to] always put the [MRSA] patient at the end of the
day or the end of the cases” (nurse). Work planning contributes to
this success: “As the charge nurse making our patient.assign-
ments, we certainly wouldn’t give a neutropenic patient or an
immunocompromised patient to a nurse assigned to an active
MRSA case.”

Time issues were mentioned by HCWs as relating to contact Knowledge/education

precautions/MRSA screening, patient care, staffing issues, and
planning and workflow. For example, time delays related to contact
precautions were reported by HCWs who review patient histories
for MRSA colonization or infection before admission: “The chal-
lenge that it has for me is that when I’m interviewing a patient and
find out that they’ve had a history of MRSA, it’s a lot of extra work to
research it out” (nurse). Isolation patients also create space de-
mands: “It restricts the rooms that we can put patients in in the
emergency department. It closes off rooms after the patient has
been moved out of the room” (nurse).
Other HCWs identified patient care- and equipment-related
delays: “It adds an extra step when you’re on a busy unit. You
may be bringing stuff in with you like Accu-checks. And it’s just
always those extra little steps that delay your efficiency. I guess
that’s the challenge” (nurse). “Time tends to be a barrier when
you’re in a hurry and have a huge patient load. You find yourself
running in real quick to grab something before putting the gown
on: ‘Oh, I’m just going to grab this out of the room’” (nurse). An
allied health staff member described the process involved in
Knowledge and educational opportunities were identified 23
times for the HCWs and 18 times for patients, visitors, and the
community. A physician noted: “People know what the right thing to
do is. How do we help people do the right thing?.We have to
remind people more constantly.” Interviewees emphasized the need
“to make sure that all the employees understand what MRSA is”
(nurse), to provide “a lot more education” (allied health), and to “get
the patients involved in prevention” (support staff). HCWs described
incidents of family members and visitors of patients with MRSA
strolling through the hospital corridors while wearing gowns and
gloves as being “very oblivious to what was going on and the
reasoning behind.wearing that stuff” (allied health). “Because lots
of people come from different countries, they do not understand
what MRSA is” (nurse). Moreover, “lots of people don’t get that ed-
ucation on a regular basis” (allied health). “I think it is all about
education, and I think we have to get buy-in from everybody.
Everybody in the hospital, all those 42 people [that, on average, enter
a patient’s room over the course of a day] for 24 hours” (physician).
408 D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 405-11

Table 2
Interview content inductively developed categories and themes with characteristic response

Category Theme Key terms Characteristic interview response

Perceptions/attitudes Positive perception/attitude Feel, think, perceive, N: “Otherwise it’s just changing an individual’s mind and
(n ¼ 61) (n ¼ 44) barrier, challenge habit. I just think.making MRSA visual and making a
person believe they actually can be empowered to stop
the transmission.”
Negative perception/attitude Feel, think, perceive, N: “You find yourself running in real quick to grab
(n ¼ 17) barrier, challenge something before put, you know, not putting the gown
on: ’Oh, I’m just going to grab this out of the room.’”
Contact precautions Challenges (n ¼ 30) Barriers, challenge N: “They need more; like their acuity is very high compared
(n ¼ 58) to a nonisolation patient. I just feel like if I have less
isolation patients.I can follow all the standards that
they require.”
Practice (adherence/nonadherence) Prevent transmission, challenge, N: “Making sure you do.wearing the gowns and gloves
(n ¼ 28) contact precautions when we are in isolation for MRSA.”
AH: “I have seen health care workers walk into a room
ungowned and hug an isolation patient.”
Time/work/planning Planning/workflow (n ¼ 22) Time, challenge, work, planning AH: “For me personally it means more time...getting
(n ¼ 53) gowned and gloved, washing hands before and after
cleaning my equipment.”
Contact precaution/ screening Affect, challenge, N: “It’s the time, it’s the time. And you know you are doing
(n ¼ 17) contact precautions this in and out very quickly. It’s a lot of work to do it
properly. A lot of thought behind it.”
Caring for patients (n ¼ 7) Time, affect, challenge N: “Well it definitely slows down the process. Just the basic
patient care...”
Staffing (n ¼ 7) Barrier, challenge, staff N: “It’s easy to slip up because you’re so short staffed and
you’re going so fast.
Knowledge, education HCW, medical offices (n ¼ 23) Prevent, knowledge, N: “We’ve educated; we’ve done everything. I just think it’s
(n ¼ 41) barriers, education just continually, just the monitoring, continually
educating people, and keep hounding them.”
Patient/visitors/community Prevent, challenges, N: “I’ve actually told a lot of people, well this is what it is.
(n ¼ 18) barriers, education Kind of like spread the word because a lot of people
actually don’t know what it is.”
Communication General (n ¼ 13) Communicate, challenge, tell, N: “They don’t understand. and they get very defensive
(n ¼ 33) educate, show when you go tell them that you cannot take this inside
the isolation rooms.”
Contact precaution signs Barrier, challenge, N: “Just the communication thing.the sign wasn’t up or we
(n ¼ 12) contact precautions can’t find a cart.and then people going in and not taking
the precautions that they should.”
MRSA status (n ¼ 8) Challenge, barrier, prevention, MD: “I think proper communication would be beneficial,
not just here at our hospital but anywhere if a patient’s
been flagged as being MRSA-positive. I think.follow-up
should be taken, like when a patient is discharged.”
Hand hygiene Perception/attitude (n ¼ 21) Feel, think, perceive, barrier, N: “If I haven’t washed my hands properly, then I’m going to
(n ¼ 28) hand hygiene be the carrier and trigger for that MRSA to go forward.”
Barrier (n ¼ 7) Barrier, hand hygiene, sink MD: “I like the idea of washing them down the sink.try
when you come out of the patient room and try and
figure out where the nearest sink is. They are behind
artificial barriers.”
Contamination Environment (n ¼ 13) Clean, prevent, transmission AH: “We have to get the room that we take them into
(n ¼ 22) terminally cleaned, so we’re not putting other patients at
risk.”
Patient/staff (n ¼ 5) Contamination, challenge N: “We have to make sure we don’t pass anything on to
patients either, from patient to patient.”
Equipment (n ¼ 4) Affect, prevent transmission AH: “You come out and if there’s no bleach wipes readily
available, it’s hard to get everything [equipment] cleaned
appropriately when you’re leaving the room.”

AH, allied health; MD, physician; N, nurse; SS, support staff.

Communication Communication about the MRSA status of patients was

Communication received 33 mentions, including general
comments, those related to contact precautions signs, and those
related to the patient’s MRSA status. Participants identified
communication (or lack thereof) as a barrier preventing imple-
mentation of recommended practices. “Make sure they are
aware, the family is aware. The lack of communication can cause
lots of problems” (nurse). Eleven remarks emphasized the
absence of appropriate contact precautions signs: “Just too many
times, [you] go to a new patient, then leave the room, come back
in an hour, and all of a sudden the isolation signs are up” (allied
health).
mentioned as a barrier, as a challenge, and as a means of pre-
venting transmission of MRSA. “Sometimes it’s difficult to find
out if the patient truly still has the infection. They may say they
were cleared by a doctor, not of this facility, but then they have
no documentation of it” (support staff). Communication of MRSA
status was viewed as a challenge by one physician: “As soon as
they hit the hospital again, if they come, in the admission thing
flags up as, MRSA-positive, and they get put into isolation. So we
changed our flow such that the patient gets informed. The pa-
tient has a letter they can take to their primary care [provider].”
One HCW reiterated the relationship between communication
and prevention: “Like I said, communication is the biggest. It
 D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 405-11
Fig 1. Categories and themes identified in 26 interview narratives.
[MRSA status] needs to be communicated right off the bat (allied
health).
Hand hygiene
Hand hygiene comment themes were classified as perceptions/
attitudes (n ¼ 21) and barriers (n ¼ 7) in work practice. One nurse
recognized the importance of handwashing as a team:
“All coworkers, all the people that work in the hospital. First they
have to wash their hands, that’s the main thing. Before they go in
the patient’s room and even after. Wash their hands before using
gloves and after they take the gloves off; wash their hands. We just
have to make sure that everybody understands as a team” (nurse).
The challenges to hand hygiene generally related to placement
of sinks:
“Well, I don’t think it is a barrier, but I think if you put a sink in
front of someone, versus hiding it in every other place.... It
409
would probably be easier if the those sinks and places to wash
hands and things like that were right in your face so that you
would bump into it to get where you are going” (nurse).
Contamination
Contamination issues were related to the environment, pat-
ients and staff, and equipment. The HCWs voiced concerns about
transmission of bacteria in the environment and provided possible
suggestions for preventing transmission:
“It’s certainly easy, even when wearing gloves, to touch a
contaminated patient and then touch a countertop. Have any of
the cleaning staff or any of the nursing staff, anyone actually,
come in contact with that unknowingly and transmit bacteria
from one place to another” (nurse).
“I think if we had more room basically, like having a secluded
area that we could just take them. Where the patient can be put
410 D.J. Seibert et al. / American Journal of Infection Control 42 (2014) 405-11
in that room, registered there, wait there until the lab is ready to
draw their blood” (allied health).
Related to equipment, a nurse identified concerns related to pa-
tient care: “We need to do a better job with wiping down the surfaces
of things we use all the time, like our pens, scissors, things like that
we might touch while we are caring for the patient.” Cross-
contamination between patients or staff to patients was identified
as a concern: “So I know it affects my daily life here and I don’t want to
bring anything home. And I’m aware we have to make sure we don’t
pass anything on to patients either, from patient to patient” (nurse).
Eleven participants reported experiencing no barriers, and 7
reported no challenges. A positive response was: “I don’t know
what barrier, I mean, they try to have sinks all over and the right
equipment for us to use” (nurse). Many HCWs identified no chal-
lenges because they considered contact precautions and hand hy-
giene to simply be standard practice: “I don’t see a challenge. The
biggest challenge is getting the cart, and that’s not hard” (nurse).
According to one managerial participant, the hospital’s adminis-
tration had “worked so hard to remove any barriers.”
DISCUSSION
Qualitative studies provide a richer insight into HCWs’ percep-
tions about prevention of MRSA and other HAIs than can be gained
by cross-sectional surveys and hand hygiene observations alone.16
The participants in this study generally had positive attitudes
about their ability and willingness to take action to reduce MRSA
transmission, along with a deep sense of responsibility to the patient
and others that serves as a motivation for adherence to preventive
practices. In agreement with previous studies, the participants
expressed ownership of professional responsibility to protect their
patients and awareness that pathogen transmission is possible when
hand hygiene and contact precautions are neglected.4-6,12
HCWs and patients have voiced concerns that contact pre-
cautions negatively affect the quality of patient care because HCWs
tend to visit isolated patients less often.17,18 Patients on contact
precautions receive fewer hourly visits than those not on contact
precautions and have less direct contact time with HCWs.18-20
Although this reduced time might not result in significant differ-
ences in patient care quality or satisfaction,21,22 the perception that
HCWs check on isolated patients less often than nonisolated pa-
tients was reported as a HCW stressor by this study’s participants.
With appropriate staff and patient education on contact pre-
cautions, it is possible to maintain patient care quality and patient
satisfaction at high levels.17,21
Isolated patients may be at increased risk for errors in care and
adverse events,23 in part because adherence to contact precautions
takes time away from immediate patient care, and because caring
for a patient in isolation often requires 2 HCWs, so that 1 HCW can
stay with the patient while the other retrieves extra equipment and
assists with care. Improved staff-to-patient ratios when HCWs are
caring for patients on contact precautions may improve patient
outcomes.24,25 Higher staffing levels and greater total hours of care
by registered nurses have been associated with reduced patient
mortality and risk of HAIs.26-29
Knowledge and education of HCWs and the public are essential
for preventing transmission of microorganisms in health care
settings. International studies have concluded that conventional
education to improve knowledge and skills will not sustain
improvement in hand hygiene campaigns.30,31 Strategies for main-
taining compliance mentioned by this study’s participants and in
previous studies include continuous education, an organizational
commitment to education; multimodal training components, such
as reminder signs and performance feedback; and the use of several
different teaching approaches in a variety of languages (given that
many HCWs, patients, and visitors are multilingual) to reach target
audiences in new ways.30-36 Our participants also suggested edu-
cation of patients, visitors, and the public. Previous researchers have
reported that patients with MRSA and their visitors often lack an
understanding of MRSA transmission.17,37 Appropriate education
may help patients and visitors to cope with their situation in the
hospital, reduce anxiety and fear, improve patient and family satis-
faction, and empower the patient to become an active participant in
helping reduce transmission of infectious agents.37-40 In addition,
communication of patient isolation status and prompting of hand
hygiene and contact precautions is critical for reducing HAIs in acute
care facilities.
Several limitations of this study design require cautious inter-
pretation of our results. First, the use of a self-selective sample
resulted in a participant list that drew disproportionately on
nurses. This means that diverse medical, allied health, and support
staff perspectives are not necessarily reflected in the transcripts. In
addition, the self-selection of participants may mean that only
those HCWs with concerns about MRSA or those with particularly
exemplary behaviors volunteered to be interviewed, and the in-
clusion of HCWs from a single hospital limits the diversity of
barriers encountered by participants seeking to engage in recom-
mended hand hygiene and contact precautions. Second, some of
the interviews were rushed because they occurred during working
hours or were conducted in noisy places like the hospital cafeteria
that did not lend themselves to extensive probing of responses. This
meant that some participants did not have time to give longer
explanations of their thoughts and perceptions.
Strengths of the study include the participation of a diverse group
of HCWs, including support staff, and conducting interviews onsite
during work shifts. The latter might have prompted better responses
from participants because they were interviewed in familiar and
comfortable places and could report on patient care issues that they
had experienced immediately before their interviews.
Despite the study’s limitations, the main findings are clear:
HCWs who perceive themselves as responsible for preventing the
transmission of MRSA and other pathogens report high motivation
to adhere to hand hygiene and contact precautions, but time
pressures and heavy workloads pose challenges to adherence. It is
important for health care administrators and infection control staff
to collaborate with patient care staff on identifying and removing
barriers to adherence and implementing positive cues to action.
Organizational leadership strategies can help create a culture in
which HCWs and others feel supported in their efforts to personally
engage in recommended behaviors and to encourage their co-
workers to do the same.11,12,36,40,41
Our findings point to the importance of acknowledging the per-
ceptions and attitudes of all HCWsdmedical, nursing, allied health,
and support staffdand removing challenges to consistent adherence
to guidelines for contact precautions and hand hygiene. Multidisci-
plinary (and, where appropriate, multilingual) educational in-
terventions for staff, education of patients and visitors, effective
communication of isolation status and patient history of MRSA to all
relevant persons, empowerment of HCWs, and enforcement of
adherence to hand hygiene and contact precautions were all sug-
gested by our participants as strategies for reducing MRSA trans-
mission in acute care settings and should be seriously considered by
infection preventionists and others responsible for reducing HAIs.
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