Exploration, sous l’angle de l’approche de la déviance positive, des pratiques cliniques d’infirmières au regard de l’hygiène des mains et des facteurs qui les influencent en contexte hospitalier québécois

Many approaches have been advocated over time to improve nurses’ hand hygiene adherence rates in order to prevent healthcare-associated infections – nosocomial infections. Nevertheless, these rates have been and continue to be low in Québec (Lacoursière, 2018), as they are everywhere else (Stella et al., 2019). In the mid-1980s, a behavioural change approach – positive deviance – appeared in public health literature. This approach proposes to identify the presence of positive deviants – individuals or groups who outperform others – and to explore the factors that explain the better performance, in order to develop ways to encourage change among other individuals or groups (Bradley et al., 2009). Although studies using the positive deviance approach have been published in the nursing literature, it is unclear whether this approach can be applied to nursing practice with regard to hand hygiene. The purpose of this study was to explore, from the perspective of the positive deviance approach, the clinical nursing practices related to hand hygiene and the factors that influence them in a Québec hospital setting, as well as to examine the applicability of this approach to hand hygiene in nursing practice. To this end, we conducted two focused ethnographies with 21 nurses on two care units (a medical surgery unit and a palliative care unit) at a university hospital centre in the Montréal region. These two units were chosen because the nurses’ hand hygiene adherence rates were higher than their colleagues’ rates on other care units at the same hospital centre. The data were collected from January to October 2015, mainly through 18 individual interviews and 14 shadowing periods. An observation grid was used to record the contextual details. According to the method described by Patton (2002, 2015), all the collected data were coded and grouped under categories and then a frequency analysis of the codes was carried out in order to allow interpretation.  The results of this study show that the clinical practices are similar on both healthcare units; the participants use mainly hydro-alcoholic solutions before entering and leaving the patients’ rooms. Some of the factors that explain the higher hand hygiene adherence rates are shared by both care teams. On the individual level, the participants recognize the importance of having knowledge about the role of hand hygiene to prevent the transmission of infections, protect themselves and protect the patients; on the organizational level, there is a collaborative practice within each team; on the environmental level, the accessibility and availability of the hydro-alcoholic solution distributors greatly facilitate hand hygiene practices; on the sociopolitical level, both teams are facing cuts under the health reform and uncertainty related to a move to a new hospital; on the cultural level, the members of both teams work together toward a common goal, which we called “social cohesion” as described by Kwok et al. (2017). However, the factors that lead to this cohesion differ in each team. On the medical surgery unit, the leadership of the head nurse mobilizes the team to improve their hand hygiene adherence rates. On the palliative care unit, the team shares a humanist care practice to protect patients who are at the end of their lives. This led us to postulate that positive deviance applies to a care team – not just to individuals – who are working together to protect patients from healthcare-associated infections.   The knowledge from this study suggests that to improve nurses’ hand hygiene adherence, it would be preferable to target the care teams that perform best, to develop interventions that include factors on several levels, not just the individual level, and to increase human and financial resources.

Keyphrases: Positive deviance, Hand hygiene, Focused ethnography, Nurses