By Marilyn Hanchett, RN, MA, CIC
Editor's Note: This is the second in a series of articles examining some of the most important and urgent issues facing the development of the infection prevention professional community.
Modern infection control, which is based on the scientific work of 19th century scientists such as Pasteur, Lister and Koch, was organized as a specialty for non-physician practitioners almost a century later. Hospital based infection control emerged as a distinct specialty in the 1970s. In its early decades the evolving specialty arena was led by registered nurses who still remain the single largest group of clinicians within what has now become a multidisciplinary field.
The early role of the infection control nurse included similar, although not identical, components of the nurse clinical specialist (CNS): staff and patient education, nurse consultations, rounding, and oversight of key clinical programs. For the infection control nurse these programs have traditionally focused on hand hygiene compliance, new employee education, immunizations, and often, employee health screening. Over time, as employee health has developed into the field of occupational health, there has been a decreasing expectation that the infection control nurse should be responsible for both areas.
25 Years of Transformative Change
However as the original concept of the infection control nurse continued to approximate a clinical specialist model, significant changes during the past 25 years rapidly and steadily mandated both a major role change as well as the skills necessary to support it. In November 1999 the Institute of Medicine released its groundbreaking consensus report To Err is Human, challenging all providers to consider the institutional, financial and human costs associated with preventable mistakes. In the aftermath of these discussions, the concept of error was expanded to harm, including a new and widespread emphasis on healthcare-associated infections (HAIs). The infection control community was prominent in the 1990s national conversation, debating whether or not all HAIs were preventable and if the institutional goal could realistically be set at zero infections in all cases. Never before had such national attention been focused on infection control, increasingly described in more proactive terms as infection prevention.
Concurrently the CDC combined three previous databases for analyzing national hospital infection trends into its new National Healthcare Safety Network (NHSN). This secure national database now aggregates and helps track infection data not only from U.S. hospitals, but also other settings known to have potential or actual serious infectious risks, e.g., long-term care, dialysis and ambulatory surgery.
Regulatory and accrediting standards also began to reflect the growing national concern for prevention. Accountability soon emerged as a central theme in new regulations and accrediting requirements. Both public and private reimbursement systems integrated these accountability expectations into payment systems and today continue to refine them.
While these national issues impact all areas of healthcare, there have been two important new demands on the infection control nurse during these twenty years of transformative change. The first has been the demand for data by both internal and external stakeholders, a trend that accelerated with the beginning of mandatory public reporting of hospital infection data in the 1990s.The second is the rapid development of computer systems and software applications to help meet these data demands. Since then infection control nurses have struggled to incorporate data demands and analytics into their pre-existing and essentially clinical role.
The infection prevention community was unprepared to cope with sustained and transformative role change. Prior to the 1990s many infection control nurses did not hold degrees, as long standing hospital based training programs remained a mainstay of basic nursing education. And although the role approximated that of a nurse clinical specialist, there was not and has never been commensurate requirements for graduate education and professional credentialing that are now the hallmarks of the CNS role. Infection control nurses shared a common background in basic clinical educational and some years of bedside patient care experience, but were now confronted with demands for computer skills, report generation, application of infection definitions, and a far more sophisticated understanding of epidemiology that had ever been necessary in the past. Compounding this was the escalating pace of change and the increasing number of external groups offering performance improvement initiatives, collaboratives, patient safety programs, care bundles, and other regional and national projects targeting the elimination of healthcare associated infections. All of these groups either required the collection and submission of new data or needed existing data to be submitted according to their programmatic requirements. For the infection control nurse, not only did the demand for data become a priority but the numbers of individuals and groups who needed that data increased exponentially.
The opposing demands for a consultative clinical role on one hand with that of data and report generation on the other has been recognized since the impact of these national changes has first been felt. Unfortunately no model has been proposed to help resolve the dilemma. The gradual change from a nurse centric to a multidisciplinary specialty is having widespread implications. For example, APIC has replaced older titles such as infection control nurse with the more generic term of infection preventionist (IP). Willingness to hire and train non nurses has allowed institutions to add individuals with other degrees and experience, bolstering their departments with new and sometimes different skill sets. But even when this has occurred, it has not yet produced a model that can be tested or replicated by others. As a result, each institution today must attempt to align its specific job demands within its particular concept of the role.
While this approach may have been successful in some situations, it has also not provided an effective national solution to the clinical /nonclinical problem. In fact, this unresolved role dilemma now presents even more serious ramifications: the approaching the end of the traditional infection control nurse role.
Definitive studies and a compelling base of evidence are lacking. But consideration of general demographic trends is useful in pinpointing the warning signs of significant role change and potential erosion of the RN base. For a concise overview of variable contributing to loss of RNs in the IP role, it is helpful to review the three Rs: recruitment, retention and retirement.
The number of RNs in full time infection control roles varies depending on the survey attempting to measure it. APIC membership demographics vary on this topic but consistently reflect fewer RNs that the earlier decades in which RN membership approached 100%. Job descriptions which formerly would state that a RN license was required, now list RN preferred. Today there is no national consensus on who is qualified to become to an IP, the minimal educational requirements for the role, and what, if any, clinical experience is necessary as a condition of employment. Today an IP may be an RN, LPN, laboratory or pharmacy technician, respiratory therapist, or come from fields such as ambulatory services, public health or long term care. Clinical experience is often a negotiable consideration.
The replacement of RNs by other individuals is a demographic trend that requires more robust study before its full implications can be fully understood. The relationship between a nursing background and turnover is also not fully understood. Likewise if infection prevention becomes predominantly a non-nursing specialty, its appeal to RNs and LPNs may diminish further, especially if nurse salaries, even when adjusted for inflation, offer more financially attractive opportunities in other areas.
The question of who should be an IP remains unanswered but is one of the most important yet difficult issues that will help determine the future course of the profession.
There is no national study that examines retention and turnover in infection prevention programs. However, anecdotal concerns abound. Empiric evidence suggests that the turnover rate within the first one to two years of IP employment is high. If proven, it would be consistent with studies of new graduate RNs. The RN Work Project sponsored by the Robert Wood Johnson Foundation has reported that RN turnover among newly licensed RN at one year at 17.5 percent and 33.5 percent at two years.(1) Another recent study reports that 43 percent of new RNs leave their first jobs with three years of employment.(2)
Healthcare providers, usually hospitals, often describe the difficulty in retaining IPs. Reasons cited for abandoning the role include higher pay elsewhere, lack of advancement in the current situation, unacceptable levels of stress, the need for unscheduled overtime, and the inability to juggle clinical and non-clinical job demands. As role pressure continues to increase with increasing institutional demands and performance expectations, the need to understand the variable impacting retention is becoming ever more urgent.
One of the least understood possible reasons for the loss of RNs in the IP role is linked to the conflict now imbedded in its most basic functions. The intense and ever escalating competition between clinical and non-clinical demands is considered by many to be one reason why RNs either elect not to pursue an IP role or leave it earlier than expected. This situation is compounded by the relentless pursuit by the healthcare sector of more data to support complex systems attempting to link safety, quality, accountability and efficiency with healthcare outcomes. IP role expectations are high, and industry signs indicate that they will rise higher.
One reliable source of data is the periodic practice analysis conducted by the Certification Board of Infection Control and Epidemiology (CBIC). While this survey gathers demographic information, is intended primarily to assure that the content of the national certification examination is closely aligned with actual practice. However its recent findings, based on almost 2,500 usable surveys, reflect the shifting trends within those currently employed in the field.
The loss of senior or advanced practitioners is a significant warning of the potential role change. The 2014 CBIC practice analysis indicates that 41.7 percent of respondents have five or less years of infection control experience. Only 21.2 percent have 16 or more years of experience. Individuals with 11-15 years of experience are 12.6 percent.(3) While this report does not explore the reasons why IPs are exiting the profession, these demographics clearly demonstrate the loss of senior IPs. The proportion of RNs within those exiting or retiring has not been reported, but as older IPs usually entered the role from nursing, it can be presumed that the majority of those planning to leave the IP role in the near future are indeed RNs.
Since 2013 APIC has reported at its national meetings an expected decline in senior level IPs. A proportion of these will be due to an aging workforce approaching retirement. As long as at least 50 percent of the IP workforce remains RNs, examination of nursing workforce research offers supporting evidence of this trend. For example, according to the 2013 HRSA report The U.S. Nursing Workforce: Trends in Supply and Education notes that one third of nurses are now over age 50. According to this report in the next 10 to 15 years at least one million RNs in the United States will reach retirement age.(4) APIC surveys, although less statistically robust, reflect similar statistics.
Implications for the Profession
In these circumstances where change is dynamic, unpredictable and there is so little evidence to guide the development of the IP future role, there is one prediction that can be made with reasonable certainty: the traditional configuration of the infection control nurse will no longer be a viable model. Current struggles to recruit and retain IPs, especially nurses, already point to the need for a new solution. An aging and rapidly retiring subset of IP RNs is reinforcing the urgent need for a radically new and forward facing vision of the role.
Considered from this point of view, it is now time for the transformative change the profession has experienced externally to now be addressed internally. Unlike external pressures, internal change must be directed by those in the role. Unfortunately change from within is even more difficult than that which is externally mandated. However as the role as it has existed for four decades begins to become something else, there is a rare and unique opportunity to intentionally and wisely create a new future. And the experienced RN can and will have a vital role to play in shaping this new future. Future articles in this series will explore possible new role configurations in the context of evolving technologies and surveillance systems.
Marilyn Hanchett, RN, MA, CIC, is an infection preventionist and independent author. She spent more than four years at the Association for Professionals in Infection Control and Epidemiology (APIC). During those years she traveled extensively and met with individuals and groups across the United States. She may be reached at [email protected].
1. Kovner CT, Brewer CS, Fatehi F, Jun J. Nurse turnover: the revolving door in nursing. Policy Polit Nurs Pract. 2014: August 25.
2. Brewer CS, Kovner CT, Greene W. et al. Predictors of actual turnover in a national sample of newly licenses registered nurses employed in hospitals. A Adv Nurs. 2012; 68: 521-538.
3. Henman :J, Corrigan R, Carrico R et al. Identifying changes in the role of the infection Preventionist through the 2014 practice analysis study conducted by the Certification Board of Infection Control and Epidemiology. AJIC July 2015. 43:7; 664-668.
4. The U.S. Nursing Workforce: trends in supply and education. Health Resources and Services Administration Bureau of Health Professions, National Center for Health Workforce Analysis. April 2013.