Infection Prevention Role Stress: A New Look at the Underlying Causes Within the Profession

By Marilyn Hanchett, RN, MA, CIC

Editor's Note: Marilyn Hanchett 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 begins a series of articles examining some of the most important and urgent issues facing the development of the infection prevention professional community. Future columns will explore the topics summarized in the introductory article and will offer insights into new, emerging healthcare issues that are having or are about to have a major impact on the infection preventionist (IP) role.

The need for infection prevention, as a multidisciplinary function, is a longstanding and widely acknowledged component of safe healthcare. Accreditation and regulatory standards specify that this function must be an organized program coordinated by an individual qualified to assure that the necessary assessments, priorities, key metrics are achieved. This individual must also assure that the program supports the provider’s mission, aligns with its safety culture, and is effectively and efficiently integrated into its operational and care delivery systems. Decades of published literature, conferences and online educational programs are available to support these requirements.

Significantly less attention has been paid to the role of the infection preventionist and to how the selection, preparation and ongoing development of the professional impacts the programmatic goals and institutional priorities the individual must achieve. The role of infection control nurse has, over four decades, morphed into a more generic title of infection preventionist (IP). This shift has simultaneously occurred with a dramatic increase in role responsibilities, especially data management and expanded surveillance requirements. Unfortunately these changes have happened without extensive analysis of the concurrent but less obvious changes in the supporting development needs of the IP community. This discrepancy, confounded by limited institutional support and ever increasing healthcare financial constraints, is the critical causative factor in the role stress widely reported by IPs across the United States.

Role stress in other disciplines has been extensively studied and is frequently linked to common healthcare issues of staffing and scheduling, workload, and compensation. Workplace concerns such as participation in decision making, career ladders, safety, verbal abuse and bullying, and the adoption of new technology have also been recognized as contributing factors. While these issues may indeed play a role in the job stress of IPs, the scope of the current situation requires a deeper analysis and a frank discussion of the root causes of today’s dilemma.

The evidence of escalating role stress is abundant, if not well quantified. Increasing numbers of retiring IPs, increasing number of experienced IPs leaving provider-based employment, lengthy periods now needed to recruit vacant positions, and the difficulty attracting clinicians to IP positions suggest the current outcomes of this unresolved stress. Another indication of change is seen in the expansion of the number of early career IPs. For example, the number of IPs with less than five years of experience is now approximately 50 percent, as reported by APIC at its 2012 annual conference; this may well be the fastest growing segment of IP professionals, but further research is needed to verify the accuracy of the estimate.

Unfortunately, measurement of these changes is minimal or, in cases where it has been attempted, exists only in the form of convenience samples of varying sizes. These occasional gross measures suggest the serious scope of the problem but are insufficient for developing future oriented action plans and newer strategies. More research into these factors is urgently needed.

Meanwhile as the profession approaches its fifth decade, it is increasingly apparent that external factors impacting the role must be balanced by renewed and more focused attention to internal factors. To streamline an initial analysis and hopefully initiate a new national conversation, these internal factors can be described in three broad categories. The categories are not exclusive; they should be viewed  as pieces in an interconnected, complex system while simultaneously identifying the distinct characteristics of each. The infection prevention community must address all of these categories of professional development needs in order to resolve the current profound stress on the IP role and pre-pare for an uncertain future.

Category One: The need for a core curriculum and standard educational goals
When infection control was performed exclusively by RNs, the nurse curriculum and mandatory clinical experiences pre-licensure provided a standard educational base, if only by default. Nurses, typically with acute-care experience, then specialized in infection control. The shared hospital experience also supported at least minimal standardization of clinical knowledge.

As more RNs exit the profession and fewer enter, individuals with varying backgrounds replace them. These may include microbiology laboratory, medicine, pharmacy and public health, although other areas may be considered. It is now possible to be hired as an IP without any formal preparation in epidemiology, microbiology or pharmacology. Many IPs have clinical experience, others do not. IPs must compensate for these differences through independent learning, professional meetings, mentoring, collaboration and social networking, and on the job training. Basic educational courses are offered by professional associations, but are costly and accessible only to those whose employers can support their attendance and travel. As IPs responsibilities expand, opportunity for on the job learning decreases and off site seminars and workshops are increasingly difficult to attend.

It is critically important to acknowledge that one of the defining criteria of a profession, and especially those labeled as a specialty, is to iden-tify and educate their members according to a distinct and consensus based body of knowledge. This assures that all professionals of that type have a minimum consistent knowledge base not only for practice but also upon which to expand and develop expertise. Encyclopedic references such as the APIC Text and other general textbooks can be used to support a core curriculum but in themselves do not define it.

Role stress is triggered when an individual is placed into a job and assigned duties and responsibilities for which he or she is unprepared. Ori-entation and mentoring programs have been and continue to be used in lieu of a standard pre-employment curriculum, but are, at best, time consuming and costly for the employer. The long term effectiveness of this on-the-job substitute for consistent educational preparation has not been studied. The relationship between on-the-job training and turnover during or at the first year of employment also has not been investigat-ed.

Category Two: The need to clarify the scope of the role and the implications of entry into practice
Related to the standard  pre-employment curriculum is consistency and clarity regarding the scope of the IP role. These are the challenging questions employers and recruiters struggle with daily: must the IP have a clinical background? Is the IP always a RN? What proportion of the role is data analysis/management and how much is clinical practice? And if clinical experience is necessary, exactly what types are most im-portant? If more than one IP is hired in a facility, should at least one be a nurse?  If non- nurses are hired will the role be different? Should it be?

Consumers sometimes ask “what is an IP?” or “who can be an IP?” Searching the internet reveals information on functions; the issue of professional qualifications and eligibility remain unanswered both within and beyond the professional community.

Recruiting individuals into specialties or subspecialties from various backgrounds exists in other area of healthcare such as quality or perfor-mance improvement, accreditation and compliance, safety etc. However there is usually some baseline knowledge, often including years of related experience, required before an individual can move into one of these specialized fields. It is possible that the infection prevention com-munity could learn from these models to develop processes that could more smoothly facilitate role transitions, but again, this is as yet unstudied.

Job stress in the IP role is often cited as the causative factor for voluntary resignation within 12 months of hire. Like most other possible contributing factors, this assumption has not been tested via reliable research methods. However, anecdotal reports of this problem are becoming so frequent that this issue indicates a pressing need for investigation.

Category Three: The need for a long term, sustainable model for recruitment into the profession
There are no college or university based programs to prepare individuals for the IP role. Certificate programs have been offered to help bridge this gap; the frequency of use of these alternatives is unknown. Without clear, minimal educational standards and entry into practice criteria, the ability to attract and retain individuals is a serious challenge. The fundamental questions of what is an IP and who can/should fill this role must be based on a new national – and perhaps international – consensus before effective long term recruitment strategies will  emerge. Internship and residency models may be useful in designing new approaches for aspiring IPs and may encourage those who express interest but are tuned away from employment due to a lack of experience. Potential other “bridging” models may also open new opportunities to introduce students, new graduates and early career professionals to the specialty.

The dilemma of recruitment demonstrates the interrelatedness of these internal causative factors of role stress. It is pointless to attempt to resolve one without considering them all. And nowhere is this more apparent than the issue of recruitment and retention of the next genera-tion of IP professionals.

When considered from this point of view, IP role stress is not a unique problem. Rather it is symptomatic of the larger issues discussed here. These macro challenges defy the corrective action of any one person. Collective, coordinated action by experienced IPs is needed to address these internal gaps. Addressing such broad, complex issues is not easy and consensus admittedly will be at times  be difficult to achieve. However without this type of action among the IP professional community, the role stress seen now will continue to increase and the negative outcomes already reported  will intensify. Future articles will explore these issues in greater depth and begin to examine possible new solutions.

Marilyn Hanchett, RN, MA, CIC, is an infection preventionist and independent author. She may be reached at hanchett14@comcast.net.