Canadian intensive care nurses’ infection prevention and control adherence and institutional trust: An update 1-year into the pandemic

ABSTRACT

BACKGROUND: Nurses are key healthcare workers whose adherence to infection prevention and control (IPC) measures is integral to the prevention of nosocomial spread of SARS-COV-2. Institutional trust is an important correlate of adherence. After initially surveying nurses early in 2020, we sought to evaluate how perceptions of IPC measures and institutional trust changed one year into the pandemic.

METHODS: We adapted an internationally distributed cross-sectional questionnaire, incorporating validated scales for items including institutional trust, and distributed it by email and Slack via the Canadian Association of Critical Care Nurses between April 29 and May 28, 2021. We evaluated adherence to IPC protocols, barriers and facilitators to IPC guideline adherence, and respondents’ level of institutitonal trust and compared results across the two time periods.

RESULTS: 141 nurses responded to the survey. In 2021, respondents reported lower rates of fear of becoming ill and providing care for patients with COVID-19 (T=3.83, p=<0.001). They reported higher levels of skill (T=3.57, p<0.001) and continued to report similarly high levels of professional expectations compared to 2020 (T=0.85, p=0.39). However, institutional trust dropped in 2021 (T=4.31, p<0.001), particularly in national and regional governmental trust.

INTERPRETATION: Respondents demonstrated less trust in national and regional governments compared to respondents in 2020, although they reported less overall concern for themselves and their family, and higher skills and knowledge around IPC procedures. Canadian nurses continue to have strong belief in the utility of PPE and IPC procedures, and strong social and professional expectations to adhere to IPC measures.

Key Words: COVID-19, infection prevention and control, pandemic preparedness, nurses, pandemics

IMPLICATIONS FOR NURSES

Throughout the pandemic, nurses report high levels of skill in infection prevention and control (IPC) and have a strong sense of social norms and professional expectations around proper IPC and PPE use.

While nurses initially reported high levels of trust in local, regional, and national institutions early in the pandemic, trust in national and regional governments fell significantly. More work at the provincial and national levels to support nurses working during the pandemic is necessary to re-build trust that was lost.

Trust-building practices, including transparent messaging, should be continued by local institutions, and improved by provincial and national institutions to support nurses during times of health care strain.

BACKGROUND

The COVID-19 pandemic poses significant issues around the use of personal protective equipment (PPE) and trust in institutions’ differing PPE recommendations and requirements (Cook, 2020). While PPE recommendations in hospital settings have been consistent, use and availability of equipment was variable, particularly at the pandemic onset (Cook, 2020). Trust in government has historically been considered an important determinant of citizens’ adherence to public health policies and guidelines. Belief in recommendations from government and public health officials leading to the adoption of necessary behaviours to decrease risk, as well as a decrease in anxieties, stems from effective communication from officials along with actions that follow-through, and satisfaction with their performance (Han et al., 2020; Quinn et al., 2013). It is likely that these findings regarding public trust in institutions applies to nurses as well.

Critical care nurses have been on the front line of the pandemic, caring for the sickest patients with COVID-19, and have faced challenging ethical issues including lack of access to PPE and other resources (Andersson, Nordin, & Engström, 2021; Lai et al., 2020; Vincent & Creteur, 2020). Understanding the experiences and beliefs of critical care nurses as they relate to infection prevention and control, their adherence to IPC measures, as well as the institutional bodies providing such recommendations, provides opportunities for improving the adherence to recommendations and safety of nurses at work.

In March through May 2020, we sought to characterize ICU and emergency department nurses’ perceptions of IPC guidelines they have received, adherence to IPC protocols, readiness to adhere to IPC guidelines to prevent SARS-CoV-2 infection in their place of work, their perceived level of personal risk, and their trust in institutional bodies (Silverberg, Ritchie, Gobat, & Murthy, 2021). Our respondents were largely from the ICU setting. One year later, in 2021, we sought to re-evaluate these same measures in a similar sample and to assess the difference in perceptions after one year of pandemic experience. We additionally sought to understand whether experiences in the COVID-19 pandemic or previous epidemics influenced perceptions of IPC guidelines and institutional trust.

METHODS

We conducted a cross-sectional online survey to assess the views of Canadian critical care nurses. We sought to follow previously published survey reporting guidelines (Bennett et al., 2010; Burns et al., 2008). Our initial paper provides further background and detail regarding survey development (Silverberg et al., 2021). In brief, the survey comprised basic respondent demographic and pandemic work experience characteristics as well as a series of closed-ended questions eliciting beliefs and practices of nurses in the context of the COVID-19 outbreak, to understand whether demographic differences or differences in experiences during the pandemic affected beliefs and practices of nurses. The survey was developed by the World Health Organization COVID-19 Research Roadmap Social Science and IPC working groups (van Hout et al., 2020; World Health Organization, 2021). The Theoretical Domains Framework (TDF) was used to evaluate the completeness of the questions included (Cane, O’Connor, & Michie, 2012; Michie et al., 2005). The TDF provides a framework that captures core constructs from multiple behavioural theories into 14 domains (Atkins et al., 2017). Questions for this survey addressed the following TDF domains: knowledge; skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; environmental context and resources; and intentions, social influences, and emotions. A previously validated measure for institutional trust was additionally included (Freimuth, Musa, Hilyard, Quinn, & Kim, 2014). Items were created on a seven-point Likert scale, ranging from “strongly disagree” to “strongly agree.” A total of 41 Likert scale questions were asked.

For the 2021 survey, we added in a question asking for participant’s province of residence, as well as whether they were infected while caring for a COVID-19 patient, and the nature of the contact they had with a COVID-19 patient (Supplementary File 1). Three open-ended questions were additionally added to the 2021 survey, with qualitative findings to be reported elsewhere, which aimed to gain an understanding of critical care nurses’ perspectives based on their lived experiences and to encourage participants to elaborate on questions to allow for emergence of perspectives that were not specifically addressed in the quantitative survey.

We employed convenience sampling through email and Slack channels (a social media tool) via the distribution lists of the Canadian Association of Critical Care Nurses (CACCN) (1,100 list serve members). The survey was distributed between April 29 and May 28, 2021, with three reminders sent out. The survey remained open for an additional two weeks following the final reminder. Any critical care nurse on the listserv or Slack was eligible for inclusion. Study data were collected and managed using REDCap electronic data capture tools hosted at BC Children’s Hospital(Harris et al., 2009). All questionnaires were self-administered digitally, with voluntary participation, and consent was implied by survey completion.

Statistical Analysis

We developed a series of composite scores as a summation of the Likert responses in the category (Silverberg et al., 2021). Likert responses were compiled under the following thematic groups to further interpret the data: emotions, service demand, environment, skills and intentions, beliefs, and social influences/professional role. A validated trust measure was  used (Silverberg et al., 2021). We assessed the mean and standard deviation of continuous variables, and numbers and percentages for categorical variables. We analysed responses to composite score measures, including the trust score, using one-way analysis of variance (ANOVA), and categorical and continuous variables using linear regressions and student t tests, respectively. Missing data for each question was not analysed; this occurred at the level of question, rather than full survey. We reported the T-statistic from Student’s t tests as T, the beta from linear regressions as B, and the F-statistic from one-way ANOVAs as F. We compared responses between the 2020 and 2021 survey results using Student’s t tests.

Ethics Approval

The protocol was approved by The University of British Columbia/Children’s and Women’s Health Centre of British Columbia Research Ethics Board (Vancouver, BC, Canada) (Reference number: H20-00803).

RESULTS

Respondent characteristics

We analysed responses from 141 nurses, of which 116 (82%) were bedside nurses. The general survey completion rate for all respondents was 79%. The total response rate was incalculable because of the nature of the distribution network across more than one distribution format. Like our initial cohort, the majority were female (86%), working in academic hospitals (60%), with a mean (SD) age of 41.5 (10.5) years (Table 1). On average, respondents were in practice for 17.1 (10.5) years, and almost all (97%) are providing direct patient care. Almost half (45%) of respondents were from Ontario, with significant responses from Alberta (18%) and British Columbia (12%), and the remainder of respondents scattered across the other provinces. Over half of respondents previously worked in a clinical setting during an epidemic (66%), while 74% had personal experience caring for patients with a novel respiratory pathogen (e.g., SARS, MERS Co-V, H1N1) (Table 2). Nearly all (99%) of respondents were working in settings that had provided care for patients with suspected and/or confirmed COVID-19, while over 90% had personally cared for patients with COVID-19. Compared to our initial survey in the Spring of 2020, there was a 30% increase in the proportion of respondents with experience caring for patients with suspected and/or confirmed COVID-19.

[Table 1]

[Table 2]

2021 Survey

Respondents reported a high rate of PPE use for suspected/confirmed cases of COVID-19 (Table 2). Over 99% of respondents indicated positively (agree or strongly agree) that they intend to always use a mask, eye protection, gown and gloves when taking care of suspected or confirmed COVID-19 patients (Figure 1).

[Figure 1]

Respondents reported a mean score of 12.8 (SD: 4.9) out of a total 21 points on the service demand score, which reflects perceptions of whether the health system can handle current and future patient demands. They reported a mean score of 24.3 (SD: 3.3) out of a total 28 points on the skills and behaviour skill, demonstrating high levels of perceived training, confidence, and use of PPE. Respondents reported a mean score of 38.1 (SD: 4.1) out of a total 42 points on the professional and social role score, demonstrating very high association of adherence to IPC measures with role identify and role formation. They reported a mean score of 41.2 (SD: 9.8) out of a total 56 points on the environment score, demonstrating clear guidance of materials and ease of access to PPE and appropriate facilities. Respondents reported a mean score of 25.1 (SD: 7.8) out of a total 49 points, where higher scores reflect more fear and concern for personal risk. Finally, on the beliefs measure, which reflects two positively scored and two negatively scored questions, they reported a mean positive score of 8.71 (SD: 2.9).

Older respondents and male respondents reported lower confidence in PPE and IPC procedures (B=-0.07, p=0.007 and T=-2.80, 95% CI: -3.69, -0.52, p=0.01), although these results do not remain significant after adjustment for multiple comparisons (Supplementary Table 1). Practitioners in academic hospital settings reported higher scores on the beliefs measure, indicating belief in the effectiveness if IPC procedures, but also on the emotions score, perceiving higher personal risk and fear on the job (F=3.89, p=0.01 and F=2.87, p=0.04 respectively); however, these results do not remain significant after adjustment for multiple comparisons (Supplementary Table 1). There was otherwise no difference on any measure amongst participants of different ages, genders, marital statuses, numbers of children, workplace settings, or those with experience working with novel pathogens (Supplementary Table 1). There was no significant difference in any of our scores based on level of exposure and care for patients with COVID-19.

Institutional trust

Respondents with more work experience reported higher levels of trust (F=6.07, p=0.003), with highest levels of trust reported by respondents in New Brunswick (mean trust score = 53.7), Quebec (mean trust score = 45.3), Nunavut (mean trust score = 43), and Nova Scotia (mean trust score = 41), compared to Alberta (mean trust score = 30.5) and Manitoba (mean trust score = 23.2). Respondents reported the least overall trust in the national government, and particularly in the government’s readiness to manage COVID-19 (Figure 1). There was no difference in institutional trust based on exposure to patients with COVID-19 (F=0.912, p=0.341), or those who contracted COVID-19 while caring for critically ill patients with COVID-19 (F=0.158, p-0.692).

Comparison between 2020 and 2021: institutional trust

Respondents in 2021 reported lower trust in the system (mean trust score = 33.7) compared to respondents in 2020 (mean trust score = 39.2) (T=4.31, p<0.001) (Table 3). Respondents report higher trust in local health facilities, with only a significant drop noted in the perception of the institution acting in the best interest of citizens (Table 3). There was a significant drop in perceptions of the readiness, honesty, and trust in institutions to act in the best interests of citizens at the level of regional and national governments (Table 3). Across all three levels of institutions, there was the most consistent loss of trust in the institution to act in citizens’ best interest, while respondents only increased their trust in one domain, being the readiness of health facilities for the pandemic.

[Table 3]

Comparison between 2020 and 2021: access to and perception of personal protective equipment

In our combined environment measure, respondents reported similar access to PPE and isolation facilities, and clear IPC policies that were well supported by public health authorities in 2021 compared to 2020 (T=-0.64, p=0.526) (Table 3). Similarly, compared to 2020, respondents in 2021 reported there is an expectation to follow IPC guidelines as part of their role, and that there is a culture of support from senior staff to junior staff to adhere to IPC protocols (T=-0.85, p=0.394) (Table 3).

Comparison between 2020 and 2021: Perceived risk of COVID-19 infection

As with our initial survey in 2020, respondents were most concerned about the risk to their families and their own risk of becoming ill (Figure 1). Respondents in 2021 reported an overall lower score on our Emotions measure (mean score of 27.9), which reflects a higher level of fear for themselves and their family, compared to respondents in 2020 (mean score of 25.1) (T=3.83, p=<0.001) (Table 3). While age and work experience were not significantly associated with respondents’ scores in 2021, there was provincial disparity in reported Emotions scores, with higher mean scores reported from respondents in central Canada (and particularly Ontario) compared to all other Canadian regions (F=5.29, p=0.006) (Supplementary Table 1).

Respondents in 2021 had a higher overall Beliefs score on our combined measure, with a mean score of 8.71, compared to respondents in 2020, with a mean score of 6.74 (T=-6.65, p<0.001), indicating higher confidence in PPE and IPC procedures and a feeling that IPC procedures are less of an unnecessary workload strain (Table 3). Respondents in 2021 also reported higher skills in PPE use and very strong intentions to use PPE, with significantly higher scores on our combined measure compared to respondents in 2020 (T=-3.57, p<0.001) (Table 3).

INTERPRETATION

We repeated our survey of Canadian critical care nurses one year after the onset of the COVID-19 pandemic, during the third wave of the pandemic, in comparison to our initial survey during the first pandemic wave. Although respondents in 2021 reported less worry for themselves and their families and higher confidence in their PPE and IPC skills, they reported less overall trust in the system. Compared to 2020, respondents’ comfort with IPC procedures surrounding COVID-19 had caught up to their perceived comfort with performing IPC procedures around other communicable diseases. Access to PPE has eased and no longer dominates concerns from healthcare workers, though intentions to use PPE remain somewhat discordant with actual use of PPE including gowns and face shields, as over 99% of respondents intended to always use PPE when taking care of patients suspected or confirmed to have COVID-19, while only 89% of respondents report use isolation gowns, 85% of respondents report use face shields, and 67% of respondents report using eye protection.

The decrease in health system trust in the 2021 survey is driven by the significant decrease in trust in the national and regional governments, particularly surrounding whether they would act in the best interest of staff when managing COVID-19. While in 2020 there was a mix of trust and distrust across all three levels of government, in 2021 there was consistently higher trust reported of individual health facilities, with loss of trust isolated to whether they act in citizens’ best interest, which is somewhat beyond their scope of influence. Such changes reflect the experience of healthcare workers over the year of the pandemic, watching government action and inaction in response to subsequent COVID-19 pandemic waves (Brophy, Keith, Hurley, & McArthur, 2021). We found that those with experience during previous epidemics of novel respiratory pathogens had no different levels of trust than those without this experience, and hypothesize whether the much more prolonged and recent experiences with the current pandemic supersede previously held beliefs stemming from previous experience. Our high rates of PPE availability and use, and particularly their consistency between the two studies, does not explain the decrease in institutional trust, unlike other implementations of this study in international contexts (Buowari et al., 2021).

Clear, specific, and knowledge-based messaging have been found in other settings to increase organizational trust (Han et al., 2021): polarisation and the timing of pandemic control measures’ introduction by government have been found to further affect levels of trust (Busemeyer, Rathgeb, & Sahm, 2021). While there has been much judgement and criticism of levels of government across Canada, there has been less unified judgement, polarization around, and criticism of individual hospitals and health authorities, which may explain the changes in levels of trust we found amongst our survey participants. Direct communication with and amongst healthcare providers, and engagement with these frontline staff in decision making is critical for building trust in local institutional policymaking (Brennan & Wendt, 2021; Gilson, 2003; McBeth, Karanas, Nguyen, Kurani, & Bhimani, 2021).

Limitations

Our survey reflects changes year-on-year amongst a similar cohort of respondents, although the limitations of our study design mean we were unable to assess whether we re-surveyed the same respondents as completed the initial 2020 survey, or whether our new cohort represents a new set of critical care nurses. Overall, our study’s limited response rate may be related to the high levels of burnout and clinical burden particularly amongst critical care nurses dealing with a third wave of COVID-19 across hospitals in Canada, as well as with research fatigue due to the high volumes of COVID-19 related research being conducted (Bruyneel, Smith, Tack, & Pirson, 2021; Chen et al., 2021; Kerlin et al., 2021; Wahlster et al., 2021). Similar to our original survey, the gender skew limited our ability to assess the extent to which gender played a role in respondents’ perspectives, and our findings might reflect stated rather than actual experiences of respondents, which is a recognized methodology limitation (Rubenfeld, 2004). We were unable to quantify or understand the perceived role and influence of media and public opinion, rather than respondents’ personal pandemic experiences, on the beliefs of critical care nurses related to IPC and institutional trust, though these are likely to have played some role in the difference in reported institutional trust between our 2020 and 2021 surveys.As our survey sought to compare data year-on-year and to gather data that could be compared to parallel international studies being conducted through the WHO COVID-19 Research Roadmap; Social Science and Infection Prevention and Control working groups, we were able to make limited adaptations to the study.

Further evaluation of year-on-year comparisons of other jurisdictions who implemented similar studies earlier in the pandemic would broaden the interpretability of our findings. Year-on-year tracking of trust levels as the pandemic continues amongst a broad set of healthcare workers and the public may help track the continuing effect of the pandemic on government healthcare relations.

Conclusion

We repeated and extended a survey of nurses in Canada during the third wave of the COVID-19 pandemic, in comparison to the initial survey conducted during the first pandemic wave. Respondents in 2021 demonstrated less trust, particularly in national and regional governments, compared to respondents in 2020, although they reported less overall concern for themselves and their family, and higher skills and knowledge around PPE and IPC procedures. Canadian nurses continue to have strong belief in the utility of PPE and IPC procedures, and strong social and professional expectations to adhere to IPC measures. Despite high rates of IPC skills, knowledge, and belief, it is important for institutions to work on maintaining the trust of its nursing workforce to improve care and retention during prolonged system stresses like the pandemic.

FIGURE 1: Responses to individual Likert-scale questions by thematic category in 2021 survey

EMOTIONS

SERVICE DEMAND

ENVIRONMENT

SKILLS AND INTENTIONS

BELIEF

SOCIAL AND PROFESSIONAL

TRUST

Table 1

Respondent characteristics

SD = standard deviation

Table 2

Respondent experiences related to COVID-19 epidemic and previous outbreaks

^*Percentages reflect the percent of respondents who answered “Yes” to the previous question (whether they have personally cared for a patient with suspected or confirmed COVID-19 infection).

Table 3

Comparison between responses in 2020 and 2021

*Measures represent combined responses to multiple seven-part Likert-scale questions to form a combined aggregate thematic score. Emotions score reflects perceived personal risk and fear on the job. Service Demand score reflects perceptions of whether the health system can handle current and future patient demands. Environment score reflects the clarity of guidance materials and ease of access to facilities and PPE. Skills and Intentions combined measure reflects training, confidence, and use of PPE. Beliefs score reflects beliefs in the effectiveness of IPC and the amount of strain procedures create. Professional and Social Role score reflects perception of how IPC measures are reflected in one’s role, and the potential influence on others.

^‡Total number of respondents included for each survey were n=319 in 2020 and n=141 2021.

Supplementary Table 1

Associations between respondent characteristics and aggregated perspective scores*†

^* Scores represent combined responses to multiple seven-part Likert-scale questions to form a combined aggregate thematic score. Emotions score reflects perceived personal risk and fear on the job. Service Demand score reflects perceptions of whether the health system can handle current and future patient demands. Environment score reflects the clarity of guidance materials and ease of access to facilities and PPE. Skills and Intentions combined measure reflects training, confidence, and use of PPE. Beliefs score reflects beliefs in the effectiveness of IPC and the amount of strain procedures create. Professional and Social Role score reflects perception of how IPC measures are reflected in one’s role, and the potential influence on others.

^†The adjusted threshold of significance (using the Bonferroni correction) was P = 0.0055. The significant findings are highlighted in bold.

^‡Associations evaluated by one-way ANOVA

^§Associations evaluated by Student’s t test

^||Associations evaluated by linear regression

^** Aggregate epidemic score, based on whether they’ve worked in a clinical setting in a previous epidemic and cared for a patient in that setting. For each score, an affirmative answer on each of the two questions was awarded one point, with each score comprising two questions worth up to one point each for a maximum of two points per score.

ANOVA = analysis of variance; CI = confidence interval; IPC = infection prevention and control; PPE = personal protective equipment.

Sarah L. Silverberg, MD, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

Lisa M Puchalski Ritchie, PhD, MD, FRCPC, Department of Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada; Department of Emergency Medicine, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.

Nina Gobat, PhD, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.

Srinivas Murthy, MD, FRCPC, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

Address correspondence to:

Dr. Sarah L Silverberg, Department of Pediatrics, BC Children’s Hospital, 4500 Oak Street, Vancouver, BC, Canada V6H 3N1.

Phone: 604-875-2345; E-mail: sarah.silverberg@alumni.ubc.ca

Funding and Conflict of Interest

Funding for this research was provided by the Canadian Institute of Health Research Grant #OV2-170359.  Srinivas Murthy, MD, FRCPC reports institutional support from the Chair in Pandemic Preparedness Research from the Health Research Foundation and Innovative Medicines Canada.  The authors have no conflict of interest to disclose.

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