Journal of Hospital Infection (2007) 65(S2) 124–127

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Putting educational theory into clinical practice

Tracey Cooper

Infection Control, Southampton University Hospitals NHS Trust, UK

KEYWORDS Clinical opinion leaders; Education; Educational theory; Behaviour change; Mandatory training; Infectionprevention and control

Introduction

Changing the clinical practice of healthcare staffis an extremely difficult task, and it is oftenassumed that providing information on a topic willlead to knowledge gain and practice improvement.However, this assumption is flawed, with manystudies demonstrating that although knowledge canbe achieved via provision of training, it does notusually result in sustained behaviour change.1,2

Provision of information via mandatory infectioncontrol training is a core component of the currentUK national focus to reduce infection.3,4 There islittle evidence for the effectiveness of mandatorytraining in general, and even less evidenceon the effectiveness of mandatory infectioncontrol training. Some work has been publishedon the effectiveness of mandatory training inimproving knowledge, but it has not investigatedthe impact on practice and patient care, nordoes it relate specifically to infection control.5,6

Therefore, infection prevention practitioners mustnot rely on mandatory training to deliver practiceimprovement.

Knowledge, skills and attitudes

The clinical practice of healthcare staff is theresult of a complex combination of knowledge,skills and attitudes. Knowledge can be taughtformally in the classroom, and informally in theworkplace, and can be considered to be the factsand theory that underpin practice. Knowledge isusually confirmed by written or verbal assessment,

* Consultant Nurse Infection Control, SouthamptonUniversity Hospitals NHS Trust, UK.

such as a written paper or CPD article assessment.Skills are practical tasks, ranging from very simpleprocedures to complex investigative techniques.They are most often taught by demonstrationfollowed by practice of the skill, and thenobservation of practice. Increasingly competencyat performing a skill is assessed via observation,and most pre-registration students in healthcarewill be familiar with the use of ObservedStructured Clinical Examinations to assess practicalapplication of skill, based upon clinical knowledge.Training and development in healthcare hashistorically focussed on development of knowledgeand competency in skill delivery, and this includesmandatory infection control training.

Whilst these aspects of training and developmentare important, there is much literature demon-strating that these alone are not sufficient toensure that staff practise in an evidence-basedmanner. The key aspect that is often overlooked isthe importance of attitudes in influencing clinicalpractice behaviour. Attitudes are a product ofindividual beliefs, professional and personal lifeexperiences. These are unique to each individual,and cannot be taught or assessed. Staff mustbelieve that change is necessary in order toeffect changes in their practice, and this mustbe supported by senior clinical leaders.7 Mostmandatory training programmes are not deliveredin a way that leads to critical challenge of attitudesby clinical staff and subsequent behaviour change.

Barriers to effective practice

The theory practice gap has existed for manyyears. Studies demonstrate that the reasons for

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Putting educational theory into clinical practice 125

this gap are multi-factorial and include issuessuch as poor access to literature and evidence,organisational restrictions including lack of supportfrom senior clinical staff, lack of critical appraisalskills, lack of resources including staff timefor development, and individual inability orunwillingness to change.8-10 Of these factors themost difficult barriers to remove are those causedby deeply held attitudes and beliefs. These canbe influenced by external factors, but will only bechanged by the individual if they wish to change.11

Infection control may be seen as unimportant bysome staff, and it has been suggested that manystaff believe their own practice has no impact oninfection rates.12,13 In order to improve clinicalpractice it is important to address all the variousbarriers, including physical and resource barriers,and to change the perception of staff so theybelieve infection control is important, and thatwhat they do matters.

Educational theory

There are many theories of educational delivery.Literature on the subject identifies a traditionalmodel of education, which is based upon studies ofchildren and their learning methods and needs.14,15

This model treats learners as passive recipients ofinformation, with no control over the content ormethod of programme delivery. The teacher plansa session and delivers that session, regardless ofthe relevance of the topic or the learner’s needs.In many places this model is still used by infectioncontrol teams, including for mandatory infectioncontrol training because it ensures facts can bedelivered quickly to a large audience. Whilst thismay allow organisations to ‘tick the box’ that staffhave attended training, the evidence is that thiswill have no effect on improving practice.

Other work by educationalists has revealed thatadults do not learn in the same way as children.16

Adults need to see the relevance of information totheir own situation, or they will not be interested.The stimulation for adults to challenge attitudesand change their perceptions will not occurthrough educational programmes delivered usingtraditional educational models. If infection controlevidence is to be implemented into practice, theeducational delivery must be based on theoriesof adult learning, with flexible and responsiveeducational methods that encourage networking,critical analysis, reflection on practice and an openquestioning approach.17 This approach allows thelearner to explore topics of interest, and to reviewtheir views and the evidence at their own pace.Some staff accept new evidence and decide to

change their practice quickly using this approach,others may take longer and many need to revisitthe subject several times. However, each time anindividual revisits a topic and explores the issuesthey will be questioning their beliefs, and this mayeventually lead to a change of views and a decisionto change their practice.

Clinical Opinion Leaders

Clearly, Infection Control Teams are not in aposition to deliver appropriate, relevant educationto all members of staff in an organisation, and donot have the resources to influence the attitudes ofevery member of staff. Use of staff within practiceareas to lead change and influence practice hasbeen described by a number of authors.18-20 Thesestaff can be described as Clinical Opinion Leaders,and key skills include enthusiasm and a beliefin the importance of good infection preventionpractice, clinical expertise, the ability to act asa role model for others, and an ability to influenceother staff in their area.21 These staff can beprovided with a range of educational materialsand techniques, and be supported to influencepractice using adult learning theory as the basisfor educational interventions. Crucially, they leadpractice change from within the area, providing arepeated stimulus for staff to examine an issue,and positive reinforcement when individuals decideto change their practice.

An action research study using link staff asclinical opinion leaders has been performed, withthe educational programme for the link staff basedupon theory of adult learning.22 This educationalapproach treated the staff as active participants intheir own learning, and gave them control over theprogramme. This ensured the content was relevantand interesting, and allowed them to question andexplore their own beliefs and attitudes to infectioncontrol. This study, involving both quantitative andqualitative aspects, demonstrated improvementsin hand hygiene facilities, some of which wereattributed to the work of link staff.21 However,this work did not examine improvements in clinicalpractice, which may or may not have beenaffected by the research study. The work alsoexplored and described the impact of involvementin the project on the link staff.23 Whilst manyreported confidence to challenge, and a belief thatthey had a greater influence on clinical practice,some also reported key organisational barrierswhich prevented them from being fully effective,including the role of senior clinical staff as barriersto behaviour change.

126 T. Cooper

Influencing senior clinical staff

Work has been published highlighting the impor-tance of organisational factors and culture ininhibiting the adoption of research evidence intopractice,24-26 including studies specifically relatedto infection control.27,28 Senior medical staff andward managers occupy a position of power and le-gitimate authority within the clinical environment,and have an important influence on organisationalculture and barriers to improvement.23,24,29 Nursesin these studies described feelings of powerlessnesswhen their views differed from senior staff. Theyalso described the difficulty they felt in challengingthe practice of senior medical staff. This occurredeven when nurses were confident of their ownknowledge of the practice issue, such as the needfor hand hygiene following clinical contact with apatient.23 Therefore, in order to overcome barriersit is important to change the views of individualmembers of staff, and crucial to change the viewsof medical and nursing leaders as they have such apowerful influence on practice.

Bridging the gap using educationaltheory

National guidelines in the UK recommend thatthere is a need for further research studies toidentify methods that successfully change attitudestowards infection control, and specifically thatresearch is required to review the effectiveness ofdifferent educational methods.30 In 2003, the ChiefMedical Officer issued a new national strategy,focused on the prevention and control of infection,which also highlighted the need for furtherresearch to aid greater understanding of the issuesinvolved.3 The infection control practice of anindividual member of staff is a result of complexinter-relationships between factors that influencethinking and behaviour.31 These factors are notwell understood, despite many studies that haveexplored the reasons for lack of compliance, andmany that have attempted to improve infectioncontrol compliance. Literature searching revealsfundamental gaps in the evidence base: little hasbeen published about the views of senior clinicalstaff in relation to infection control, and thereappears to be very little evidence about thefactors which influence this group of staff and theirattitudes in relation to infection control.29,31

Further work is therefore required to illuminatethe complex area of attitude and behaviourmodification, and in particular to explore how theviews of senior clinical staff can be influencedeffectively. Until this work is available, use of

educational measures based upon theories of adultlearning could be used successfully by infectionprevention practitioners to lead to improvementsin infection control practice.

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