What works: a realist evaluation case study of intermediaries in infection control practice

ORIGINAL RESEARCH

What works: a realist evaluation case study of intermediaries

in infection control practice

Lynne Williams, Christopher Burton & Jo Rycroft-Malone

Accepted for publication 2 June 2012

Correspondence to L. Williams:

e-mail: [email protected]

Lynne Williams MSc RN

Lecturer in Adult Nursing

Centre for Health Related Research, School

of Healthcare Sciences, Bangor University,

UK

Christopher Burton BN RGN DPhil

Senior Research Fellow in Evidence Based

Practice

School of Healthcare Sciences, Bangor

University, UK

Jo Rycroft-Malone MSc PhD

Professor of Health Services and

Implementation Research

University Director of Research, School of

Healthcare Sciences, Bangor University, UK

WILL IAMS L . , BURTON C . & RYCROFT -MALONE J . ( 2 0 1 2 ) What works:

a realist evaluation case study of intermediaries in infection control practice.

Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/j.1365-2648.2012.

06084.x.

AbstractAim. To report a study of an intermediary programme in infection control

practice in one hospital in the UK.

Background. Promoting best evidence in everyday practice is a constant problem

in infection control. Intermediaries can influence the transfer and use of evidence

in health care, but there remains a lack of evidence and theory about the specific

actions and change processes, which can be successful in improving infection

control practices.

Design. An in-depth mixed methods case study.

Methods. The study was undertaken in 2011. Participants were recruited through

purposive sampling and included frontline staff, managers and nurses in

intermediary roles in infection control.

Results. For frontline staff, intermediary presence triggered a modification in

behaviour. Different reactions were noted from the intermediaries’ high level of

physical presence in clinical areas, the facilitative approaches they used to give

feedback and the specific teaching strategies they employed to meet frontline staff

needs. The specific intermediary actions uncovered in this study were contingent

on the prevailing systems for performance management, organisational

commitment and efforts in clinical areas to foster a collegiate environment.

Conclusions. The study provides theoretical threads of how intermediaries can be

successful in promoting evidence use under certain contextual conditions. Further

testing of the specific intermediary mechanisms uncovered in this study will

contribute to understanding different approaches that work in infection control in

embedding evidence in practice.

Keywords: case study, evidence-based practice, infection control, intermediary,

nursing, realist evaluation

© 2012 Blackwell Publishing Ltd 1

JAN JOURNAL OF ADVANCED NURSING

Introduction

Across the globe, priority is given to reducing rates of

healthcare-associated infections (HCAIs), ‘the most frequent

harmful event in health-care delivery’ (World Health Orga-

nization 2011a). Although policy directives and innovative

ways of working have led to improvements in recent years,

infection rates are still unacceptable. According to the

World Health Organization (2011b:22), ‘of every 100 hos-

pitalized patients at any given time, 7 and 10 of them will

acquire a HCAI in developed and developing countries,

respectively’. The implications for patients, both physical

and psychological, can be severe and the problems they

present greatly influence the public’s perception of the qual-

ity of healthcare services.

Policy intentions are clear: governments promote a zero

tolerance approach to HCAIs (Welsh Government 2011)

and the duty of all healthcare providers is to protect

patients from their risks (Infection Control Nurses Associ-

ation 2004). Current UK policy directs individuals to

assume responsibility and contribute towards prevention of

HCAIs (Welsh Assembly Government 2004). However,

despite important investment in infection control policy

and education programmes, understanding how this invest-

ment has influenced individual clinician behaviour change

in infection control practice is a complex phenomenon

(Wilcox 2009).

Background

Drawing on social influence theory, behaviour change is con-

sidered to be more likely to occur when individuals are influ-

enced by others, either individuals or groups (Rashotte

2007). This has led to an exploration of the potential impact

of ‘intermediaries’ (Ferguson et al. 2004, Thompson et al.

2006), a range of individuals who influence the transfer and

use of evidence (Milner et al. 2006). In the literature, certain

individuals are classed as intermediaries through their work

as linking agents, facilitators, change agents, champions and

opinion leaders (Ferguson et al. 2004, Thompson et al.

2006). The champion, for example, is perceived as an indi-

vidual having specialist knowledge, recognizing a need for

change, promoting a new idea with enthusiasm and determi-

nation and demonstrating passion for a project (Thompson

et al. 2006). However, although the evidence-based move-

ment has embraced the promise of different intermediaries

with their potential to promote knowledge transfer at the

edge of practice (Hoong Sin 2008), not enough is known

about what they do and how their skills may be used most

effectively.

In infection control, better understanding of how inter-

mediaries operate and what their unique contribution may

be to eradicating HCAIs is required (Gardam et al. 2009).

To date, few studies have explored the potential impact of

intermediaries. Lewis and Edwards (2008) reported on one

initiative in a UK healthcare organization. Clinical manag-

ers were identified as ‘champions’ during a period when

local levels of MRSA bacteriaemia were found to be unusu-

ally high. The initiative was found to contribute to a reduc-

tion in infection rates, improved staff confidence in their

own practice and anecdotal feedback found that patients

felt reassured in the presence of clinical champions. How-

ever, the champions were chosen on the basis of their

seniority, contrasting with opinions that determining who

champions are should be guided by their personal traits

rather than their position (Northway & Mawdsley 2007).

Moreover, the subsequent evaluation focused on the cham-

pions’ views of the initiative, rather than exploring the par-

ticular actions they used in their role, how these actions

impacted on the people around them in terms of evidence

use and the potential of the actions to be transferable else-

where.

In the USA, a recent study explored data on types and

numbers of champions operating in infection control in

hospitals (Damschroder et al. 2009). Despite recognition

that contextual factors affected successful implementation

practices to reduce the rates of infections, there was agree-

ment that champions were able to overcome contextual

barriers and enable them to promote evidence-based care.

Although the study offered some guidance, additional

insight into how intermediary actions can influence the pro-

motion of evidence-informed practice would have been

informative. However, the study did highlight how pre-

existing relationships in healthcare systems can affect the

degree of intermediary impact, of significance when efforts

are focused on tailoring intermediary interventions to

particular settings (Damschroder et al. 2009).

To date, few studies have examined the constituents of

successful intermediary actions, or identified their actual

impact in promoting evidence-informed practice. Although

evolving intermediary roles are considered important for

infection control (Dawson 2003, Barry & Carter 2010), lit-

tle guidance is available as to what they do and how they

could operate most effectively.

This present study is an in-depth exploration of an

intermediary programme in a specific setting. The inten-

tion was to generate theoretical explanations about how

specific change processes by both intermediaries and the

programme more generally were used and to highlight

how these could be transferred to other locations to

2 © 2012 Blackwell Publishing Ltd

L. Williams et al.

improve the promotion of evidence-informed infection

control practice.

Methodology

To enable an in-depth exploration of the intermediary pro-

gramme, realist evaluation was chosen as the overarching

framework, now an established approach to health services

research (Sullivan et al. 2002, Byng et al. 2005, Tolson

et al. 2007, Rycroft-Malone et al. 2008, 2010, Greenhalgh

et al. 2009). The growing popularity of realist evaluation is

in its potential to tease out transferable lessons from inter-

ventions (i.e. intermediary programmes operating in infec-

tion control) embedded in social systems (i.e. clinical areas/

wards). Tilley (2000) explains that the purpose of realist

evaluations is to give ‘context-mechanism-outcome configu-

rations’ (CMOCs), which will explain what works for

whom and in which circumstances (Pawson 2006), so that

the framework is explanatory in nature.

Teasing out the ‘mechanisms’ in any evaluation process is

not easy. For this study, mechanisms are considered to be

the cognitive and behavioural impacts of resources embed-

ded in the intermediary programme and are described as

the ‘causal pathway’ through which the impacts of pro-

grammes are realized (Marchal et al. 2010). Mechanisms

are not interventions or activities, they are what make an

intervention or activity work, its underlying mechanism of

action. Context may be interpreted as any space or place

where human interaction takes place, described as ‘appro-

priate social and cultural conditions’ (Pawson & Tilley

1997:57). Stakeholder involvement took place from the

early stages of the study to guide literature reviewing and

early hypotheses development.

Theoretical framework

A framework was drawn up for the case study driven by

the realist methodology (Figure 1). Key concepts were

defined through an earlier scoping of the literature and

stakeholder discussions. As a focus of the research was the

programme’s ability to ensure the use of evidence in infec-

tion-control practice, the context section of the framework

was guided by the work of Greenhalgh et al. (2004) which

was useful for its interpretations of context for diffusion,

dissemination and sustainability of innovations in health-

care. The theoretical framework was intentionally broad so

that it provided enough guidance to shape the data collec-

tion methods and analysis, but flexible enough to ensure

that new ideas could emerge and refinement of the frame-

work to be undertaken.

The study

Aims

The aim of the study was to explore and explain how an

intermediary programme in infection control practice

worked in one hospital in the UK.

Design

The investigation was a single mixed methods case study

of an infection control intermediary programme operating

in one healthcare organization in the UK. Case study

research is recognized as being particularly useful when

the focus is on seeking answers to ‘why’ and ‘how’ ques-

tions (Yin 1994) and is compatible with realist evaluation

which seeks theoretical propositions about what works, for

whom and in what contexts. Case study has been used

successfully in healthcare studies driven by the principles

of realist evaluation (Marchal et al. 2010, Rycroft-Malone

et al. 2010), both design and methodology are linked by a

recognition of the importance of context (Rycroft-Malone

et al. 2010).

Sample/participants

The site was selected for its specific infection control inter-

mediary programme which included designated intermedi-

ary posts to address challenges in infection control

practice. In addition to intermediaries, purposive sampling

was used to identify others in the organization with profes-

sional or organizational responsibilities in infection control

(Procter et al. 2010). The inclusion criteria were partici-

pants who were employees of the chosen NHS Trust who

would consent to take part in the study, participants with

infection control responsibilities and adults over 18 years

with the capacity to consent. Individuals were recruited

through the local collaborator for the study. Participants

were contacted by invitation letter that included an infor-

mation sheet.

Data collection

Data were collected in 2011 through observation and

focused interviews, using an interview guide based on the

content of the theoretical framework. Unstructured observa-

tions were guided by an observation schedule, underpinned

by Gold’s typology (1969). Spradley’s (1980) dimensions of

observation was useful in guiding the observer as partici-

pant approach, where the focus is mainly on behaviour and


JAN: ORIGINAL RESEARCH Realist evaluation intermediaries infection control

events, but where there is some level of interaction with

participants (Watson et al. 2010). For example, the obser-

vation guide was used to record settings, people, emotions

and accomplishments. Observation periods were planned

around the participants’ work and were all followed up by

individual audio-taped interviews. Observations took

place during participants’ clinical shifts, lasted on average

3–4 hours, with different clinical areas being visited during

each observation period. The observations were useful in

setting the scene for being able to describe the participants’

working environments and patterns. Documentation relat-

ing to the organization and the geographical setting also

provided contextual information and included audit reports,

annual reports, policies, job descriptions, newsletters and

other resources.

Ethical considerations

Research Ethics Committee approval was sought and

granted by the University Research Ethics Committee, NHS

Research Ethics Committee and access to site granted by

the local R&D Committee.

Data analysis

The approach to analysis was informed by the study’s theo-

retical framework and the analysis approach proposed by

Miles and Huberman (1994). An initial list of codes was

drawn up based on the theoretical framework. Codes were

assigned to the interview and observation data as individual

units and then compared and merged across the case. A

Context

+

Mechanisms

OUTCOMES

Intermediary

Actions

Activities

Behaviors

Outer SocialPerceptions

Attitudes

Behaviors

Environmental Political Drivers

Media

Inner

Organization Control

Strategic Direction

Management Systems

Leadership

Resource Allocation

Infrastructure

Degree of change Empowerment Levels of knowledge Patient safety

Figure 1 Theoretical framework (guided by Greenhalgh et al. 2004).


L. Williams et al.

revised set of codes was formed through familiarizing with

the data and patterns of categories were derived. The codes

were mapped to the main categories and were then analysed

in more depth to formulate a set of sub-categories (Miles &

Huberman 1994). Although some initial codes were impor-

tant, the revised coding framework included those which

were emerging through scrutinizing the data sets. From this,

patterns could be located to match to the descriptive frame-

work. Patterns of themes were derived, based on the main

categories of context, mechanisms and outcomes. The cate-

gories were then fed into a thematic clustered matrix. This

approach is useful when analysis is attempting to shift away

from roles (i.e. what people are called or do) as was the case

in this study, which was more concerned with the mecha-

nisms of action of intermediaries (Miles & Huberman

1994). This was followed by an iterative process of identify-

ing potential mechanisms, contextual factors and outcomes

between LW, JRM, CB (Miles & Huberman 1994). The

process then moved to clarifying links between different

context, mechanisms and outcome threads and refining this

process repeatedly, to form a final range of inferred (or con-

jectured) context-mechanism-outcome configurations.

Rigour

The quality of the case study was attended to, through con-

sideration to four tests (Yin 1994). To address construct

validity, multiple data collection methods were used and the

case site report was sent back to the site to ensure accuracy.

The data analysis process was overseen by two experienced

researchers to ensure internal validity. External validity was

attended to through applying the study results to broader the-

ory. Reliability was addressed through the use of a research

protocol and keeping an audit trail throughout the process.

Results

The findings are reported as conjectured context, mecha-

nisms and outcomes configurations (Table 2) and are sup-

ported by verbatim quotations from interviews. The aim is to

give an overall initial description of what worked, for whom

and how, commencing with a description of the study site.

The site

The case study site was one Hospital in the UK belonging to

a group of Hospitals forming an NHS Foundation Trust.

Trust objectives were driven through having the status of a

public benefit corporation. The Trust’s vision and key priori-

ties indicated its commitment to reducing the risk of HCAIs,

visible through different strategies to promote patient safety,

such as walkabouts by Board Directors and collaboration

with patient groups, governors and members of the Founda-

tion Trust. Monitoring systems for governance requirements

and feedback reporting mechanisms through the independent

regulator of health and social care services for England

were noted. The Trust had also invested in an intermediary

programme to promote evidence-based infection control

Table 1 Participant recruitment and data

collection methods.Manager

(n = 1)

Matron

(n = 1)

Clinical nurse

specialist (n = 1)

Intermediary

(n = 4)

Healthcare

support

worker

(n = 1)

Staff nurse

(n = 1)

Interview

(approx

1 hour)

Interview

(approx

1 hour)

Interview

(approx

1 hour)

Observations

(3–4 hours)

Interviews

(approx

1 hour)

Interview

(approx

1 hour)

Interview

(approx

1 hour)

Documentation review: Audit reports, Annual reports, Policies, Job descriptions, News-

letters and other resources.

Table 2 Conjectured context-mechanism-outcome configurations.

CCMO 1 In clinical areas, high levels of intermediary presence

and being alert to what is happening (surveillance)

leads to monitoring of infection control practice

CCMO 2 In clinical areas, high levels of intermediary presence

and increased attention to intermediary presence leads

to modification of behaviour

CCMO 3 Performance management and tailoring ways of

facilitating feedback lead to people being prompted

to change their practice

CCMO 4 Organizational commitment and increased attention to

intermediary presence enhances the availability of

support for staff

CCMO 5 Organizational commitment and increased attention to

intermediary presence trigger recognition by patients

CCMO 6 A practice-based approach to teaching and making

teaching relevant to local context leads to more

meaningful learning for staff

CCMO 7 Collegiate approaches in clinical areas and building

rapport into relationships enhances the availability of

support for staff



practice. There was evidence of recognition of the investment

that the Trust had made in terms of staffing. In the clinical

area, matrons were observed to be responsible for groups of

wards, beds, waiting lists and capacity with infection control

specified in their job descriptions with ward audits conducted

on a regular basis. The intermediaries were qualified nurses

operating under the direction of the Consultant Nurse for

Infection Control, collaborating with clinical leads and the

infection control team to contribute to the prevention and

control of healthcare-associated infections in one NHS Trust.

The intermediaries had clinical responsibilities, for example,

working alongside staff in clinical areas, maintaining infec-

tion control audits and policy implementation. Other respon-

sibilities included the provision of educational programmes

for staff, liaising and giving advice and administration.

In this case study, the main focus of the analysis centred

on uncovering what the mechanisms were and for whom

were they important. Mechanisms revolved around the

presence of and surveillance by the intermediaries in clinical

areas, ways of giving feedback, increased attention to their

being seen in practice, bringing education into the work-

place and building trust into relationships.

Watching practice

The clinical remit of the intermediaries had led to a high

level of presence in clinical areas:

And because they see us all the time on the ward they sort of just

get used to us being there and it then becomes a lot easier when

challenges need to happen because they don’t feel threatened and

you’re almost part of the team anyway (I4)

In turn, this allowed them to be alert to what was hap-

pening in practice, described by one participant as being

the ‘eyes and the ears’ for infection control and interpreted

here as a mechanism of seeing practice, incorporating the

surveillance of practice:

When we go on, so if we feel that something’s not being done

properly we’ll say to them Well actually if you don’t do this poten-

tially this patient could develop an infection (I4)

Intermediaries were observed seeing practice, enabling

the monitoring of evidence-based infection control practice

in day to day ward routines:

we just want to see…as well how nursing staff are doing things.

For example, we go round and we’ll wash a patient, but the staff

are ‘Oh great, she’s washing the patient’, but we’re seeing how they

dispose of that…bowl of water…are they tipping it down the hand

wash sink (I1)

Attention to infection control (frontline staff)

The clinical remit of the intermediary in clinical areas and

high levels of presence led to increased attention by front-

line staff:

People see you as like a police…policeman or policewoman…They

see you as…here comes infection control and that’s why I actually

said to you this morning, no doubt, somebody’s probably (whis-

pers) Infection control (I1)

In turn, intermediary presence and increased attention to

being seen in practice were observed to trigger modifica-

tions of behaviour by the frontline staff:

because we’re always there to see these things, we’re always there

to see if doctors are coming on, if they’re using the hand gel, if

they are bare below the elbows and nurses, if they’re wearing wrist

watches, they’ve got jewellery on and …so we’re sort of the eyes

and ears on the wards really (I4)

Thoughtful feedback

Organizational systems and processes where performances

in infection control were managed included feedback for

frontline staff. Approaches used by the intermediaries to

give feedback were very carefully chosen to encourage

frontline staff motivation and to promote best practice:

They also have the skills and…and the people skills that they need

to deal with… because they can’t keep coming down heavy

handed, I actually don’t think you get the best from people like

that (M1)

In their interactions with frontline staff, intermediaries

were observed to use facilitative approaches to give feedback:

It’s like I said on the wards before, if you go in guns blazing it gets

their backs up straight away and you won’t get anywhere with

them because they’ll class you as somebody coming in and having

a go at them (I2)

Through observations of intermediary actions, feedback

was observed to be given discreetly and in context:

And to be honest I don’t think anybody likes being challenged. So,

as you saw, I went up and I just whispered to him ‘You need to

take your watch off’, to which he took his watch off straight away.

I think if I’d have said ‘What are you doing with your watch on?’

and I’d had a bit of attitude towards it he’d have automatically put

a barrier up (I4)

In turn, this prompted individuals to consider their prac-

tice and, if required, modify their behaviour:


L. Williams et al.

And if you speak to the doctors they will do it and they’ll say…if

they forget to take to their watch off they’ll say ‘Ever so sorry, I

forgot to take it off’ and they’ll take it straight off and there’s not

a problem (I2)

Availability of support

The organization’s commitment and subsequent high levels

of presence in clinical areas led to availability of support

for frontline staff, especially access to advice about infec-

tion control issues:

It’s not the same as an e-mail and then you have to wait a week, or

until you’re next back on shift or…and then that’s the whole time

then…it could be your next audit due then and nothing’s change and

nothing’s gone further, but to be visibly present there (SN1)

Individual frontline staff decisions to access the interme-

diaries for infection control issues were also noted from a

manager’s perspective:

But I think the…more junior staff in the ward tend to go to (the

intermediary) first, simply because she’s around and they…like I

say, they’ve developed that relationship with her now, where

they’re not…they don’t feel intimidated (M1)

High level of presence and specific approaches chosen by

the intermediaries resulted in observations of frontline staff

valuing a supportive resource:

I find that they’re my…they’re my support network and then they’ll

come and spend time with me and explain anything to me (SN1)

Attention to infection control – patients

Organizational commitment (also reflected in feedback

from patients on infection control procedures and cleanli-

ness) and attention to intermediary presence led to an

enhanced sense of recognition for patients. Intermediaries

were recognized by individual patients through their work

with them:

Now, if you’ve noted we’ve gone onto areas and a few patients

have recognized me and they recognize the other (intermediaries)

that go out (I1)

Being able to identify staff with specific infection control

responsibilities was noted to be important for relatives as well:

if they can see a name badge, whoever they’re talking to, if you

greet them through the door or if you’re sitting at the desk, they’ll

always look at your name badge to know who you are and it’s nice

just to hear them, when they talk to you they say ‘Oh you’re the

… you’re the link nurse that we saw on the ward. Can I just ask

you why my Dad’s got this card? (SN1)

Practice-based teaching

The intermediaries tailored education for frontline staff

through practice-based approaches to teaching. Although

formal teaching through staff mandatory induction or

updating was observed, there was also an effort to bring

education into the workplace through a focus on the rele-

vance to practice and local context:

it’s not always a formal based thing because somebody could ask

you a question and you could quite happily go off on a tangent

from what you’ve gone on there to do and go and…end up doing

something totally different that you hadn’t planned (I3)

Intermediaries were observed to adapt their teaching

strategies to suit frontline staff needs and they recognized

the challenges of addressing education in busy clinical envi-

ronments:

We do educational packages, on the job and…we do…instead of

doing big ‘come and sit down’ packages, as in sort of a proper…

educational session, we do little snapshots on the areas. So we do

teaching packages there. We try and teach things like aseptic tech-

nique (I4)

Bringing education into the workplace resulted in more

meaningful and real learning for frontline staff:

She can show somebody a hundred times how to do and MRSA

swab in the lab with a dummy, but if you…want to show them on

a real life patient, it’s so much easier if you’re there working with

that nurse (M1)

Building rapport

Intermediary actions to build relationships with frontline

staff were facilitated by general efforts to foster a collegiate

environment in clinical areas and were observed to be

focused on building rapport and trust:

you’ve got to build a relationship. It’s no good going into the areas

and being aggressive, being nasty, because you only then build up

this wall. You’ve got to go in and have a rapport with the staff (I1)

Intermediary efforts were focused on being accessible for

frontline staff:

if I’ve got any worries or anything I’ve always got in touch with

(the intermediary) like, you know…I’ve got her page number to

page her if I’ve got a problem (SW1)



Intermediary actions to promote effective relationships

with frontline staff, through building trust and engaging

with them, were noted:

because I was impressed with how she engages with the staff and

how actually…she really feels for them when things go wrong and

really tries hard to put it right and get in there and…you know,

‘Come on, I’ll show you how we do this’ and has really, really…

really got them all working together (M1)

Discussion

The principal aim of the case study was to uncover interme-

diary mechanisms of action to explain what worked to pro-

mote best practice in infection control. Realist evaluation

facilitated the generation of a group of theoretical supposi-

tions of what was working in certain contexts (Table 2).

Visibility

By virtue of intermediary frequency of presence in clinical

areas, visibility triggered a range of reactions from different

individuals. For frontline staff, seeing the intermediaries in

practice had a cognitive impact, reminding them of practic-

ing according to the evidence. However, despite being seen

as an important strategy for infection control teams (Gardam

et al. 2009), little evidence exists as to the impact of the

theory of visibility on quality and effectiveness in infection

control. Findings from this study show that the matron’s

responsibilities for infection control were supported by the

intermediaries. In this case, organizational commitment led

to enhanced visibility, a policy remit of the modern matron

role (Department of Health 2001, Dealey et al. 2007).

Although in the literature the focus is centred on the visibility

of leaders and managers in clinical areas for the promotion

of effective infection control practice (Healthcare Commis-

sion 2007), this study has highlighted the visibility of other

people (in a non-managerial role, with ascribed responsibility

for specific clinical issues) as being important.

Intermediary visibility resulting in recognition for patients

and reassurance for frontline staff reflects the relationship

found elsewhere in other public services, for example, the

significance of the relationship between police visibility and

public reassurance (HM Inspectorate of Constabulary

2002).The findings of this study raise important questions

about how visibility is operationalized in other contexts/

areas of health care, where responsibility for infection con-

trol lies with different structures to those described here.

Conversely, in this study, visibility of practice allowed the

intermediaries to monitor and intervene where required so

that infection control risks were minimized. Surveillance

has long been used as a powerful tool to protect social val-

ues (Dawson et al. 2005). Although behavioural surveil-

lance theory is a concept more likely to be applied in public

health (McQueen 1999), the impact of human surveillance

on behaviours in infection control practice requires further

unpacking.

Practice-based teaching

The frequency of presence of this group of intermediaries

enabled swift identification of frontline staff educational

needs and their skills and abilities to give adaptable models

of education facilitated this approach. Although infection

control education and training for frontline staff were fully

supported by the organization, it emerged that adapting

flexible strategies/approaches were crucial to ensure staff

needs were met and improving their understanding of infec-

tion control issues. Therefore, in addition to mandatory

training programmes and formal means of teaching, clini-

cally based teaching was employed, based in wards and

often focused on the problem frontline staff were concerned

with at the time. Intermediaries were instrumental in facili-

tating this approach and staff preferences for these interac-

tive approaches reflect findings of previous studies

(Wisniewski et al. 2007). These findings reflect the prob-

lem-based focus of andragogy in adult learning theories

(Gilmore 2011). Understanding the impact of different

learning styles for frontline staff in infection control is

important and requires further exploration.

Performance management and feedback

The call to consider the impact of organizational context on

quality of care is not new (Burton et al. 2009). However,

implementation research seeks further exploration of specific

contextual factors which contribute to making evidence use

part of day-to-day practice (Stetler et al. 2009). In this

study, performance management and ways of providing

feedback were found to be instrumental in motivating peo-

ple to change. In contrast to a general learning climate as

part of the context for evidence implementation, high level

of feedback for individuals, teams and systems has already

been recognized as an important element for successful

implementation of evidence-based practice (Rycroft-Malone

2004). Greenhalgh et al. (2004) found that in complex

service innovations, providing feedback as an active imple-

mentation strategy increased the likelihood of success in

establishing evidence use. Using performance feedback in

infection control reflects the findings of Grol and Grimshaw


L. Williams et al.

(2003) who stress that regularity is the key, with withdrawal

of feedback affecting the impact on practice. However, in

this study, it was the manner of performance feedback, facil-

itated by the intermediaries, which appeared to be most

important, warranting additional exploration.

Facilitation

The ‘facilitative’ approach uncovered here reflects, to a

degree, the findings of Harvey et al. (2002:585) who

conclude that a facilitator who ‘provides face to face com-

munication and uses a range of enabling techniques has

some impact on changing clinical and organizational prac-

tice’. The concepts of building trusting relationships and

working in partnership with staff, support the enabling

attributes required of different intermediaries facilitating

evidence in organizations (Milner et al. 2005, Stetler et al.

2006). Furthermore, the potential contribution of the

intermediary in supporting frontline staff promotes effec-

tive team working (Firth-Cozens 2004), a key characteris-

tic of quality care for the infection control arena (Griffiths

et al. 2008).

Context

Organizational commitment for the intermediary pro-

gramme was instrumental in triggering the availability of

support for frontline staff. One organizational feature

recognized for its success in standardizing care based on

the best evidence is the micro system (Ferlie & Shortell

2001), based on the ethos of a core team caring for a

defined population and possessing the right resources to

support frontline staff and patients (Nelson et al.1998).

While, in terms of organizational culture, the use of micro

systems appears to be beneficial in supporting services,

their ability to branch out in different areas of health care

is highly dependent on investment and resources available.

Additional evaluation of how other areas of health care

promote the uptake of evidence in infection control would

enhance understanding of different enabling systems in

play.

Limitations

Although the case study generated a small sample of

respondents, it addressed the principal intention which was

to explore in depth what was working in terms of a partic-

ular infection control intermediary programme. Although it

is not possible to draw generalizations from one case study,

the findings give some insight into certain contextual condi-

tions which can trigger successful mechanisms of actions

and potential for theoretical transferability. Furthermore,

influence of other contextual factors requires further explo-

ration as to how they impact on important mechanisms. In

line with the principles of realist evaluation, further work

will be conducted to test these findings and generate better

understanding of the relationships between the contexts,

mechanisms and outcomes configurations uncovered here,

to develop clearer theory about what works in complex

programmes.

What is already known about this topic

● Across the globe, the provision, uptake and implemen-

tation of available evidence that promotes best prac-

tice in infection control and reduces the risks to

patients is a key priority.

● Understanding how to get what is already known to

work into everyday practice firstly requires the

unpacking of contextual factors that influence individ-

ual and organizational behaviour.

● In healthcare, a range of individuals, collectively

known as intermediaries, are recognized as having the

potential to influence the transfer and use of evidence

in practice.

What this paper adds

● High levels of visibility of people in intermediary roles

in clinical areas trigger a range of reactions from

frontline staff and patients.

● Specific ways intermediaries give feedback on perfor-

mance and develop relationships in clinical areas can

impact on individuals’ behaviour.

● A practice-based approach to teaching and making it

relevant to local context leads to more meaningful

learning for staff.

Implications for practice and/or policy

● Intermediary programmes in infection control can

influence behaviour, but their success will be contin-

gent on organizational commitment, including invest-

ment.

● For the infection control arena, a clearer understand-

ing of the impact of intermediary presence and visibil-

ity in clinical areas is required.

● Intervention planning in infection control requires

early consideration of contextual conditions which are

likely to influence its success or failure.



Conclusion

In this study, specific actions employed by infection con-

trol intermediaries have emerged as having the potential to

trigger change, providing theoretical suppositions of how

intermediaries can be successful in promoting appropriate

infection control practice in certain contextual conditions.

Through the use of realist evaluation as a framework,

important elements have emerged about visibility, facilita-

tion, performance feedback and ways of providing educa-

tion. To increase the potential for change, managers and

policy makers need to be made aware of the ways inter-

mediary programmes can influence behaviours and build

these into initiatives. For the infection control arena, a

clearer understanding of the impact of intermediary

presence and visibility in clinical areas is required. Inter-

vention planning in infection control requires early consid-

eration of contextual conditions, which are likely to

influence its success or failure, which includes organiza-

tional commitment and investment. Further testing of the

specific intermediary mechanisms of action uncovered in

this study will contribute to understanding different

approaches that work in infection control in embedding

evidence in practice.

Funding

This research was conducted as part of a PhD Fellowship

awarded to Lynne Williams by the research capacity build-

ing collaboration (rcbcwales) in January 2010.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors meet at least one of the following criteria (rec-

ommended by the ICMJE: http://www.icmje.org/ethi-

cal_1author.html) and have agreed on the final version:

● substantial contributions to conception and design, acqui-

sition of data, or analysis and interpretation of data;

● drafting the article or revising it critically for important

intellectual content.

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What works: a realist evaluation case study of intermediaries in infection control practice

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