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Infection control link nurses in acute care hospitals: a scoping review

Infection control link nurses in acute care hospitals: a scoping review Background: Involving link nurses in infection prevention and control is a strategy to improve clinical practice that has been implemented in hospitals worldwide. However, little is known about the use, the range and benefits of this strategy. We aimed to identify key concepts of infection control link nurses (ICLN) and ICLN programs, to evaluate the effect of such programs, and to identify gaps in the evidence base. Methods: In a scoping review, we searched PubMed, CINAHL, Google and Google Scholar for manuscripts on ICLN in acute care hospitals. We included research- and opinion-based papers, abstracts, reports and guidelines. Results: We included 29 publications and identified three key concepts: the profile of ICLN, strategies to support ICLN, and the implementation of ICLN programs. The majority of included studies delineates the ICLN profile with accompanying roles, tasks and strategies to support ICLN, without a thorough evaluation of the implementation process or effects. Few studies report on the effect of ICLN programs in terms of patient outcomes or guideline adherence, with positive short term effects. Conclusion: This scoping review reveals a lack of robust evidence on the effectiveness of ICLN programs. Current best practice for an ICLN program includes a clear description of the ICLN profile, education on infection prevention topics as well as training in implementation skills, and support from the management at the ward and hospital level. Future research is needed to evaluate the effects of ICLN on clinical practice and to further develop ICLN programs for maximal impact. Keywords: Liaison nurse, Nosocomial infections, Infection prevention and control, Infection control guidelines, Cross infection Background between their own clinical area and the infection control Health care associated infections cause significant morbid- team and raise awareness of infection prevention and con- ity and mortality in patients and form a financial burden to trol. They are trained to educate colleagues and motivate health care systems [1], Appropriate application of universal staff to improve practice [5, 6]. Since their first introduction precautions (e,g. hand hygiene) by health care workers has in the 1980’s, ICLN have been appointed in hospitals world- been proven effective in reducing transmission of microor- wide; they usually work within a hospital-based network ganisms and subsequent acquisition of health care associ- [7–13]. The major investment in time and effort of the ated infections [2]. Still, in general, compliance with these infection control team and link nurses that accompanies simple infection control measures is low [3, 4]. the implementation of an ICLN program is generally A strategy to improve compliance is to involve dedicated perceived as worthwhile [5, 14, 15]. nurses in infection prevention and control. Such dedicated An initial search for literature on ICLN and the inter- nurses or infection control link nurses (ICLN) act as a link ventions (e.g. programs) that are used to set up and main- tain ICLN networks, however, revealed a lack of research * Correspondence: m.vanoijen@vumc.nl on the effectiveness of ICLN in improving compliance Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical with infection control guidelines or their impact on pa- Microbiology and Infection Prevention, De Boelelaan 1118, room PK1X132, tient outcomes (e.g. health care associated infections) [16]. 1081 HV Amsterdam, The Netherlands Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 2 of 13 Before advocating ICLN programs, a better understanding control link nurses, and focused on acute care hospitals. of the use, range and benefits of these programs is needed. Papers could be in the English, Dutch, German or French A recent systematic review, focusing on facilitators and language. Studies investigating link nurses not specific to barriers of ICLN networks, included ten studies with a large infection control or studies describing role models, e.g. variationindesignand outcomes [17]. The authors searched ‘champions,’ that led implementation of infection control only medical orientated databases, although the subject of guidelines were excluded from this review. study were nurses. Not searching nursing-orientated data- We retrieved full text articles that fulfilled the inclusion bases nor the grey literature in a relative unexplored field criteria outlined above. Two reviewers (SW&MD, IJ&MD) resulted in a small set of studies. To be able to assess all the independently selected eligible papers and hand-searched available literature on link nurse programs in infection con- reference lists for additional papers. Inter-rater reliability trol in acute care hospitals we searched for studies published was tested after screening titles/abstracts (Kappa = 0.6). in different databases and in the grey literature. We looked Results were compared, and disagreements resolved by at the key features of ICLN and ICLN programs, and aimed consensus. When full texts were not available, corre- to evaluate the effects of such programs on awareness of in- sponding authors were contacted. Each step of the study fection prevention, guideline adherence and patient out- selection was discussed within the study team. comes. Finally, we sought to identify gaps in the evidence Two team members (SW&MD, IJ&MD) independently base for ICLN networks, and opportunities for research. extracted and charted data on a predefined data charting form on country, study design, setting, key findings, and Methods outcomes relevant to our research question. Scoping reviews are useful when available research is Themes emerging from the data were analyzed and limited and heterogeneous in studies designs. They ad- discussed within the research team. Descriptive numer- dress broad questions and examine evidence regardless ical and thematic analyses are presented as narrative of study design [18–21]. The improved five-stage meth- summaries given the heterogeneity of the literature. This odological framework of Arksey and O’Malley was used process followed the Preferred Reporting Items for Sys- to structure this study [18, 20]. This entails an iterative tematic reviews and Meta-Analyses extension for Scop- technique of formulating and redefining the research ing Reviews (PRISMA-ScR) [22]. question, identifying relevant studies, selecting studies, charting of the data, and collation, summarization and Results reporting of the results. As suggested by Daudt and Col- Initially, we identified 312 articles in PubMed and CINAHL quhoun, a quality assessment of the included studies and additionally 963 papers in Google and Google Scholar. was also performed [19, 21]. After screening for title and abstract, 36 articles were con- After the initial review of the literature the following re- sidered potentially relevant, of which 26 met our criteria. search question was developed to guide the review: What Hand searching reference lists identified 9 additional stud- is known about ICLN programs and their effectiveness in ies, of which 2 were included. One article was included raising awareness of infection control or in the improve- after the last search update. In total 29 papers were ment of infection prevention practices, and do these pro- included (Fig. 1). grams reduce the risk of healthcare-associated infections? The 29 included articles, 27 of which were peer Ebsco/Cumulative Index for Nursing and Allied Health reviewed papers, one guideline and one report represent Literature (CINAHL) and PubMed were explored on 18 literature from 5 continents. The majority of studies July 2017 for index terms and text words with the initial originated from the UK (n = 14). The other studies were search term “link nurs*”. Ebsco/CINAHL and PubMed conducted in the USA (n = 3), Australia (n = 2), China were searched from inception up to 24 July 2017 (n = 2), Japan (n = 2), Germany (n = 2), the Netherlands (MD&JCFK). The following terms were used (including (n = 1), Egypt (n = 1), and Canada (n = 1). Belgian and synonyms and closely related words) as index terms or UK researchers collaborated on one abstract. Most stud- free-text words: ‘link’ or ‘liaison’ or ‘intermediary’ and ies had a descriptive design (n = 12) or were before-after ‘nurses’ and ‘infection control’ or ‘handwashing’. Google comparisons (n = 7). Other studies included qualitative and Google Scholar were searched for grey literature on 25 studies (n = 4), cross sectional surveys (n = 2), studies November 2017 and 8 February 2018. The search was up- using action research (n = 2), a mixed methods study th dated on the 25 September 2018 (IJ&MD). The full search (n = 1), and a randomized controlled trial (n = 1). strategies for all resources can be found in the Add- By charting the studies and summarizing the findings itional file 1. Duplicate articles were excluded. The follow- we identified that part of the studies focused on three ing criteria for inclusion were adopted: research- and major themes: the profile of ICLN, the implementation opinion-based papers, abstracts, reports and guidelines, of ICLN programs, and strategies to support ICLN. The published between 1980 and 2018, specifically on infection other part of the publications focused on outcomes of Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 3 of 13 Fig. 1 PRISMA flow diagram strategies that involve ICLN. Table 1 provides the details [5, 15, 26], improve clinical practice at ward level [5, 6, 13, of studies including methodological comments and limi- 15, 23, 26], act as a role model [6, 23, 27], and assist in tations of individual studies. research [13, 26].The task of transferring information to peers and other healthcare staff is described in five articles Key features [5, 13, 23, 25, 26]. One article states that the influence of The profile of ICLN ICLN might lay more in improving practice than in the Nine articles highlighted the ICLN profile with accom- dissemination of knowledge upon which these practices panying roles, tasks and competences [5, 6, 9, 13, 15, are based [5]. 23–26] using different terminology (e.g. roles vs tasks). The core competences of ICNL for fulfilling these ICLN were first described in 1981 as a liaison between roles and tasks include: receptive for feedback, proactive, the epidemiology department and clinical wards [9]. In non-judgmental, approachable, resilient, authoritative, the following years, the educational role was added [5, assertive and charismatic [5, 15, 24, 27]. Two out of five 14, 25]. The Royal College of Nursing published a studies that describe the enrollment of ICLN stress the national ICNL role profile for the UK in 2012. Four core importance of voluntary registration. It is seen as an ex- themes were identified for the link nurse role: “act as a pression of motivation and enthusiasm for infection pre- role model and visible advocate, enable individuals and vention and control, which are perceived as core teams to learn and develop infection prevention and competences for the uptake of the ICLN role [5, 23–25, control practice, act as a local communicator, and 28]. Authority is perceived as essential for carrying out support in audit and surveillance” [12]. the role. Therefore clinically experienced nurses are pre- Tasks of the link nurse role that were considered viable ferred as ICLN [5, 24, 27]. The Royal College of Nursing included: perform surveillance of infections [9, 13, 15, 25, summarized competences of ICLN as: “to be passionate 26], monitor infection prevention and control practices [5, about infection prevention and control, responsible for 9, 13], aid in the early detection of outbreaks of infection own actions, an active participant in the ICLN network, Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 4 of 13 Table 1 Summary of included studies Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations Braekeveld Abstract – interactive workshop and 450 voluntarily participants A joint professional profile for (2016) UK & questionnaire on perception on the (link nurses, nurses, head infection control link nurses Belgium role of link nurses in infection nurses and infection control will follow prevention practitioners) in the UK and Belgium Ching (1990) Cluster randomized controlled trial 1000 bed hospital in Hong Three specific standards for One hospital China – introduction of a guideline for Kong - urinary catheter care were One baseline measurement catheter care Control group: three wards significantly improved by link No follow up (surgical medical and nurses educating their peers. Differing numbers in control gynecology) Incorrect practices before and intervention wards Test group: twenty-four wards intervention: (sampling bias) - 63% intervention group - 68% control group (p = 0.4) Incorrect practices 5 weeks after intervention: - 36% intervention group - 48% control group (p < 0.05) Cooper (2001) Descriptive paper- outline of the – Education of ICLN should be UK educational theory that underpinned based on educational theories. infection control link nurses’ education Cooper (2004) Descriptive paper - prologue of A district general hospital Methodological considerations UK action research study and argumentation for action research. Cooper (2004) Action research A district general hospital - Three out of four barriers for Small sample size No follow UK fourteen wards compliance with hand up hygiene were significantly improved 3 months after intervention in 14 clinical areas Cooper (2005) Qualitative research - Focus group Ten ICLN ICLN reported increased No information on topic list, UK feelings of empowerment, non- participants, number of ownership and motivation data coders, data saturation, during one focus group with member check 10 link nurses Dawson (2003) Narrative review - outline of the role – ICLN have a role in UK of the ICLN surveillance and education or peers. The role of the ICLN is still evolving. In 59% of National Health Services Trusts link nurses are active. Graaf de (2013) Descriptive paper – outline of the One hospital 8 link nurses As a result of an outbreak 8 Netherlands appointment of 8 link nurses to nurses were appointed ICLN support the infection prevention and They support the infection and control team in a Dutch hospital prevention and control unit for 8 h a week and their departments are financially Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 5 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations compensated Horton (1988) Descriptive paper - outline of a pilot Sixteen ICLN in various Monitoring performance of UK course services of a NHS trust participants is crucial to the maintenance of high standards Jacobsen Descriptive paper –outline of an 560 bed adult teaching Isolation of the OT can make it – (1999) Australia educational program / hospital - Operating Theatre more difficult for the ICN to implementation strategy encourage changes in infection control practice. ICLN can help to overcome this difficulty. Monitoring tools are necessary for long-term evaluation Macduff (2009) Full report - Evaluation of Cleanliness NHS health facilities in Program has substantive No process or outcome UK Champions Program using a mix of Scotland positive influence on the measures (as guideline qualitative and quantitative methods prevention and control of adherence or Healthcare health care associated Associated Infection rates infections in Scotland stated) Perceived impact stated Manley (2012) NICE guideline - based on two – A national role profile and Consensus based guideline UK workshops analyzed by an approach core competences to support termed concept analysis link practitioners, their managers or organizations with a ICLN network Lene (2002) Descriptive paper – outline of A general acute care hospital A program requires dedicated Australia structure and developments of a link coordination, flexible and well program planned education and effective support from management Lloyd-Smith Implementation of link nurse Three acute care hospitals - 16 Seven link nurses produced an Convenience sampling, no (2014) Canada program, focus group & economic clinical units 8 with link nurses action plan. 10 focus groups information on data saturation, estimate evaluation 8 without link nurse with stakeholders led to 5 no member check are risks for themes for a successful bias program Key factor is effective Important and relevant costs monitoring of effectiveness and consequences for each and sustainability alternative were not identified The program was cost effective. (cost for link nurse program per bed ($490) vs cost for extra infection prevention practitioner per bed ($596)) Millward (1993) Cross-sectional - Audit tool & Three districts’ health Audits on eight infection Sample sizes too small for UK knowledge questionnaire authorities. One location with control topics for 20 wards. analyses. link nurse program. Wards with infection control link nurses obtained higher Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 6 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations scores on compliance with infection control standards (p = 0.0006). Link nurse showed higher scores on knowledge (69%) than non-link nurses (52%) (p = 0.008). Miyachi (2007) Quasi experimental design A 1133-bed University hospital Significant decrease of As stated in article, risk of Japan monthly MRSA rates (from 6.3 regression to the mean, to 5.0%) after implementation maturation effects and of link nurse system and confounding during 2 year follow-up. Increase in monthly use of hand soap (17.3%). Ross (1981) Pre-post implementation study - A 650-bed, university-affiliated Implementation of ICLN and No baseline, no follow-up USA establishing of ICLN on patient units general hospital determination of health care data. associated infections rates in years one. Year two monitoring infection rates. Education met expectations of link nurses (96%). In 9 of 11 wards rates were reduced. Seto (2013) Before – after study & participatory A private 850-bed institution Involving ICLN in brainstorm Single centered uncontrolled China action sessions, poster competition, study, maturation effects identification of points of care and monitoring compliance improved hand hygiene practice significantly from 50 to 83%. Use of hand rub increased from 8.1 l/1000 patient days to 9.1 l/1000 patient days. Shabam (2012) Cross-sectional survey Twenty hospitals, 205 head Survey results showed that No description or definition of Egypt nurses who work as a ICLN in ICLN have a role in education “perception as a link of various departments (medical, (25%), consultation (25%), infection control” surgical, neonatal, pediatric, administration (90%), research obstetrics, gynecology, dialysis, (21%) and supervision of safe outpatients’ clinics, emergency, practice (99%) burn and urology) The majority of head nurses participated in a training program related to infection prevention and control but not on their ICLN roles 48% of head nurses never performed ICLN roles. 54% had a low level of Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 7 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations knowledge on infection prevention and control 79% had a high perception of infection prevention and control When head nurses’ knowledge and perception increased the performances on the 5 identified roles increased (p = 0.0001) Sopirala (2014) Quality improvement study (pre-post A 1191-bed University Medical After a 2 year baseline period No randomization, no follow- USA design) Center link nurses were introduced up during a year. In that year MRSA rates reduced (28%, p = < 0.01), MRSA bacteremia rates reduced (41%, p = 0.003), hand soap consumption increased(from 19 to 31 oz) as compliance with hand hygiene (from 30 to 93%). Sopirala (2018) Before – after study evaluating a A 699-bed tertiary care aca- After a 21 month baseline Single centered study, no USA CAUTI prevention program with two demic medical center period (data on urine cultures follow-up different CAUTI definitions of 5 ICU units) link nurses were trained in CAUTI prevention, participated in training of colleagues and patients, and committed to ward based actions. CAUTI rates declined in with new definition (IRR 0.67, 95% CI [0.48–0.93]) CAUTI rates increased with old definition (IRR 1.12, 95% CI [0.88–1.43]) Teare (1996) Interventions study - outlining how District general hospital Implementation in 3 phases: No baseline measurements, no UK to design the ICLN network for the set up, setting standards on follow-up. No exact numbers hospital wards, management given. ownership. Infection control practices were divided in 8 areas. ICLN (n = 51) had a role in education of peers and the audit of infection control practices. The link nurse system had a positive effect on clinical practices. Infection rates did not reduce. The infection control team was added to the trusts risk Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 8 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations management group. Teare (1998) Descriptive paper - reporting Mid-Essex trust Link nurses have a role in UK experiences and encountered education and surveillance. benefits ICLN system has raised awareness and increased the profile for infection control. Teare (2001) Descriptive paper - outlining a study Mid-Essex trust Six interactive sessions on UK day for ICLN infection prevention knowledge and governance. A questionnaire quantified the self-assessed re- sults of ICLN on their wards. This assessment of capabilities and limitations may be useful in the communication with ward management . Tebest (2017) Cross-sectional survey among ICLN University hospital Response rate 29% (n =29). One hospital Germany (n = 64) Intended services were rarely Small sample performed Barriers were the lack of release from other duties and the lack of acceptance of the role by physicians Tsuchida (2007) An intervention study with before 560-bed acute hospital located In year one risk factors for Single centered study, No Japan and after comparison in a major urban area in Japan CLABSI in catheter care were randomization, no follow-up identified with the help of 4 link nurses. In the following 2 years interventions were implemented. ICLN educated colleagues and observed catheter care. In those two years CLABSI rates declined from 4.0/1000 catheter days to 1.1/1000 catheter days (p < 0.005) Ward (2016) UK Descriptive paper outlining the role – Currently there is limited of the link nurse evidence of the efficacy of ICLN in improving practice Wilbrandt prospective controlled study Eight hospitals – four The concept of link nurses was No randomination (2001) intervention and four controls introduced successfully. Unclear duration of follow –up Germany Improvements on the level of No definition for ‘success’ of process quality (increase of the link nurses contact moments between INLN and infection control staff) . No reduction of nosocomial Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 9 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations infections. Wright (2002) Pre-post implementation A 87-bed neonatal intensive Decrease of nosocomial No N, percentage or 95%CI USA observational study care unit at a Children’s infections stated hospital The role of the ICLN is flexible and can be tailored to the specific needs Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 10 of 13 approachable, non-judgmental, inclusive, reflective, and nursing practice, education in auditing and surveillance, respectful” [12]. and skills for the dissemination of this knowledge to peers [5, 10, 14, 23, 24, 31]. The latter is perceived as vital for Implementation of ICLN programs ICLN to become effective role models [5, 14, 31]. In order Five papers describe operational barriers of implement- to expand these skills experts (e.g. a psychologist) contrib- ing an ICLN program [5, 11, 16, 24, 29, 30]. Two papers uted to two programs to tutor on leadership and report on ICLN programs that discontinued due to oper- change-management skills [10, 24]. Four studies suggest ational difficulties [5, 16]. ICLN struggle with low staff- an introduction course (range 1–10 days) [5, 7, 9, 10]. This ing and high workload leaving insufficient time for ICLN introduction course could be given as e-learning, to per- activities [5, 11, 24, 29, 30]. High staff turnover chal- mit ICLN to start their activities at any time at their own lenges hospitals to keep the number of trained ICLN up pace [5]. Four studies report on regular meetings with one to standard [5, 24]. To overcome these operational bar- to three months intervals [7, 10, 14, 27]. Education modes riers an ICLN program in a Dutch hospital was set up vary from interactive sessions [7, 14], lectures, tutorials with only eight ICLN. These ICLN were exempted from [28] and visits to the Microbiology Laboratory [7], laundry duty eight hours a week in order to propagate infection services and sterile processing department [10],to control practices at the ward and hospital level [23]. self-learning packages [11] and sharing copies of relevant The difficulties encountered by ICLN in their educa- literature [29]. Lectures are repeated several times [7, 28] tional role are discussed in six studies [15, 24, 29–32]. or held during (a provided) lunch to facilitate attendance Two studies noted that medical staff lacked acceptance [7, 15]. Support by the infection prevention and control of the role of the ICLN or the need for infection preven- team is described in five studies [6, 7, 10, 24, 25]. Support- tion and control practice [29, 30]. Jacobsen reports a ing activities include providing ICLN promotional and lack of participation of medical staff in educational ses- educational materials [24], through newsletters, and by sions by ICLN [32]. mentoring the ICLN through regular ward visits for the Three papers describe the presence of ICLN as a risk. discussion of progress and current ward-based problems Although visibility of ICLN in their role is perceived es- [7, 10]. Action research or brainstorm sessions are used to sential to trigger behavioral change, other health care collaborate in research, for the development of an imple- workers may foster the idea that infection prevention mentation program and for ward-based action plans or as- and control is not their concern and rely on the ICLN signments [6–8, 10, 24]. for all infection prevention and control matters [15, 24, Three studies describe the role of the ward manage- 31]. None of the studies provided clues or insights in ment in the empowerment of ICLN in fulfilling their what aspects of ICLN programs were most effective. role [5, 9, 29]. This support can be promoted by refer- ring other staff to ICLN, by scheduling infection preven- Strategies to support ICLN tion and control topics for discussion at ward meetings, Strategies to support ICLN were listed in 17 papers and and by allowing ICLN training time [5, 29]. Support of include education, commitment and coordination by the Senior ward management is described in three studies as infection prevention and control team, support from enabling factor for the program as a whole [24, 25, 31]. ward management, support from the senior hospital Three studies describe networking between ICLN as a management, and support between ICLN themselves support mechanism. To create mutual communication, [5–11, 14, 23–25, 27–29, 31, 33, 34] Thirteen studies re- discussion and sharing of experiences with other ICLN port on educational components of ICLN programs [5, is encouraged in regular meetings [24, 29, 33]. 7–11, 14, 23, 24, 27, 28, 31, 34] The Scottish Govern- ment provides a national training to aid education [34]. Twelve studies report on a local educational program The effect of ICLN programs under the direction of the infection prevention and con- Five studies have evaluated the introduction of ICLN with trol team [5, 7–11, 14, 23, 24, 27, 28, 31]. It is advocated respect to infection rates [7, 8, 26, 35, 36]. Two studies with to underpin this program with theory on adult learning a before-after design and one with a quasi-experimental de- [31], engage in active learning forms [5], communicate sign showed that the introduction of ICLN led to improved on topics of interest prompted by ICLN themselves [7, compliance with hand hygiene or increased hand soap / 31] and to communicate on one topic per year to create sanitizer consumption and a reduction of Methicillin-Re- focus [27]. There is a large variation in the content of sistant Staphylococcus aureus (MRSA) rates [7, 8, 35]. In these programs. The curricula include content related to two other studies ICLN achieved a reduction of CLABSI knowledge of microbiology, modes of transmission, [36, 37]. In the USA the reduction of nosocomial infections nosocomial infections, and infection prevention and in a neonatal intensive care unit was linked to the introduc- control policies, the application of this knowledge in tion of an ICLN [26]. Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 11 of 13 In three studies clinical practices improved with the help number of factors are considered vital for the support of of ICLN [28, 32, 38]. In a HongKonghospitalICLN im- ICLN in the completion of their tasks. First of all educa- proved the care for urinary catheters in a cluster random- tional programs are important. This is in line with previ- ized controlled trial. The second study demonstrated ous findings that show that, to improve infection higher compliance rates with infection prevention policies prevention practices education of health care workers is on wards with ICLN [38]. The third study described vital [42]. The content and delivery of education in improved compliance with standard precautions in an ICLN programs is not standardized, but in general, edu- operating theatre with an ICLN. The role of the ICLN was cation of ICLN by the infection prevention and control perceived pivotal. Compliance was not reported on [32]. team to educate on infection prevention topics in regu- One paper described a positive effect of “raising the profile lar meetings is considered best practice. This education for infection prevention and control” [15]. Another study can be extended by training in implementation skills by reported a perceived improvement of infection prevention experts. With respect to how to set up educational meet- and control practice [27]. Furthermore one study reported ings, focusing on one topic at each meeting is seen as “an improvement at the level of process quality” in a gen- important [27]. eral sense after the implementation of ICLN [33]. The ICLN profile is flexible and must be tailored to the local needs [5, 6, 39]. This is essential to facilitate Discussion nurses in the ownership of the ICLN role. A role profile This scoping review revealed a lack of research evidence clarifies expectations of ICLN for all stakeholders. It fa- on the effects of infection control link nurses on guide- cilitates communication on the ICLN role and tasks line adherence and patient outcomes. The majority of within the organization [43]. included papers delineate the ICLN profile with accom- Support by the management at ward level can em- panying roles, tasks and strategies to support ICLN power ICLN to act as a role model and to disseminate without an evaluation of the implementation process or knowledge to their peers. The adherence to guidelines effects in clinical practice. Only two of these articles in- will improve when management supports infection pre- cluded a brief evaluation of the impact of their ICLN vention and control measures [44] since this improves program on healthcare-associated infections [9, 26]. their leadership. De Bono et al. found an association be- Therefore the value and impact of ICLN programs is dif- tween effective leadership and better adherence to infec- ficult to assess [5, 39]. Studies that report on the effect tion prevention and control policies (e.g. hand hygiene of ICLN programs in terms of patient outcomes or and personal protective equipment) [45]. guideline adherence describe positive short term effects. In the UK a generic role profile for ICLN is established Several ICLN programs appeared to have discontinued, by the Royal College of Nursing [12], but it is not clear none of these studies, however, mentioned that they did in how many hospitals ICLN actually are appointed. so because of negative or no results [5, 16]. ILCN are present in several hospitals throughout the Six of the studies that did report on the effect of ICLN Netherlands, but not everywhere [46]. In German acute programs had a single-center uncontrolled study design care hospitals ILCN are mandatory [17]. Furthermore, [7, 8, 26, 35, 36, 38]. These studies hold a high risk of se- link nurses have shown potential in other settings [47– lection bias [40]. Prevention of healthcare-associated in- 51]. It is therefore justified to invest in further research. fections may be influenced by many other factors than There is a lack of studies that evaluate the process of the ICLN program itself, and controlled studies may not implementation of ICLN and the outcomes of ICLN find significant effects due to low statistical power (type programs. Evaluation should consider how to tailor and II error) [41]. The combination of study design and lim- deliver an ICLN program to maximize impact of link ited research output holds a risk for selective reporting nurses on guideline adherence and patient outcomes. By of positive findings and publication bias. This might assessing in which context which program has impact, have influenced our findings. research findings can help to tailor ICLN programs to The narrative synthesis is based on studies that vary in the local situation [52]. An in-depth description on how quality, design and outcome. We assessed study outcomes ward management, the infection prevention and control as having equal weight. Although standardized data extrac- team and the ICLN interrelate can help understand how tion and an iterative team approach strengthened reliability, to support ICLN in fulfilling their tasks [53]. Damschro- this may have led to bias in the categorization of our find- der et al. confirms the importance of cooperation be- ings. Possibly, we missed relevant papers, since we chose to tween professionals from different disciplines to realize exclude studies on the role of champions and opinion behavioral change [54].Information on the perception of leaders. link nurses and their peers on the role and the perceived Although the quantity and quality of research on ICLN effectiveness of their effort can contribute to this in is limited, a common theme that emerges is that a depth description. Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 12 of 13 Interdisciplinary collaboration in infection control net- Consent for publication Not applicable. works may help overcome resistance of other health care workers [11, 54]. In this respect, studies focusing on Competing interests how to involve other health care workers in general, and The authors declare that they have no competing interests. physicians in particular are needed . Finally, there is a research gap in how to sustain ICLN Publisher’sNote programs, and on their economic value. For further re- Springer Nature remains neutral with regard to jurisdictional claims in search, we advocate the use of mixed method designs, published maps and institutional affiliations. since the implementation of an ICLN network can be Author details considered a complex intervention. By measuring struc- 1 Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical ture and process outcomes, the implementation of the Microbiology and Infection Prevention, De Boelelaan 1118, room PK1X132, 1081 HV Amsterdam, The Netherlands. Amsterdam UMC, Vrije Universiteit intervention can be monitored and evaluated. Qualita- Amsterdam, Department of Public and Occupational Health, Amsterdam tive designs can help to understand and explain these 3 Public Health research institute, Amsterdam, The Netherlands. Amsterdam findings and link them to the context in which the im- UMC, Vrije Universiteit Amsterdam, Medical Library, Amsterdam, The Netherlands. plementation took place [55], Received: 7 November 2018 Accepted: 21 January 2019 Conclusion There is a lack of robust evidence on the effectiveness of References ICLN programs. Available studies have methodological is- 1. Pittet D, Donaldson L. Clean care is safer care: a worldwide priority. 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Does classroom-based crew resource management training improve patient safety culture? A systematic review SAGE Open Med. 2014; 2:2050312114529561. 41. Brown C, Hofer T, Johal A, Thomson R, Nicholl J, Franklin BD, et al. An epistemology of patient safety research: a framework for study design and http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance & Infection Control Springer Journals

Infection control link nurses in acute care hospitals: a scoping review

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Biomedicine; Medical Microbiology; Drug Resistance; Infectious Diseases
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Abstract

Background: Involving link nurses in infection prevention and control is a strategy to improve clinical practice that has been implemented in hospitals worldwide. However, little is known about the use, the range and benefits of this strategy. We aimed to identify key concepts of infection control link nurses (ICLN) and ICLN programs, to evaluate the effect of such programs, and to identify gaps in the evidence base. Methods: In a scoping review, we searched PubMed, CINAHL, Google and Google Scholar for manuscripts on ICLN in acute care hospitals. We included research- and opinion-based papers, abstracts, reports and guidelines. Results: We included 29 publications and identified three key concepts: the profile of ICLN, strategies to support ICLN, and the implementation of ICLN programs. The majority of included studies delineates the ICLN profile with accompanying roles, tasks and strategies to support ICLN, without a thorough evaluation of the implementation process or effects. Few studies report on the effect of ICLN programs in terms of patient outcomes or guideline adherence, with positive short term effects. Conclusion: This scoping review reveals a lack of robust evidence on the effectiveness of ICLN programs. Current best practice for an ICLN program includes a clear description of the ICLN profile, education on infection prevention topics as well as training in implementation skills, and support from the management at the ward and hospital level. Future research is needed to evaluate the effects of ICLN on clinical practice and to further develop ICLN programs for maximal impact. Keywords: Liaison nurse, Nosocomial infections, Infection prevention and control, Infection control guidelines, Cross infection Background between their own clinical area and the infection control Health care associated infections cause significant morbid- team and raise awareness of infection prevention and con- ity and mortality in patients and form a financial burden to trol. They are trained to educate colleagues and motivate health care systems [1], Appropriate application of universal staff to improve practice [5, 6]. Since their first introduction precautions (e,g. hand hygiene) by health care workers has in the 1980’s, ICLN have been appointed in hospitals world- been proven effective in reducing transmission of microor- wide; they usually work within a hospital-based network ganisms and subsequent acquisition of health care associ- [7–13]. The major investment in time and effort of the ated infections [2]. Still, in general, compliance with these infection control team and link nurses that accompanies simple infection control measures is low [3, 4]. the implementation of an ICLN program is generally A strategy to improve compliance is to involve dedicated perceived as worthwhile [5, 14, 15]. nurses in infection prevention and control. Such dedicated An initial search for literature on ICLN and the inter- nurses or infection control link nurses (ICLN) act as a link ventions (e.g. programs) that are used to set up and main- tain ICLN networks, however, revealed a lack of research * Correspondence: m.vanoijen@vumc.nl on the effectiveness of ICLN in improving compliance Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical with infection control guidelines or their impact on pa- Microbiology and Infection Prevention, De Boelelaan 1118, room PK1X132, tient outcomes (e.g. health care associated infections) [16]. 1081 HV Amsterdam, The Netherlands Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 2 of 13 Before advocating ICLN programs, a better understanding control link nurses, and focused on acute care hospitals. of the use, range and benefits of these programs is needed. Papers could be in the English, Dutch, German or French A recent systematic review, focusing on facilitators and language. Studies investigating link nurses not specific to barriers of ICLN networks, included ten studies with a large infection control or studies describing role models, e.g. variationindesignand outcomes [17]. The authors searched ‘champions,’ that led implementation of infection control only medical orientated databases, although the subject of guidelines were excluded from this review. study were nurses. Not searching nursing-orientated data- We retrieved full text articles that fulfilled the inclusion bases nor the grey literature in a relative unexplored field criteria outlined above. Two reviewers (SW&MD, IJ&MD) resulted in a small set of studies. To be able to assess all the independently selected eligible papers and hand-searched available literature on link nurse programs in infection con- reference lists for additional papers. Inter-rater reliability trol in acute care hospitals we searched for studies published was tested after screening titles/abstracts (Kappa = 0.6). in different databases and in the grey literature. We looked Results were compared, and disagreements resolved by at the key features of ICLN and ICLN programs, and aimed consensus. When full texts were not available, corre- to evaluate the effects of such programs on awareness of in- sponding authors were contacted. Each step of the study fection prevention, guideline adherence and patient out- selection was discussed within the study team. comes. Finally, we sought to identify gaps in the evidence Two team members (SW&MD, IJ&MD) independently base for ICLN networks, and opportunities for research. extracted and charted data on a predefined data charting form on country, study design, setting, key findings, and Methods outcomes relevant to our research question. Scoping reviews are useful when available research is Themes emerging from the data were analyzed and limited and heterogeneous in studies designs. They ad- discussed within the research team. Descriptive numer- dress broad questions and examine evidence regardless ical and thematic analyses are presented as narrative of study design [18–21]. The improved five-stage meth- summaries given the heterogeneity of the literature. This odological framework of Arksey and O’Malley was used process followed the Preferred Reporting Items for Sys- to structure this study [18, 20]. This entails an iterative tematic reviews and Meta-Analyses extension for Scop- technique of formulating and redefining the research ing Reviews (PRISMA-ScR) [22]. question, identifying relevant studies, selecting studies, charting of the data, and collation, summarization and Results reporting of the results. As suggested by Daudt and Col- Initially, we identified 312 articles in PubMed and CINAHL quhoun, a quality assessment of the included studies and additionally 963 papers in Google and Google Scholar. was also performed [19, 21]. After screening for title and abstract, 36 articles were con- After the initial review of the literature the following re- sidered potentially relevant, of which 26 met our criteria. search question was developed to guide the review: What Hand searching reference lists identified 9 additional stud- is known about ICLN programs and their effectiveness in ies, of which 2 were included. One article was included raising awareness of infection control or in the improve- after the last search update. In total 29 papers were ment of infection prevention practices, and do these pro- included (Fig. 1). grams reduce the risk of healthcare-associated infections? The 29 included articles, 27 of which were peer Ebsco/Cumulative Index for Nursing and Allied Health reviewed papers, one guideline and one report represent Literature (CINAHL) and PubMed were explored on 18 literature from 5 continents. The majority of studies July 2017 for index terms and text words with the initial originated from the UK (n = 14). The other studies were search term “link nurs*”. Ebsco/CINAHL and PubMed conducted in the USA (n = 3), Australia (n = 2), China were searched from inception up to 24 July 2017 (n = 2), Japan (n = 2), Germany (n = 2), the Netherlands (MD&JCFK). The following terms were used (including (n = 1), Egypt (n = 1), and Canada (n = 1). Belgian and synonyms and closely related words) as index terms or UK researchers collaborated on one abstract. Most stud- free-text words: ‘link’ or ‘liaison’ or ‘intermediary’ and ies had a descriptive design (n = 12) or were before-after ‘nurses’ and ‘infection control’ or ‘handwashing’. Google comparisons (n = 7). Other studies included qualitative and Google Scholar were searched for grey literature on 25 studies (n = 4), cross sectional surveys (n = 2), studies November 2017 and 8 February 2018. The search was up- using action research (n = 2), a mixed methods study th dated on the 25 September 2018 (IJ&MD). The full search (n = 1), and a randomized controlled trial (n = 1). strategies for all resources can be found in the Add- By charting the studies and summarizing the findings itional file 1. Duplicate articles were excluded. The follow- we identified that part of the studies focused on three ing criteria for inclusion were adopted: research- and major themes: the profile of ICLN, the implementation opinion-based papers, abstracts, reports and guidelines, of ICLN programs, and strategies to support ICLN. The published between 1980 and 2018, specifically on infection other part of the publications focused on outcomes of Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 3 of 13 Fig. 1 PRISMA flow diagram strategies that involve ICLN. Table 1 provides the details [5, 15, 26], improve clinical practice at ward level [5, 6, 13, of studies including methodological comments and limi- 15, 23, 26], act as a role model [6, 23, 27], and assist in tations of individual studies. research [13, 26].The task of transferring information to peers and other healthcare staff is described in five articles Key features [5, 13, 23, 25, 26]. One article states that the influence of The profile of ICLN ICLN might lay more in improving practice than in the Nine articles highlighted the ICLN profile with accom- dissemination of knowledge upon which these practices panying roles, tasks and competences [5, 6, 9, 13, 15, are based [5]. 23–26] using different terminology (e.g. roles vs tasks). The core competences of ICNL for fulfilling these ICLN were first described in 1981 as a liaison between roles and tasks include: receptive for feedback, proactive, the epidemiology department and clinical wards [9]. In non-judgmental, approachable, resilient, authoritative, the following years, the educational role was added [5, assertive and charismatic [5, 15, 24, 27]. Two out of five 14, 25]. The Royal College of Nursing published a studies that describe the enrollment of ICLN stress the national ICNL role profile for the UK in 2012. Four core importance of voluntary registration. It is seen as an ex- themes were identified for the link nurse role: “act as a pression of motivation and enthusiasm for infection pre- role model and visible advocate, enable individuals and vention and control, which are perceived as core teams to learn and develop infection prevention and competences for the uptake of the ICLN role [5, 23–25, control practice, act as a local communicator, and 28]. Authority is perceived as essential for carrying out support in audit and surveillance” [12]. the role. Therefore clinically experienced nurses are pre- Tasks of the link nurse role that were considered viable ferred as ICLN [5, 24, 27]. The Royal College of Nursing included: perform surveillance of infections [9, 13, 15, 25, summarized competences of ICLN as: “to be passionate 26], monitor infection prevention and control practices [5, about infection prevention and control, responsible for 9, 13], aid in the early detection of outbreaks of infection own actions, an active participant in the ICLN network, Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 4 of 13 Table 1 Summary of included studies Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations Braekeveld Abstract – interactive workshop and 450 voluntarily participants A joint professional profile for (2016) UK & questionnaire on perception on the (link nurses, nurses, head infection control link nurses Belgium role of link nurses in infection nurses and infection control will follow prevention practitioners) in the UK and Belgium Ching (1990) Cluster randomized controlled trial 1000 bed hospital in Hong Three specific standards for One hospital China – introduction of a guideline for Kong - urinary catheter care were One baseline measurement catheter care Control group: three wards significantly improved by link No follow up (surgical medical and nurses educating their peers. Differing numbers in control gynecology) Incorrect practices before and intervention wards Test group: twenty-four wards intervention: (sampling bias) - 63% intervention group - 68% control group (p = 0.4) Incorrect practices 5 weeks after intervention: - 36% intervention group - 48% control group (p < 0.05) Cooper (2001) Descriptive paper- outline of the – Education of ICLN should be UK educational theory that underpinned based on educational theories. infection control link nurses’ education Cooper (2004) Descriptive paper - prologue of A district general hospital Methodological considerations UK action research study and argumentation for action research. Cooper (2004) Action research A district general hospital - Three out of four barriers for Small sample size No follow UK fourteen wards compliance with hand up hygiene were significantly improved 3 months after intervention in 14 clinical areas Cooper (2005) Qualitative research - Focus group Ten ICLN ICLN reported increased No information on topic list, UK feelings of empowerment, non- participants, number of ownership and motivation data coders, data saturation, during one focus group with member check 10 link nurses Dawson (2003) Narrative review - outline of the role – ICLN have a role in UK of the ICLN surveillance and education or peers. The role of the ICLN is still evolving. In 59% of National Health Services Trusts link nurses are active. Graaf de (2013) Descriptive paper – outline of the One hospital 8 link nurses As a result of an outbreak 8 Netherlands appointment of 8 link nurses to nurses were appointed ICLN support the infection prevention and They support the infection and control team in a Dutch hospital prevention and control unit for 8 h a week and their departments are financially Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 5 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations compensated Horton (1988) Descriptive paper - outline of a pilot Sixteen ICLN in various Monitoring performance of UK course services of a NHS trust participants is crucial to the maintenance of high standards Jacobsen Descriptive paper –outline of an 560 bed adult teaching Isolation of the OT can make it – (1999) Australia educational program / hospital - Operating Theatre more difficult for the ICN to implementation strategy encourage changes in infection control practice. ICLN can help to overcome this difficulty. Monitoring tools are necessary for long-term evaluation Macduff (2009) Full report - Evaluation of Cleanliness NHS health facilities in Program has substantive No process or outcome UK Champions Program using a mix of Scotland positive influence on the measures (as guideline qualitative and quantitative methods prevention and control of adherence or Healthcare health care associated Associated Infection rates infections in Scotland stated) Perceived impact stated Manley (2012) NICE guideline - based on two – A national role profile and Consensus based guideline UK workshops analyzed by an approach core competences to support termed concept analysis link practitioners, their managers or organizations with a ICLN network Lene (2002) Descriptive paper – outline of A general acute care hospital A program requires dedicated Australia structure and developments of a link coordination, flexible and well program planned education and effective support from management Lloyd-Smith Implementation of link nurse Three acute care hospitals - 16 Seven link nurses produced an Convenience sampling, no (2014) Canada program, focus group & economic clinical units 8 with link nurses action plan. 10 focus groups information on data saturation, estimate evaluation 8 without link nurse with stakeholders led to 5 no member check are risks for themes for a successful bias program Key factor is effective Important and relevant costs monitoring of effectiveness and consequences for each and sustainability alternative were not identified The program was cost effective. (cost for link nurse program per bed ($490) vs cost for extra infection prevention practitioner per bed ($596)) Millward (1993) Cross-sectional - Audit tool & Three districts’ health Audits on eight infection Sample sizes too small for UK knowledge questionnaire authorities. One location with control topics for 20 wards. analyses. link nurse program. Wards with infection control link nurses obtained higher Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 6 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations scores on compliance with infection control standards (p = 0.0006). Link nurse showed higher scores on knowledge (69%) than non-link nurses (52%) (p = 0.008). Miyachi (2007) Quasi experimental design A 1133-bed University hospital Significant decrease of As stated in article, risk of Japan monthly MRSA rates (from 6.3 regression to the mean, to 5.0%) after implementation maturation effects and of link nurse system and confounding during 2 year follow-up. Increase in monthly use of hand soap (17.3%). Ross (1981) Pre-post implementation study - A 650-bed, university-affiliated Implementation of ICLN and No baseline, no follow-up USA establishing of ICLN on patient units general hospital determination of health care data. associated infections rates in years one. Year two monitoring infection rates. Education met expectations of link nurses (96%). In 9 of 11 wards rates were reduced. Seto (2013) Before – after study & participatory A private 850-bed institution Involving ICLN in brainstorm Single centered uncontrolled China action sessions, poster competition, study, maturation effects identification of points of care and monitoring compliance improved hand hygiene practice significantly from 50 to 83%. Use of hand rub increased from 8.1 l/1000 patient days to 9.1 l/1000 patient days. Shabam (2012) Cross-sectional survey Twenty hospitals, 205 head Survey results showed that No description or definition of Egypt nurses who work as a ICLN in ICLN have a role in education “perception as a link of various departments (medical, (25%), consultation (25%), infection control” surgical, neonatal, pediatric, administration (90%), research obstetrics, gynecology, dialysis, (21%) and supervision of safe outpatients’ clinics, emergency, practice (99%) burn and urology) The majority of head nurses participated in a training program related to infection prevention and control but not on their ICLN roles 48% of head nurses never performed ICLN roles. 54% had a low level of Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 7 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations knowledge on infection prevention and control 79% had a high perception of infection prevention and control When head nurses’ knowledge and perception increased the performances on the 5 identified roles increased (p = 0.0001) Sopirala (2014) Quality improvement study (pre-post A 1191-bed University Medical After a 2 year baseline period No randomization, no follow- USA design) Center link nurses were introduced up during a year. In that year MRSA rates reduced (28%, p = < 0.01), MRSA bacteremia rates reduced (41%, p = 0.003), hand soap consumption increased(from 19 to 31 oz) as compliance with hand hygiene (from 30 to 93%). Sopirala (2018) Before – after study evaluating a A 699-bed tertiary care aca- After a 21 month baseline Single centered study, no USA CAUTI prevention program with two demic medical center period (data on urine cultures follow-up different CAUTI definitions of 5 ICU units) link nurses were trained in CAUTI prevention, participated in training of colleagues and patients, and committed to ward based actions. CAUTI rates declined in with new definition (IRR 0.67, 95% CI [0.48–0.93]) CAUTI rates increased with old definition (IRR 1.12, 95% CI [0.88–1.43]) Teare (1996) Interventions study - outlining how District general hospital Implementation in 3 phases: No baseline measurements, no UK to design the ICLN network for the set up, setting standards on follow-up. No exact numbers hospital wards, management given. ownership. Infection control practices were divided in 8 areas. ICLN (n = 51) had a role in education of peers and the audit of infection control practices. The link nurse system had a positive effect on clinical practices. Infection rates did not reduce. The infection control team was added to the trusts risk Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 8 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations management group. Teare (1998) Descriptive paper - reporting Mid-Essex trust Link nurses have a role in UK experiences and encountered education and surveillance. benefits ICLN system has raised awareness and increased the profile for infection control. Teare (2001) Descriptive paper - outlining a study Mid-Essex trust Six interactive sessions on UK day for ICLN infection prevention knowledge and governance. A questionnaire quantified the self-assessed re- sults of ICLN on their wards. This assessment of capabilities and limitations may be useful in the communication with ward management . Tebest (2017) Cross-sectional survey among ICLN University hospital Response rate 29% (n =29). One hospital Germany (n = 64) Intended services were rarely Small sample performed Barriers were the lack of release from other duties and the lack of acceptance of the role by physicians Tsuchida (2007) An intervention study with before 560-bed acute hospital located In year one risk factors for Single centered study, No Japan and after comparison in a major urban area in Japan CLABSI in catheter care were randomization, no follow-up identified with the help of 4 link nurses. In the following 2 years interventions were implemented. ICLN educated colleagues and observed catheter care. In those two years CLABSI rates declined from 4.0/1000 catheter days to 1.1/1000 catheter days (p < 0.005) Ward (2016) UK Descriptive paper outlining the role – Currently there is limited of the link nurse evidence of the efficacy of ICLN in improving practice Wilbrandt prospective controlled study Eight hospitals – four The concept of link nurses was No randomination (2001) intervention and four controls introduced successfully. Unclear duration of follow –up Germany Improvements on the level of No definition for ‘success’ of process quality (increase of the link nurses contact moments between INLN and infection control staff) . No reduction of nosocomial Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 9 of 13 Table 1 Summary of included studies (Continued) Author details Study design Setting Key findings & Outcomes Methodological comments & & Location limitations infections. Wright (2002) Pre-post implementation A 87-bed neonatal intensive Decrease of nosocomial No N, percentage or 95%CI USA observational study care unit at a Children’s infections stated hospital The role of the ICLN is flexible and can be tailored to the specific needs Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 10 of 13 approachable, non-judgmental, inclusive, reflective, and nursing practice, education in auditing and surveillance, respectful” [12]. and skills for the dissemination of this knowledge to peers [5, 10, 14, 23, 24, 31]. The latter is perceived as vital for Implementation of ICLN programs ICLN to become effective role models [5, 14, 31]. In order Five papers describe operational barriers of implement- to expand these skills experts (e.g. a psychologist) contrib- ing an ICLN program [5, 11, 16, 24, 29, 30]. Two papers uted to two programs to tutor on leadership and report on ICLN programs that discontinued due to oper- change-management skills [10, 24]. Four studies suggest ational difficulties [5, 16]. ICLN struggle with low staff- an introduction course (range 1–10 days) [5, 7, 9, 10]. This ing and high workload leaving insufficient time for ICLN introduction course could be given as e-learning, to per- activities [5, 11, 24, 29, 30]. High staff turnover chal- mit ICLN to start their activities at any time at their own lenges hospitals to keep the number of trained ICLN up pace [5]. Four studies report on regular meetings with one to standard [5, 24]. To overcome these operational bar- to three months intervals [7, 10, 14, 27]. Education modes riers an ICLN program in a Dutch hospital was set up vary from interactive sessions [7, 14], lectures, tutorials with only eight ICLN. These ICLN were exempted from [28] and visits to the Microbiology Laboratory [7], laundry duty eight hours a week in order to propagate infection services and sterile processing department [10],to control practices at the ward and hospital level [23]. self-learning packages [11] and sharing copies of relevant The difficulties encountered by ICLN in their educa- literature [29]. Lectures are repeated several times [7, 28] tional role are discussed in six studies [15, 24, 29–32]. or held during (a provided) lunch to facilitate attendance Two studies noted that medical staff lacked acceptance [7, 15]. Support by the infection prevention and control of the role of the ICLN or the need for infection preven- team is described in five studies [6, 7, 10, 24, 25]. Support- tion and control practice [29, 30]. Jacobsen reports a ing activities include providing ICLN promotional and lack of participation of medical staff in educational ses- educational materials [24], through newsletters, and by sions by ICLN [32]. mentoring the ICLN through regular ward visits for the Three papers describe the presence of ICLN as a risk. discussion of progress and current ward-based problems Although visibility of ICLN in their role is perceived es- [7, 10]. Action research or brainstorm sessions are used to sential to trigger behavioral change, other health care collaborate in research, for the development of an imple- workers may foster the idea that infection prevention mentation program and for ward-based action plans or as- and control is not their concern and rely on the ICLN signments [6–8, 10, 24]. for all infection prevention and control matters [15, 24, Three studies describe the role of the ward manage- 31]. None of the studies provided clues or insights in ment in the empowerment of ICLN in fulfilling their what aspects of ICLN programs were most effective. role [5, 9, 29]. This support can be promoted by refer- ring other staff to ICLN, by scheduling infection preven- Strategies to support ICLN tion and control topics for discussion at ward meetings, Strategies to support ICLN were listed in 17 papers and and by allowing ICLN training time [5, 29]. Support of include education, commitment and coordination by the Senior ward management is described in three studies as infection prevention and control team, support from enabling factor for the program as a whole [24, 25, 31]. ward management, support from the senior hospital Three studies describe networking between ICLN as a management, and support between ICLN themselves support mechanism. To create mutual communication, [5–11, 14, 23–25, 27–29, 31, 33, 34] Thirteen studies re- discussion and sharing of experiences with other ICLN port on educational components of ICLN programs [5, is encouraged in regular meetings [24, 29, 33]. 7–11, 14, 23, 24, 27, 28, 31, 34] The Scottish Govern- ment provides a national training to aid education [34]. Twelve studies report on a local educational program The effect of ICLN programs under the direction of the infection prevention and con- Five studies have evaluated the introduction of ICLN with trol team [5, 7–11, 14, 23, 24, 27, 28, 31]. It is advocated respect to infection rates [7, 8, 26, 35, 36]. Two studies with to underpin this program with theory on adult learning a before-after design and one with a quasi-experimental de- [31], engage in active learning forms [5], communicate sign showed that the introduction of ICLN led to improved on topics of interest prompted by ICLN themselves [7, compliance with hand hygiene or increased hand soap / 31] and to communicate on one topic per year to create sanitizer consumption and a reduction of Methicillin-Re- focus [27]. There is a large variation in the content of sistant Staphylococcus aureus (MRSA) rates [7, 8, 35]. In these programs. The curricula include content related to two other studies ICLN achieved a reduction of CLABSI knowledge of microbiology, modes of transmission, [36, 37]. In the USA the reduction of nosocomial infections nosocomial infections, and infection prevention and in a neonatal intensive care unit was linked to the introduc- control policies, the application of this knowledge in tion of an ICLN [26]. Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 11 of 13 In three studies clinical practices improved with the help number of factors are considered vital for the support of of ICLN [28, 32, 38]. In a HongKonghospitalICLN im- ICLN in the completion of their tasks. First of all educa- proved the care for urinary catheters in a cluster random- tional programs are important. This is in line with previ- ized controlled trial. The second study demonstrated ous findings that show that, to improve infection higher compliance rates with infection prevention policies prevention practices education of health care workers is on wards with ICLN [38]. The third study described vital [42]. The content and delivery of education in improved compliance with standard precautions in an ICLN programs is not standardized, but in general, edu- operating theatre with an ICLN. The role of the ICLN was cation of ICLN by the infection prevention and control perceived pivotal. Compliance was not reported on [32]. team to educate on infection prevention topics in regu- One paper described a positive effect of “raising the profile lar meetings is considered best practice. This education for infection prevention and control” [15]. Another study can be extended by training in implementation skills by reported a perceived improvement of infection prevention experts. With respect to how to set up educational meet- and control practice [27]. Furthermore one study reported ings, focusing on one topic at each meeting is seen as “an improvement at the level of process quality” in a gen- important [27]. eral sense after the implementation of ICLN [33]. The ICLN profile is flexible and must be tailored to the local needs [5, 6, 39]. This is essential to facilitate Discussion nurses in the ownership of the ICLN role. A role profile This scoping review revealed a lack of research evidence clarifies expectations of ICLN for all stakeholders. It fa- on the effects of infection control link nurses on guide- cilitates communication on the ICLN role and tasks line adherence and patient outcomes. The majority of within the organization [43]. included papers delineate the ICLN profile with accom- Support by the management at ward level can em- panying roles, tasks and strategies to support ICLN power ICLN to act as a role model and to disseminate without an evaluation of the implementation process or knowledge to their peers. The adherence to guidelines effects in clinical practice. Only two of these articles in- will improve when management supports infection pre- cluded a brief evaluation of the impact of their ICLN vention and control measures [44] since this improves program on healthcare-associated infections [9, 26]. their leadership. De Bono et al. found an association be- Therefore the value and impact of ICLN programs is dif- tween effective leadership and better adherence to infec- ficult to assess [5, 39]. Studies that report on the effect tion prevention and control policies (e.g. hand hygiene of ICLN programs in terms of patient outcomes or and personal protective equipment) [45]. guideline adherence describe positive short term effects. In the UK a generic role profile for ICLN is established Several ICLN programs appeared to have discontinued, by the Royal College of Nursing [12], but it is not clear none of these studies, however, mentioned that they did in how many hospitals ICLN actually are appointed. so because of negative or no results [5, 16]. ILCN are present in several hospitals throughout the Six of the studies that did report on the effect of ICLN Netherlands, but not everywhere [46]. In German acute programs had a single-center uncontrolled study design care hospitals ILCN are mandatory [17]. Furthermore, [7, 8, 26, 35, 36, 38]. These studies hold a high risk of se- link nurses have shown potential in other settings [47– lection bias [40]. Prevention of healthcare-associated in- 51]. It is therefore justified to invest in further research. fections may be influenced by many other factors than There is a lack of studies that evaluate the process of the ICLN program itself, and controlled studies may not implementation of ICLN and the outcomes of ICLN find significant effects due to low statistical power (type programs. Evaluation should consider how to tailor and II error) [41]. The combination of study design and lim- deliver an ICLN program to maximize impact of link ited research output holds a risk for selective reporting nurses on guideline adherence and patient outcomes. By of positive findings and publication bias. This might assessing in which context which program has impact, have influenced our findings. research findings can help to tailor ICLN programs to The narrative synthesis is based on studies that vary in the local situation [52]. An in-depth description on how quality, design and outcome. We assessed study outcomes ward management, the infection prevention and control as having equal weight. Although standardized data extrac- team and the ICLN interrelate can help understand how tion and an iterative team approach strengthened reliability, to support ICLN in fulfilling their tasks [53]. Damschro- this may have led to bias in the categorization of our find- der et al. confirms the importance of cooperation be- ings. Possibly, we missed relevant papers, since we chose to tween professionals from different disciplines to realize exclude studies on the role of champions and opinion behavioral change [54].Information on the perception of leaders. link nurses and their peers on the role and the perceived Although the quantity and quality of research on ICLN effectiveness of their effort can contribute to this in is limited, a common theme that emerges is that a depth description. Dekker et al. Antimicrobial Resistance and Infection Control (2019) 8:20 Page 12 of 13 Interdisciplinary collaboration in infection control net- Consent for publication Not applicable. works may help overcome resistance of other health care workers [11, 54]. In this respect, studies focusing on Competing interests how to involve other health care workers in general, and The authors declare that they have no competing interests. physicians in particular are needed . Finally, there is a research gap in how to sustain ICLN Publisher’sNote programs, and on their economic value. For further re- Springer Nature remains neutral with regard to jurisdictional claims in search, we advocate the use of mixed method designs, published maps and institutional affiliations. since the implementation of an ICLN network can be Author details considered a complex intervention. 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