Turning policy into practice – Infection Control Practitioner perspectives on implementation of Standard 3 Criteria 10 Aseptic Technique of the NSQHS Standards

Sally Havers 1,2, Lisa Hall 2, Katie Page 2, Andrew Wilson 3

Hand Hygiene Australia, Heidelberg, VIC, Australia

QUT, Kelvin Grove, QLD, Australia

Menzies Centre for Health Policy, University of Sydney, Sydney, NSW, Australia


In 2010 the National Safety and Quality Health Service (NSQHS) Standards were introduced including a criterion addressing aseptic technique (AT) practices. Minimal understanding of AT practice in Australia existed and it was unknown how hospitals would implement AT in line with new requirements. This study investigated Infection Control Practitioner (ICP) perspectives on this process and aimed to identify contextual factors that influenced how policy was implemented.

An exploratory qualitative research approach was used and data collected via focus groups (n=4). ICPs were invited to participate and purposeful sampling provided representation from public and private, regional and metropolitan services. All participants had been involved in implementation of AT policy in their hospital. Focus group questions were guided by the Theoretical Domain Framework, a validated framework used in implementation research. A thematic analysis using interpretive description was undertaken to determine key themes discussed.

Data was collected in early 2015. Three focus groups were held in Melbourne, Adelaide and Brisbane. A fourth session (conducted via teleconference) included ICPs from regional settings. Analysis identified several key organisational factors that influenced implementation including preparedness and resourcing; internal systems and processes; and roles, responsibilities and relationships. Other key themes included perception of policy (including the trigger for policy) and competency of clinical staff prior to implementation.

Identification of key factors that influence infection control policy implementation provides practitioners and policy makers with better understanding of implementation processes and with further research, the potential to maximise impact of policy on patient care.

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