Methicillin-resistant Staphylococcus aureus (MRSA) pose a serious threat to neonatal patients, and multiple MRSA outbreaks have been reported.Reference Mean, Mallaret and Andrini1–Reference Scheithauer, Trepels-Kottek and Hafner3 Transiently and persistently colonized healthcare workers (HCWs) can be responsible for MRSA clusters.Reference Albrich and Harbarth4 In January 2018, the neonatal ward of the University Hospital Zurich, Switzerland, experienced an MRSA outbreak affecting 10 patients and 2 relatives. The outbreak was controlled by a multimodal intervention including voluntary MRSA staff screening.
Literature about HCW behavior in staff screenings during hospital outbreaks is limited. The Theory of Planned Behavior describes 3 determinants of intention to perform a behaviorReference Ajzen5: (1) ‘attitude toward the behavior,’ that is, how an individual thinks and feels about the behavior and its consequences; (2) the ‘subjective norm,’ that is, beliefs about the social expectations; and (3) ‘perceived behavior control,’ that is, how capable and confident the individual is to perform the behavior.
In this study, we have described the participation behavior of HCWs in a MRSA screening, and we retrospectively assessed determinants for or against participation based on the Theory of Planned Behavior using a questionnaire.
Methods
Study setting and participants
The study was conducted at the University Hospital Zurich, Switzerland, a 950-bed tertiary-care teaching hospital. The Department of Neonatology comprises an intensive care and an intermediate care unit with a total of 30 beds. A formal ethical evaluation was waived by the Cantonal Ethics Commission (Req-2020-00993).
MRSA staff screening
All neonatology employees were encouraged to participate in the screening by oral and e-mail invitation, and they were informed about the necessity for decolonization in case of MRSA detection. Swabs of nares, pharynx, and groin were taken by infection prevention and control (IPC) team members in the neonatal ward during 2-hour time slots on 6 work days. All samples were pseudonymized and were unblinded only for the hospital medical officer.
Questionnaire survey
Four months after the staff MRSA screening, all nurses and physicians were invited to anonymously answer an online questionnaire (Survey Monkey, San Mateo, CA) comprising the following (Supplement 1 online): (1) demographics; (2) reasons for participation or non-participation in screening, assessing all 3 determinants of intention; (3) motivators for participation, assessing the subjective norm; and (4) evaluation of pseudonymization process, assessing attitude. Nonresponders were reminded by e-mail thrice. HCWs whose employment started after the screening were excluded from analysis.
Statistical analysis
We used logistic regression analysis to assess differences in screening participation regarding profession, age, and work experience groups. The χ2 test was used to assess differences in questionnaire participation. A P value of <.05 was considered statistically significant. All analyses were performed using Stata version 15 software (StataCorp, College Station, TX).
Results
Of 116 nurses and 24 physicians invited to be screened, 83 (72%) and 12 (50%) participated, corresponding to a participation rate of 68%. None of the screened HCWs tested positive for the MRSA outbreak strain.
Of 140 HCWs invited to answer the survey, 87 (62%) responded, 74 nurses (64%) and 13 physicians (54%). We excluded 3 participants from the analysis because they did not work in the neonatal ward during the MRSA screening. The remaining 84 HCWs, 73 nurses and 11 physicians, were included in the analysis. Among them, 65 (77%) had participated in the MRSA screening. HCWs who participated in the screening were more likely to complete the survey (P = .017).
Professional category, age group, or professional experience were not significantly associated with screening participation (Table 1). Table 2 lists the reasons of HCW for participating or not participating in the screening. The 2 most commonly mentioned reasons for participating belonged to the determinant attitudes: the wish to avoid transmission and concern about own or family’s health. The most common reason for not being screened was inconvenient screening time, which was included with the determinant ‘perceived behavioral control.’ The remainder of those not being screened reported negative attitudes such as perceiving screening to be senseless. By assessing subjective norms, we found that 49% of HCWs felt that they had been motivated to get screened by at least 1 of the following: the clinic management (35%), IPC team (27%), colleagues (24%), or the hospital medical officer (11%). Most respondents (87%) found that pseudonymization was sufficiently guaranteed. However, some of the individuals not screened reported negative attitudes related to the screening conditions, namely whether their personal information was fully protected by pseudonymization. HCWs considered the blinding of the results toward others to be important as follows: toward colleagues (92%), clinic management (77%), the IPC team (32%), and the hospital medical officer (12%).
Table 1. Participant Characteristics and Analysis of Association With Screening Participation (N=84)
Note. OR, odds ratio; CI, confidence interval; MRSA, methicillin-resistant Staphylococcus aureus.
Table 2. Reasons for Participation and Nonparticipation in MRSA Screening (n=84)
Note. HCW, healthcare worker; MRSA, methicillin-resistant Staphylococcus aureus
a The third column matches the participant’s answers to the determinants of intention according to the Theory of Planned Behavior: attitude (‘attitude toward the behavior,’ ie, how an individual thinks and feels about a behavior), ‘norm’ (‘subjective norm,’ ie, does the behavior correlate with norms of the individual’s social network or cultural norms), and control (ie, ‘perceived behavior control,’ how capable and confident the individual is to perform the behavior).
Discussion
After a voluntary staff screening during a MRSA outbreak on a neonatal ward with a screening participation rate of 68%, a survey among nurses and physicians assessed determinants for screening participation or nonparticipation. Among HCW attitudes, ‘the desire to preclude MRSA transmission from HCW to patients’ and ‘concern about own and family members’ health,’ were important determinants for screening participation. HCWs not participating in the screening most often mentioned the inconvenient screening times (a nonmotivational factor belonging to the determinant ‘perceived behavioral control’) as reason for nonparticipation.
Very few studies investigating the intentions and behavior of HCWs in staff screenings were identified in a literature search. Joseph et al.Reference Joseph, Shrestha-Kuwahara and Lowry6 investigated factors influencing HCW adherence to tuberculosis screening with comparable findings. They showed that HCW perceived screening to be an effective way to protect themselves, their families, and coworkers.Reference Joseph, Shrestha-Kuwahara and Lowry6 The attitudes of HCWs (eg, concern about the health of others, be it a patient or their family) seem to be the most important predictor for the intention to be screened.
The factor ‘perceived behavioral control’ was negatively associated with screening participation. Like the aforementioned study,Reference Joseph, Shrestha-Kuwahara and Lowry6 we found logistic difficulties like inconvenient screening times to be the most important barrier. Additionally, some HCWs in our study mentioned that they felt inadequately informed about the screening and its consequences, with some doubting that results were kept confidential. This finding is in agreement with a study that identified the ‘fear of stigmatization if confidentiality and anonymity protection fails’ to be a challenge in staff MRSA screening.Reference Papastergiou and Tsiouli7
‘Subjective norms’ seem to play an inferior role in predicting HCW behavior; only half of HCWs felt that they had been motivated by others to participate in the screening. Still, the invitation for screening by superiors might be beneficial because other studies have shown that counselling and emotional support from the decreeing authority is a facilitator for participation.Reference Joseph, Shrestha-Kuwahara and Lowry6
Our study has several limitations. Survey participation was voluntary, with a response rate of ~60%, and nonparticipators of the MRSA screening were underrepresented among the respondents. The generalizability of this single-unit, single-institution survey is limited. Also, we did not detect any outbreak strain in the HCW screenings. Although the questionnaire was answered anonymously, social desirability bias (ie, an individual answering in a way that makes him look more favorable) cannot be excluded.
In conclusion, staff screening for MRSA was accepted by most HCWs, and participation was primarily driven by HCW attitudes. HCWs wanted to prevent infections in their patients but also to protect themselves, and these attitudes have already been described in the literature.Reference Seibert, Speroni, Oh, Devoe and Jacobsen8,Reference Erasmus, Brouwer and van Beeck9 Convenient testing times and sufficient blinding of results might improve participation rates. For HCWs who still do not intend to participate in screenings, individual approaches (eg, having a clarifying discussion or offering self-testing opportunities) might help to overcome refusal.
Acknowledgment
Financial support
A.W. is supported by the academic career program “Filling the Gap” of the Medical Faculty of the University of Zurich.
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2020.1319
