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In this blog, hub topic lead Julie Storr talks about her new book Infection prevention and control: A social science perspective, which explores new perspectives on and approaches to infection prevention and control (IPC). The book examines how people and their behaviour affect IPC, and how they are in turn affected by IPC measures. Julie highlights the importance of compassion in IPC policy and implementation and outlines the unintended negative consequences that IPC measures can have. Among other contributors, Patient Safety Learning's Chief Executive Helen Hughes has written a chapter for the book highlighting the need for patient safety to be treated as a core purpose of health and social care. Almost every book or film review podcast I listen to these days starts with the author or director explaining that [insert name of book/film] was conceived or developed during the COVID-19 pandemic. My new book about infection prevention and control (IPC) and social sciences, written with two colleagues, is no different. We started work on the book well before 2020, and right in the middle of writing it, the COVID-19 virus dropped. Many of the themes we were focusing on suddenly materialised right before our eyes, and this inevitably influenced the book. Focusing on people, not germs From the outset, our focus was not on germs but on people–those at risk from germs and those who can stop or limit them from spreading. We were also interested in the impact germs have on those who go on to develop an infection, including how individuals with infection and their loved ones are treated by their fellow humans. For example, in the book we give a voice to some of the people directly affected by the restrictions that were imposed on access to health and social care during the pandemic; where IPC was used as a blunt rationale for what became widely termed ’visitor bans’. Our book could not have been timelier, focusing on infection and the behaviour of human beings to stop its spread, and completed during this once-in-a-hundred-years global public health emergency. The journey to embed the social sciences in IPC In Leadership Without Easy Answers,[1] written almost 20 years ago, Ron Heifetz suggested that one of the most common leadership mistakes is expecting technical solutions to solve adaptive problems. This theme gained traction with patient safety advocates such as Peter Pronovost and colleagues[2] over the intervening years and had a profound influence on my own perceptions on what we need to focus on in our endeavours to improve healthcare practices through IPC. The COVID-19 pandemic has quite rightly elevated the importance of social sciences in patient safety and IPC, something we see in the World Health Organization’s (WHO’s) commitment to harness the power of behavioural science to improve health.[3] I could not agree more with this focus. As our book reveals however, there is considerable work to do to embed social sciences into IPC competence, decision making and practice. Each of the book’s authors have long held the view that an understanding of the concept of the social sciences and its implications within IPC is important. Our first book, Infection Prevention and Control: Perceptions and Perspectives,[4] published in 2015, sowed the seeds of this journey of exploration into the non-technical aspects of IPC and set the foundations for our latest book. Keeping people safe from the risk of infection in healthcare requires deep understanding of medical microbiology and the epidemiology of infectious diseases. You only have to look at the existing textbooks, conferences, academic publications and even podcasts to see this. But we need more than this. At present the scales are categorically tipped in the direction of the very technical, disease specific aspects of IPC. In our book, we are calling for a rebalancing in this regard. What’s in the book? Opening up the social science perspective As we state at the start of the book, there is a growing appetite in IPC to look beyond the technical and towards the social, psychological and philosophical factors that influence human behaviour. This is the ethos of the book. We acknowledge that we still only touch the surface of many matters that comprise the social sciences, but our ambition is that we build on existing work so that this thinking continues to trickle outwards. We want it to influence others to pick up this topic and build the body of knowledge in this important area of safety and quality. There are sixteen chapters and together with our 10 wonderful chapter authors who span several countries and disciplines, we consider a range of IPC issues and try to pull in some social science perspectives. We draw on psychology, sociology, anthropology and philosophy. In some chapters, this is done in a subtle and nuanced way and in others it is much more explicit. The book opens by considering the relevance of psychological theories and concepts and then builds on this across each chapter. It explores leadership and influence, power and compliance, patient safety and governance and compassion. Compassion as a social construct[5] is a permeating discourse within the field of healthcare quality[6] and I’m particularly delighted that we include a stand-alone chapter on communication and compassion that addresses the service user perspective. Given my own personal interest in compassion and IPC, the chapters I’ve penned reflect what happens in a ‘compassion void’. I use the example of the restrictions imposed across health and social care during the COVID-19 pandemic, explore the adverse consequences of this and outline the case for compassionate implementation of IPC guidance, explaining how the two are not mutually exclusive. The final part of the book looks at some real-world perspectives starting with a comprehensive exploration of human factors in IPC. It explores the use of words and the meaning of language in IPC, drawing on research that provides powerful insights into how the brain mediates behaviour. This focus on the words used in an IPC context has the potential to support guideline implementation. Other topics include social media, infectiousness and stigma and the unintended consequences of campaigns, including whether IPC campaigns make people anxious rather than reassured. Language is again a strong focus of scrutiny in this section. Some personal reflections from a frontline practitioner on the reality of IPC also add an important perspective to the book. The book concludes with some musings on philosophy and IPC, even considering the moral worth of microbes, and demonstrates that IPC has a value and philosophical imperative to continue to do what it does to protect humans from harm. We are not social scientists and it’s important to acknowledge that this book doesn’t purport to be an academic social science textbook. It is our attempt to unpack the social science dimension of IPC so that those responsible for keeping people safe from healthcare associated infection–be they leaders or front-line implementers—consider the social influences and implications of the evidence-based guidance on this topic. We start the book by suggesting that the social sciences are the beating heart of infection prevention and control and hope that by the end, readers can make their own mind up on the extent to which this is true. Related reading Infection prevention and control: A social science perspective (1 June 2023) Patient Safety Spotlight interview with Julie Storr, global infection prevention and control expert Infection Prevention and Control should be an enabler, not a barrier to safe, compassionate human interaction References 1 Heifetz R. Leadership Without Easy Answers. Harvard University Press, 1998 2 Pronovost P. Navigating adaptive challenges in quality improvement. BMJ Qual Saf, 21 May 2011 3 Altieri E, Grove J, Lawe Davies O et al. Harnessing the power of behavioural science to improve health. Bull World Health Organ, 1 November 2021 4 Elliott P, Storr J & Jeanes A. Infection Prevention and Control Perceptions and Perspectives. Routledge, 2016 5 Blackstone A. Doing Good, Being Good, and the Social Construction of Compassion. Journal of Contemporary Ethnography, 1 February 2009 6 Fotaki M. Why and how is compassion necessary to provide good quality healthcare? Int J Health Policy Manag, 16 March 2015

Jane Carthey, Human Factors and Patient Safety Specialist, shares her reflections on COVID-19 vaccination centres and the risk they may present for covid transmission. Last Friday I took my mother-in-law, Margaret, for her vaccination at a local vaccination centre in Chiswick, London. First let me start with what is being done well. We received a call from our GP practice nurse on Thursday offering Margaret an appointment for the Pfizer vaccine the following day. Margaret is 77 and, because several over-80s had cancelled or declined appointments, GP practices had been contacted to open up the appointments to the clinically vulnerable over 75s. Once defrosted, the Pfizer vaccine has to be used; so to avoid waste, they had proactively sought to get other patients to use up the appointment slots that were free. The GP practice nurse forewarned us about the queues, so my husband and I were able to safety plan to ensure Margaret, who is wheelchair bound and has chronic obstructive pulmonary disease (COPD) and hypertrophic cardiomyopathy, would not be queuing in the cold for an hour. I am sure you have seen the news stories about non-socially distanced, long waits outside vaccination centres in the media this weekend. Patient safety concerns: Social distancing – before.* Once inside the vaccination centre, it is not physically possible to maintain one-metre plus social distancing as the centre is so busy. All staff were wearing masks. Most patients and carers were too, but some patients have exemptions. A positive in our centre is that the windows were all open and the staff were doing their level best to ventilate the room. However, we ended up in a cubicle far away from the windows, close to the door, and so there was a flow of patients, carers and staff who, even with their best efforts, could not maintain social distancing. Social distancing – after. After receiving the vaccination, patients are asked to wait 15 minutes before leaving. This is to ensure they are observed for a period of time in case they have an adverse reaction. It is best practice in vaccination administration and adheres to national and manufacturers' guidelines. However, in following best practice, patients and carers are kept in an environment where social distancing is not viable for a time period which increases the risk of COVID-19 transmission. I am wondering if there needs to be a policy-level conversation about trading off the risk of transmission versus adverse transfusion reaction? Or do we need to reflect on the side effect of the goal to vaccinate the most clinically vulnerable as soon as possible may be introducing congestion risks at vaccination centres? Is there scope to reduce the 15 minute observation period post-vaccination? I know some GP practices and community pharmacies have reduced the observation time frame for flu vaccines. Consent. As the cubicles are back to back, you can hear the conversation with the patient in the next cubicle. Next to Margaret was a lady who at first was not clear why she had been sent for the appointment and who then spent around ten minutes with both a nurse and doctor trying to decide whether she wanted to consent to have the vaccine or not. She did not come across as someone who had lacked capacity, rather just unclear about why she had been sent for and who then (understandably) had to ask the questions she needed answering. My reflection is that the consent conversation needs to start when the appointment is booked or confirmed over the telephone. This happened for Margaret, and it meant that on the day of the appointment staff were able to quickly confirm consent, check if she had had reactions to previous vaccines, taking anticoagulation medication or symptomatic, before administering the vaccine. If a patient is having surgery, good consent practice is to start the consent conversation at the outpatient appointments. Then confirm it on the morning of the procedure. Human Factors and the last task step in a sequence of tasks. It is a well documented source of human error that human beings have a tendency to omit the last task step in a sequence of tasks if the primary goal has been achieved before the last task step occurs. Think photocopying and walking away from the photocopying machine once you had done the photocopying, then realising that you have left the originals on the flatbed. In the context of vaccination centres, the last task step is getting the patient and their carer out of the building after they have been told they can leave. In our case, this meant being directed to a small lift which the over-80s were crowding into. Some had walking sticks, so the stairs are not an option. Some just were not aware of the risk of crowding in a lift with other folk. There was no-one managing the exit process from the building, so there was congestion in the lift area, stairwell and the lift itself. My point is that we need to identify vaccination centres where the environment is suited to the user (i.e. over-75s who may have mobility issues) and where over-crowding at entry and exit points are thought through/planned for. Guidelines and staff deployment/education needs to cover the omission of the last task step problem in the vaccination centre context. Otherwise the exit becomes a transmission hotspot. I am mindful one response to my reflections may be that the risk is not that great because the patients have been vaccinated by the time they leave. However, my understanding is that the vaccine is not effective for a few weeks and it is only patients who are vaccinated. The carers/relatives who accompany them are not eligible to be vaccinated yet, so are very exposed. Many of the relatives/carers I observed were in the 50s or 60s, and they, like me, were accompanying a loved-one who was frail. Regulators and Public Health England might find it useful to use the discussion threads on community websites to capture patient and carer feedback. Charles Vincent, Susan Burnett and I have written on the importance of soft safety intelligence like this in our Health Foundation-funded Measurement and Monitoring of Safety Framework. The discussion forum on Chiswick's website, for example, provides a timely feedback mechanism. Given the social distancing challenges I have mentioned, is anyone measuring how many patients get COVID-19 in the weeks between being vaccinated and the vaccine taking effect? And how many accompanying carers? We need to be measuring potential transmission in vaccination centres in the same way we trace back whether a patient has visited a restaurant, supermarket, had contact with school children etc.. What do you think? The staff at the vaccination centres are another example of our wonderful NHS teams; doing their best in an environment not best suited to the task. Let’s not forget they too may be at risk; so as well as the patient safety issues I have highlighted, we need to get the task and environmental design right to keep NHS staff safe. Going forward, we need to proactively iron out these safety issues. Otherwise, we may find in a few months time that vaccination centres have been a breeding ground for the fourth wave. *For other patient and carers' views click on the Forum tab on www.chiswickw4.com, and the thread started on 6 January referred to as 'the over-80s queuing for the vaccine.' Jane Carthey

The House of Commons Science and Technology Committee and Health and Social Care Committee have published their Report following a joint inquiry, which began in October 2020, examining six key areas of the UK's response to COVID-19: the country's preparedness for a pandemic; the use of non-pharmaceutical interventions such as border controls, social distancing and lockdowns to control the pandemic; the use of test, trace and isolate strategies; the impact of the pandemic on social care; the impact of the pandemic on specific communities; and the procurement and roll-out of COVID-19 vaccines. The 150-page Report contains 38 recommendations to the Government and public bodies, and draws on evidence from over 50 witnesses as well as over 400 written submissions. The inquiry concluded that some initiatives were examples of global best practice but others represented mistakes. Both must be reflected on to ensure that lessons are applied to better inform future responses to emergencies.