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Table 2 Anaysis of the demonstration of sterile procedures including process evaluation. The demonstration is performed on the basis of the order of actions with a view to reducing contamination

From: Motivating healthcare professionals (nurses, nurse assistants, physicians) to integrate new practices for preventing healthcare-associated infections into the care continuum: turning Positive Deviance into positive norms

Practice Presentation of the gray area on the action continuum (definition of the problem) The correction as performed by the demonstrator Quotes from the correction process by the demonstrator Feedback on the process – retrospection by the demonstrator on the effect of the demo
Inserting a urine catheter (sterile practice) 1. Preparing the equipment and placing it on the patient’s bed.
In this situation the equipment can scatter and fall off of the patient’s bed, and can also be outside of the nurse’s field of vision. This can interrupt the insertion procedure and break sterility.
Preparing equipment in advance by order of use, placing it on the wagon in an accessible place for the nurse. “When I prepare all of the equipment in advance on the wagon, I see everything with my eyes and I arrange it in the order of what I’m going to need for each stage. Then I don’t forget anything and have to run in the middle of the procedure to bring something and then take my gloves off and sanitize my hands again.” General evaluation of the model: “Since I demonstrated, I’ve been even stricter. If they could show us one procedure at a time in the form of a video, that would be amazing.”
Filling out the gray area: For instance, we emphasized all kinds of things that aren’t in the guidelines, such as putting your name tag in your pocket before you begin, and bringing a garbage bag, because it helps, and every little thing like that can reduce contamination.”
Raising difficulties on the care continuum: “A lot of people slip, for example, when they get to the part of spreading the patient’s legs. It’s difficult. And there are lots of moments where you can break sterility there. We learned how to talk to each other about the preparation you have to do.”
The contribution of TA: “We plan what we do and say it out loud one step at a time, and I say what I’m going to do step-by-step.”
Processing information by the analytical route: “These videos completely refresh what we do all the time, and sometimes there are little tips that help in the places we miss and make mistakes from stress and pressure...”
The contribution of filming: “When you watch such a video, it’s not like when they hand you a page and tell you these are the guidelines, read about how you insert a urine catheter. When you see the video and then you approach a patient, you remember what you saw.”
Correct and efficient planning of the insertion procedure according to the number of staff performing the procedure “If there are two staff members it makes the work easier and we divide it between us, with me being the nurse that performs the insertion while the other nurse is responsible for the equipment and handing it to me sterilely in order of the stages.”
2. The physical preparation of the bed and the patient (making the bed, removing the blanket, changing position, raising gown and spreading patient’s legs) when the equipment is at the patient’s feet rather than on a dedicated wagon, it might break the sterility of all of the equipment. Instructing the patient, preparing the equipment in advance on the wagon, physical preparation of the patient and their surroundings. “The matter of preparing the patient is critical and facilitates all of the subsequent actions. When you have easy access to the equipment and to the insertion site, the chance of breaking sterility are low.”
3. Bending over to the patient in order to begin the procedure and contact of staffer’s name tag with the patient’s surrounding (blanket, open abscesses on the patient’s body).
The name tag can serve as a vector for transmitting contamination, in addition to potentially breaking sterility in the course of the insertion.
Putting the staffer’s name tag in their pocket – to prevent contact with the patient’s surrounding and the patient. “When I bend over toward the patient, my name tag swings towards the patient along with me, and it can break the sterility at the insertion site.”
4. Disposing of the waste on the patient’s bed until the end of the insertion. The waste can scatter, fall off the bed, and be a vector for transmitting contamination. Preparing a garbage bag in advance for equipment waste and laying it out on the lower part of the patient’s bed,
with the nurse having easy access to deposit waste into it.
“In the very first stages, after I explain to the patient the action I’m going to perform, I put an open bag at the foot of the bed near the insertion site so I have easy access to dispose of the waste that piles up during the procedure directly into the bag and not on the bed itself.”
Changing dressing for central line
(sterile practice)
1. Planning the sterile field in the patient’s surroundings, which is crowded and surrounded by a curtain and does not enable a wide and safe range of movement. This fact reduces the nurse’s access and makes it very difficult for the nurse to lay out the sterile field and keep it sterile. Preparing equipment in advance on the wagon by order of use and thinking about preventing contamination when laying out the sterile field. This fact helps prevent unnecessary movements in the workspace. “We always try to prepare the equipment in advance, but you don’t really think about where you place each thing and how much room you leave on the wagon to spread out the sterile field.”
“I prefer to prepare the equipment in advance by the order I will need to use it, one thing after another, so that I don’t forget anything.”
Processing information by the analytical route. “Sometimes we forget very essential things about the actions we perform and then we have to stop and refilm the video.”
Filling out the gray area. “I learned so much from the process: it highlights our daily activities and flashes a red light about all kinds of little situations on the continuum that we sometimes forget, that have to do with hygiene maintenance.”
The contribution of filming. “To see a video today is more practical and interesting than reading a boring procedure.”
The contribution of diffusion. “And I can already see that after it was passed on to staff members through staff meetings, people are starting to implement it.“
2. Direct transition from a nonsterile action to a sterile action. This situation creates confusion for the nurse because the sterile field was already prepared but she has to perform the act of removing the existing dressing with regular gloves, before she puts on sterile gloves in order to apply the new dressing. After preparing the sterile field, the nurse divides the practice into two parts. She calls the first part the “non-sterile” stage and declares it out loud, while removing the existing dressing with regular gloves. Then she begins the second part, which she calls the “sterile” stage, in which she performs HH and puts on sterile gloves. “After I prepare everything, I look at the field and make sure I didn’t forget anything, and then I perform hand hygiene, put on regular gloves, and perform the nonsterile part, while declaring out loud and removing the existing dressing, and only then, before I sterilize the catheter entry site, I become sterile.”
Performing suction on a respirated patient 1. Preparing equipment in advance on the patient’s locker and using sterile water directly out of the sterile water bottle.
Performing HH and putting on gloves.
Preparing the equipment in advance on the patient’s locker: Pouring sterile water into a disposable cup for washing the suction system at the end of the procedure. “We hurry and most of the time we draw the water directly from the sterile water bottle, and then all of the water in the bottle becomes contaminated, and the bottle stays there until next time.” The contribution of diffusion. “Actually, since we made this video it was sent to everyone, and I noticed that me and my staff have been stricter. Especially, the order we decided on became a habit.”
The contribution of repetition until reaching the final outcome. “These stops are good (stopping the filming every time there is a breach) because they let you look close up in real time at what’s happening now, what’s wrong, and to think and correct the action.”
Evaluation of the model: “Today I think it would be good to do this for every action. There’s no question that after this process we developed a practice that’s more correct and effective to reduce the risk of contamination. It’s really a unique project, I’ve never been exposed to a project like this at a hospital before.”
Assimilating the process. “In retrospect, after you see the final film once or twice, it becomes a habit, you do it automatically and it becomes easier.”
  Preparing the sterile glove and pumping catheter above the patient’s blanket in a convenient site to guarantee access to equipment and prevent its falling. “If I perform the procedure alone and there’s nobody to hand me the equipment, it’s important for me to put it in a place where it will be easy for me to take it and use it... After I disconnect the patient from the respirator, I carefully put on the sterile glove with the hand with which I’m performing the procedure, and then pull the cover over like this (holding under the armpit) and immediately grasp the catheter with my sterile hand.”
2. It’s difficult to maintain the sterility of the hand with the sterile glove and the catheter right before the insertion procedure. When preforming the action as a single staff member – disconnecting the patient from the respirator, putting on the sterile glove, and removing the catheter wrapper with the armpit to prevent direct contact between the catheter and the opposite hand (which is not sterile).  
3. Drawing sterile water directly from the sterile water bottle. In this case, inserting the used catheter into the bottle contaminates all of the water in the bottle and provides fertile ground for microbe proliferation. Usually staff members do not use a disposable cup but draw directly out of the bottle, thinking that this is an action that is performed at the end and the water is not inserted directly into the patient. Drawing sterile water from water prepared in advance in a disposable cup. “When I finish the suction, I take the catheter out gently and roll it directly into the internal part of the glove so as not to contaminate the whole surroundings.”
4. Placing the catheter on the bed and collecting it with the rest of the equipment and throwing it in the garbage. The catheter contains discharges from the patient and can contaminate the environment. Rolling the catheter and inserting it into the used glove and collecting the rest of the waste and throwing it into the garbage.