Dear Editor,It was with great interest that I read the paper by Wendt and colleagues (Wendt et al., 2022) exploring infection prevention practices in home-based nursing care. The design, using participants’ observations of invasive care-delivery situations, supported by focus-group discussions and semi-structured interviews, is commendable since it provides data on what nurses actually do in practice rather than telling what they think they do in interviews. They reflected on their practice in the subsequent focus-group discussions and spoke about the reasoning behind their behavior. This interesting piece of research also focused on a very timely subject - preventing infections.The Covid-19 pandemic illustrates the importance of being constantly on guard in relation to the transmission of infections, be they air-born or linked to physical procedures. In Sweden the high COVID-19 death rate in home care and in nursing-home care revealed many problems; hygiene practices was one which was significant (Hallberg, 2020). Today's infection prevention practices in home care, as reported in the paper, indicate that we may have downsized the importance of keeping patients safe and protecting them from harm due to poor practice. The authors’ conclusion is:“This study shows from a first-hand observational view-point that the daily practice of infection prevention in home-based nursing care appears to be suboptimal. Furthermore, this study reveals considerable variation with regard to the work environment; the application of hand hygiene; the proper use of personal protective equipment; the handling of communication devices and organizational policies, procedures and support.” (Wendt et al. 2020 p1)A fair conclusion (perhaps too mild) based on the results presented.This research raises questions related to the nurses’ obligations, bearing in mind that they are licensed and act according to law, existing evidence and best practice, codex and regulations protecting the safety of patients. It also raises questions concerning the provider organization's obligations in relation to healthcare laws as well as their responsibility for keeping track of practices that put the patient in harm's way, i.e. patient safety. I may be mistaken but it appeared to me that current practice stood out as violating the knowledge base, laws etc. and put the patients as well as the staff at risk. The violation of laws and regulations took place at a micro-level, during nurse-patient interventions and at a meso‑level, neglect on the part of the organizations of the laws under which they operate.In my understanding, licensed nurses have an independent and personal responsibility for their actions and are obliged to work according to evidence and what is known to be best practice. Regulations probably differ from country to country but in Sweden there is a Patient Safety Law (2010). The Netherland's Government website (Government of the Netherlands 2022) presents a similar view on safety and healthcare with the information that the purpose of the Healthcare Professionals Act (WET BIG) is to “promote and monitor quality in health care and to protect patients from careless or incompetent treatment by healthcare professionals” (Ministry of health, Welfare and Sport, 2022).It may not be clear what “personal and independent responsibility” means for practice. Can nurses, for example, put the blame on organizational failure when they have to go against their training? Can bad practice possibly be excused with the explanation that home care differs from nursing care provided in physical care facilities? The Netherlands government website further states that “Patients should be confident that the care they are receiving is safe”, followed by “Care providers and care professionals are responsible for safe, patient-centered, good quality care. Standards on this are laid down in law” (Government of the Netherlands 2022).The organizational level, which is the responsibility of the providers, is concerned, on the one hand. with providing instructions and recommendations and on the other with applying, and giving feed- back from observations, a systematic quality and safety management system. The focus group discussions in Wendt's study reveal a lack of coherent instructions and recommendations that create a barrier, not from the perspective of violating laws or national regulations, but in an absence of information about what to do. The Netherlands Government states that “management boards (of hospitals and care homes) are responsible for the quality of care in their organization” and this is to be overseen by the Healthcare Inspectorate (Health and youth care inspectorate, Ministry of health welfare and sport (2022)). It is also said that “Steps to improve safety in long-term care settings include: introducing safety management systems in nursing and personal care, home care and care for people with disabilities”. The Swedish Patient Safety Act states that any care provider is obliged to work for patient safety in a systematic and ongoing manner. This applies to private as well as public providers, irrespective of where the care is provided (Government of the Netherlands 2022).In summary, the findings presented in this paper illustrate poor practice, both at the level of the nurses and at the level of the organizations responsible for the provision of care. There may be several explanations for this; unawareness of the risks, economic prioritizing, discrimination against those with long-term healthcare problems etc. Also, nurses may be too obedient to the organization compared to their knowledge, patients and their right to safe care provision and safe work environment. It is interesting, however, that this violation of knowledge, regulations and laws is not brought up in the discussion. Harsh criticism, directed both at the practice of the nurses and at the management responsible for directives, risk management and support for those carrying out the tasks, would in my view be appropriate. Nevertheless, by using participants observations instead of relying only on interviews, this paper brings to the surface a serious problem, that patients as well as staff are being put in harm's way. Research is needed to produce knowledge about what actually takes place in practice and perhaps standing up for the knowledge already available.
Declaration of Competing Interest
There is no conflict of interest related to the submitted paper.