Bridging the Gap

Effective infection prevention and control (IPC) is essential in aged care facilities. Residents are particularly vulnerable to infections due to compromised immune systems, multiple comorbidities, and the very nature of communal living environments. Healthcare-associated infections (HAIs) in aged care settings are not just a minor concern; they can lead to significant morbidity and mortality, escalate healthcare costs, and severely reduce the quality of life for residents. The recent COVID-19 pandemic served as an undeniable reminder of the vital need for robust IPC practices and well-trained teams caring for these vulnerable residents.

While countries like Australia and New Zealand have made commendable progress in developing national IPC guidelines and policies, such as Australia's Aged Care Quality Standards and New Zealand's IPC program, a troubling disconnect persists. There remains an identifiable gap between theoretical knowledge gained from IPC training and the actual, consistent execution of IPC principles among healthcare workers and professional staff in aged care settings. Healthcare teams are routinely trained in the essential protocols such as hand hygiene and the correct use of personal protective equipment (PPE), yet, in daily practice, these important precautions often lapse, particularly when direct supervision is removed. This isn't necessarily due to a lack of understanding or ignorance, but rather a complex interplay of systemic and behavioural challenges within the facility environment.

To understand the urgency of this "know-do" gap, consider these statistics:

• A global issue of non-compliance: Studies consistently reveal a significant gap between knowledge and practice in healthcare. For instance, one study highlighted that while over 70% of medical students knew the hygiene guidelines, their actual adherence in clinical rotations was very limited. Similarly, a recent hospital survey conducted in Ethiopia reported that only 36.5% of healthcare workers complied with standard precautions, despite approximately half of them demonstrating adequate IPC knowledge. This clearly illustrates that knowing what to do doesn't automatically translate into consistent use of that knowledge.
• The Hawthorne Effect's deceptive influence: This phenomenon occurs when individuals modify their behaviour in response to being observed. This further complicates an accurate assessment of compliance. One study demonstrated that healthcare providers were twice as likely to perform hand hygiene if they realised they were being watched, while hand-washing rates plummeted by over 30% when subjects were not aware of observers. This powerful effect emphasises that observed compliance can be misinterpreted; therefore, behaviour must be continuously reinforced if it is to become routine in the working day.
• The human cost of preventable harm: Beyond individual lapses, the collective impact of these inconsistencies is severe. In the U.S. alone, preventable harm in healthcare is estimated to be the equivalent of almost three fatal plane crashes per day. This chilling statistic highlights the dire urgency for healthcare, particularly aged care, to adopt more robust safety practices and cultural frameworks than other high-reliability industries.

This pervasive "know-do" gap poses serious, tangible risks to the health and safety of aged care residents, demanding immediate, strategic, and comprehensive interventions. This blog post will delve into the multifaceted reasons WHY IPC habits lapse in aged care, draw actionable lessons from other industries that have successfully navigated similar challenges, and provide evidence-based strategies to bridge this critical gap. Then, foster sustained and reliable IPC compliance across all aged care facilities.

Even well-intentioned and educated professionals may inadvertently drift into suboptimal IPC practices. This regression is rarely due to malicious intent but stems from a complex interplay of individual, environmental, and organisational factors. Understanding these root causes is vital to developing effective and sustainable solutions.

5. Disconnect Between Training and Practice (Compliance Gaps): Even when training is provided, a substantial gap can exist between theoretical knowledge and actual practice.

6. Lack of Ongoing Monitoring and Feedback: Without consistent auditing of IPC practices (e.g., hand hygiene compliance, correct PPE usage) and constructive feedback, staff may revert to old habits or neglect established protocols. Audits are vital for identifying where training has been ineffective or where compliance is faltering.

7. Perceived Difficulty or Inconvenience of IPC Practices: Some IPC measures may be perceived by staff as time-consuming or inconvenient, leading to shortcuts or non-compliance. For instance, teams might avoid using full PPE if they feel it hinders their ability to provide quick care, particularly during busy periods.

8. Cultural Norms and Peer Influence: The prevailing workplace culture profoundly impacts behaviour. If non-compliance is frequently observed among colleagues or if there is a perceived lack of visible leadership commitment to IPC, it can significantly erode individual adherence to trained practices. A strong organisational culture that prioritises safety and continuous improvement is critical for consistent IPC compliance.

9. Lack of Enforcement or Accountability: Many facilities possess detailed IPC policies on paper but lack effective day-to-day mechanisms for enforcement. Without consistent feedback or clear consequences, busy teams may rationalise cutting corners. A 2024 study identified the absence of an active enforcement system as a key independent predictor of IPC non-compliance.

10. Perceptions, Attitudes, and Risk Assessment: If a healthcare worker genuinely believes a protocol is not important, effective, or necessary for a given situation, they may consciously choose to ignore it. For example, some may skip hand hygiene if a patient "looks clean" or avoid wearing uncomfortable N95 masks if they doubt an airborne risk. A false sense of security, such as "I've never gotten sick before, so it's fine this time," can also be perceived. This highlights the crucial need to strengthen beliefs about the real consequences of non-compliance for both patients and staff teams.

11. Workflow Integration Issues: In some instances, IPC protocols are not well integrated into daily routines, making them easier to overlook. If performing an IPC step not embedded in the standard process (e.g., a missing isolation precaution sign or a checklist that omits a safety step), busy providers might miss it. Conversely, when a preventative action is built into the workflow—such as an electronic order set requiring confirmation of hand hygiene—staff are much more likely to comply.

12. Burnout and Fatigue: High levels of stress, burnout, and fatigue among aged care teams can significantly and negatively impact their attention to detail and adherence to strict IPC protocols.

Other fields with critical safety requirements – aviation, manufacturing, and the military – have successfully grappled with similar "knowing-doing" gaps, offering valuable lessons for aged care.

1. Aviation: The Gold Standard for Safety
Commercial aviation has achieved near-zero fatal accidents by implementing pilot checklists, standardised communication, and a "just culture" that encourages error reporting without fear of punishment.

Procedural compliance is non-negotiable; any crew member can halt a process if a step is missed.

Crew Resource Management (CRM) training empowers junior crew to speak up without fear of reproach.

*Lesson for Healthcare: Surgical safety checklists, modelled after pilot checklists, have significantly reduced complications. The key is systematic processes and a supportive culture where adherence is expected and enforced.

2. Manufacturing and Industry: Systems and Empowerment High-reliability manufacturing embeds safety through engineering controls, worker training, and an empowered workforce culture.

Regular safety audits are used, and the "stop the line" concept is used for safety breaches.

*Lesson for Healthcare: Importance of clear communication, worker involvement, constant vigilance through audits, and incentives aligned with safe performance. Safety protocols are "the way we do business".

Military: Discipline, Standardisation, and Team Accountability

The military manages high-risk operations through rigorous, realistic, and ongoing training (e.g., simulations) and explicit Standard Operating Procedures (SOPs).

A strong sense of accountability and unit cohesion means individuals know skipping a safety step could cost lives, fostering a collective responsibility.

Concepts like "Left of Bang" (proactive awareness) and after-action reviews are used for continuous learning.

*Lesson for Healthcare: Training must be ongoing and realistic, and a team culture where members watch out for each other's compliance (akin to a “buddy check”) reduces errors.

In summary, these high-stakes industries demonstrate unequivocally that procedural adherence is best sustained when it is built into the very fabric of daily work. Recurring themes include checklists, standardised protocols, continual training, open reporting of near misses, and a non-punitive culture of accountability. Healthcare organisations are increasingly adapting these high-reliability practices to effectively close the persistent gap between knowing IPC best practices and consistently executing them.

1. Redesigning Training for Lasting Impact:

2. Strengthening Systems: Making the "Right" Thing Easy:

Often, the physical environment and organisational systems can be redesigned to make IPC compliance the default, easiest behaviour to use.

• Optimise resources and infrastructure to ensure the consistent availability of necessary IPC supplies (including adequate hand hygiene stations, appropriate PPE, and cleaning agents). Adequate facilities, such as sufficient hand-rub dispensers in convenient locations, are crucial. Simply having cleaning supplies and disinfectants available has significantly improved staff compliance rates.
• Integrate IPC into the daily workflow by embedding IPC principles seamlessly into daily care routines and documentation processes using visual aids, checklists, and prompts at the point of care. Tools from industrial engineering, such as Lean and Six Sigma, can be used to streamline processes and eliminate error-prone steps, making the right thing to do also the easiest.
• Allocate dedicated, protected time for staff to undertake IPC training, acknowledging it as an essential part of their work rather than an added burden. Ensure every facility has an adequately resourced IPC Lead, potentially with dedicated hours for IPC responsibilities, and access to specialist IPC advice. "Train-the-Trainer" programs can empower and adequately train a team of internal IPC champions within facilities, helping to overcome limited access to external experts.
• Implement real-time cues or prompts like smart badge reminders or posters placed at handwash stations (e.g., "Stop – gel in, gel out!") to reinforce training when it's needed most. Behavioural nudges, such as a blinking light or gentle alarm if a healthcare worker approaches a patient’s bed without sanitising their hands, have also been piloted with success. Design IPC stations with logical placement of supplies and clear signage to facilitate compliance.
  
  

3. Fostering a Culture of Safety and Accountability:

While education is necessary, it is not sufficient alone; the surrounding culture and organisational support systems ultimately determine whether safe practices endure.

• A strong culture of safety begins at the top with visible leadership commitment and role modelling. Senior management must visibly champion IPC, allocating necessary resources, demonstrating adherence to protocols, and never pressuring teams to cut corners. If a chief physician or charge nurse in a hospital setting strictly follows isolation protocol and hand hygiene at all times, it sends a powerful message. Leadership commitment was identified as a key facilitator of IPC compliance in a 2025 systematic review.
• In a robust safety culture, anyone can speak up if they observe a risk, without fear of reprisal. Healthcare can adopt the aviation industry’s "just culture," wherein reporting errors or near-misses is encouraged for learning, not for punishment. Staff teams need to feel psychologically safe admitting a mistake or pointing out a colleague's lapse so that issues are addressed promptly. Designating unit-based IPC champions who are trained and empowered to mentor peers and call out non-compliance in a supportive way can be very effective in overall compliance. Confidential "hotlines" or mobile apps for staff to report IPC concerns can also be beneficial. The absence of fear is vital.
• Pioneers like Dr. Peter Pronovost advocate for a fractal management approach to sFoster a culture of collective responsibility where team members actively enforce protocols among peers. This approach, akin to a military "buddy check," can significantly reduce errors.afety, where every level of the organisation mirrors the same accountability structure. From the executive level setting clear goals (e.g., "80% hand hygiene compliance by year’s end") to frontline teams holding themselves and each other accountable, everyone knows the targets and their role. This can involve empowering bedside nurses to stop physicians if a checklist step is missed, a radical cultural shift that prioritises patient safety over hierarchy.
• Foster a culture of collective responsibility where team members actively enforce protocols among peers. This approach, akin to a military "buddy check," can significantly reduce errors.
  
  

4. Monitoring, Feedback, and Recognition:

You cannot improve what you do not measure. Establishing routine monitoring of IPC practices provides accountability and identifies where reinforcement is needed.

• Implement consistent, transparent auditing of IPC practices (e.g., hand hygiene compliance, correct PPE usage). Audits should be both overt (for transparency) and covert (to get a true picture, minimising the Hawthorne effect). The data from these audits must be fed back to the staff teams in a constructive manner, for example, by posting unit-by-unit compliance dashboards or discussing results at team meetings. Regular feedback on compliance levels is a strong motivator for improvement, especially when coupled with clear targets.
• Learn from incidents and near misses, so if a breach in IPC protocol does lead to an infection, or when a near-miss occurs, how the organisation responds is crucial. A blame-free root cause analysis should be conducted to understand why the lapse happened. Industries like aviation treat near misses as "golden opportunities to learn" and avert future disasters. Promoting a no-blame culture for reporting IPC breaches or near misses allows them to be used as valuable learning opportunities to refine processes and training.
• People respond positively to recognition. Introduce reward systems to acknowledge and celebrate teams or individuals with exemplary IPC compliance. This could be simple public recognition (e.g., a shout-out in a newsletter), small prizes, or "Caught Doing It Right" nomination slips for peers. When done correctly, recognition programs send a powerful message that infection prevention excellence is valued, fostering pride and camaraderie around safety achievements.
  

Learning from successful interventions proves that closing the compliance gap is achievable.

Case 1 – Drastically Reducing Central Line Infections (The Keystone ICU Project)

Led by Dr. Peter Pronovost in Michigan ICUs, this project eliminated catheter-related bloodstream infections (CLABSIs).

It combined simplified, evidence-based guidelines (a 5-item checklist) with significant culture change.

A hospital in Spain implemented a comprehensive, multimodal hand hygiene program.

Phase 1 included WHO elements: training, reminders, hand rub availability, and audit-feedback.

Phase 2 introduced Continuous Quality Improvement (CQI) measures, increasing audit frequency ("3/3 strategy"), using statistical process control, and requiring corrective actions.

The outcome found hand hygiene compliance rates at ~82% (up from ~57% baseline), with a corresponding drop in MRSA rates.

*Key takeaway: Long-term IPC behaviour requires continued vigilance, adaptation, and a combination of education, convenient product placement, frequent monitoring, and data-driven feedback.

Case 3 – Adapting Aviation CRM to Surgical Teams

A large academic hospital trained surgical teams in Crew Resource Management (CRM) principles (communication, checklist use, flattening hierarchy).

They introduced a Surgical Safety Checklist (WHO-based) and a policy allowing any team member to call a timeout.

Through continuous encouragement and strong leadership support, compliance climbed.

Results showed a significant reduction in surgical complications and improved infection rates for clean surgeries.

*Key takeaway: Importing training frameworks from aviation (CRM, checklists) can close compliance gaps in healthcare, but requires persistent training and strong leadership endorsement, empowering all team members as guardians of safety.

Closing the persistent gap between IPC training and real-world practice is undoubtedly challenging, but as both extensive research and cross-industry experience attest, it is feasible. The reasons for non-compliance are multifaceted, ranging from understandable time pressure and resource constraints to deeply ingrained cultural attitudes and complex human psychology. Accordingly, the solutions must be comprehensive, integrated, and sustained to be effective.

Aged care institutions must make a strategic investment in ongoing, practical training that not only builds essential skills but also profoundly reinforces the "why" behind every written protocol. Even more importantly, they must actively cultivate a robust culture of safety where following IPC procedures is the unquestioned norm – a culture powered by visible leadership commitment, strong peer accountability, and systems that are meticulously designed to make safe behaviour the path of least resistance.

Infection prevention leaders in aged care can draw immense inspiration and practical lessons from the checklists and open reporting systems of aviation, the worker engagement and standardisation practices of manufacturing, and the discipline and constant readiness instilled by the military. Strategies such as frequent and transparent audits with constructive feedback, empowering all staff teams to speak up without fear, ensuring the consistent availability of adequate supplies and supportive environments, and actively recognising exemplary adherence are immediately actionable and have proven to be highly effective in various settings.

Most importantly, aged care organisations should learn to view every deviation from protocol not as an individual failure to be punished, but as invaluable information – a vital clue to where the system itself can be strengthened and improved. By consistently addressing these root causes – be it a flawed process, an unaddressed knowledge gap, or a faltering organisational commitment- continuous and meaningful improvements can be made. The goal is to reach a point where safe IPC practices are seamlessly integrated into daily tasks, not merely when someone is watching. Achieving this will lead to a significant reduction in infections, save precious lives, and build deep trust, firmly establishing high-quality IPC as a fundamental and indispensable pillar of exceptional aged care. It is now up to aged care leaders and professionals to implement these evidence-based insights, thereby protecting their vulnerable residents and dedicated workforce from preventable harm.

If you enjoyed reading this post, we want to delve deeper into some of the subjects just touched on here. There will be more information in the next few posts. 

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