Study design

An inductive qualitative design was used. The participants’ perceptions and experiences of the phenomena under examination are described under a qualitative descriptive approach [18], which produces a straightforward explanation of participants’ experiences in their own words [19]. The aim of a qualitative description is not thick description (ethnography), theory development (grounded theory), or interpretative meaning of an experience (phenomenology), but a rich, straight description of an experience or an event [18].

Participants and data collection

To meet conditions similar to the skills required for a subcutaneous injection, the participant selection criteria were as follows: (1) worked as a staff nurse with more than 10 years of experience and (2) acquired CNIC qualification. We adopted convenience sampling. The first author contacted the director of nursing at the hospitals in which the CNIC worked. The researchers asked a total of 10 nursing department directors of hospitals with over 300 hospital beds to be introduced to the CNIC by telephone and letter. The director of one hospital’s nursing department declined to cooperate because the significance of the study was not understood. Nine directors of hospital nursing departments agreed to participate, and introduced their hospital’s CNIC to the researchers one by one. One nursing manager introduced two CNIC from her hospital there are usually only one or two such nurses in a hospital. The researchers visited the 10 CNIC, explained the purpose of the study to them, and sought their voluntary participation. To ensure that the study ideas did not influence the participants, the researchers did not disclose their own views on skin disinfection before subcutaneous injection.

The 10 CNIC agreed to participate in the study. Each of them had 15–26 years of nursing experience and 3–7 years of experience as CNIC. They worked primarily in non-profit hospitals, and seven of them worked in hospitals with bed numbers ranging from 300 to 500. The remaining three nurses worked in 500- to 900-bed hospitals. One of the ten nurses was a ward head nurse, and one was a staff nurse. The other eight were not assigned to a ward, but were assigned to a department for which they worked across the hospital departments as infection control specialists. The CNIC had all worked in several wards as staff nurses for more than 10 years. Therefore, although there were participants who did not intervene frequently in their colleagues’ work, all participants were in a position to instruct nurses on infection control measures, including skin disinfection before injection.

Data were collected from August to November, 2013 using individual semi-structured interviews. Data collection and analysis were performed simultaneously. After interviewing five participants individually, analysis and categorizations were made. After each interview, an analysis confirmed the emergence of new categories. Up to the eighth participant, a new category was identified each time; hence, more interviews were conducted with additional participants. Two more participants were interviewed, but no new categories emerged. Therefore, data collection was considered complete with 10 participants.

Each interview lasted 30 to 60 minutes. The interviews were held in a private room that allowed two people to converse calmly at a site with convenient participant access. All participants requested to be interviewed at the hospital where they worked, and the first author conducted their interviews accordingly. Using a semi-structured interview guide, questions were asked in the order shown in Table 1.

Table 1

Interview guide.

Questions
1	Do you disinfect the patient’s skin before subcutaneous injection?
2	Do you think that skin disinfection before a subcutaneous injection is necessary?
3	What is the evidence and reasoning behind these beliefs?
4	How do you perceive the reasons for skin disinfection in clinical practice?
5	What do you think about omitting skin disinfection?

An interview guide was developed for this study; it was pilot tested with two nurses. After evaluating their responses, a few questions were revised. One of the modifications was adding “evidence” to the third question to elicit concrete evidence. A second modification was the inclusion of the fifth question, broadly asking about participants’ ideas regarding omission of skin disinfection before subcutaneous injection. At the beginning of the interview, participants were asked about their years of experience as a nurse, their years of experience as a CNIC, and their department. They were also asked some follow-up questions such as “What do you mean?” to clarify some answers or “Can you explain further?” to encourage them to expound on their narrative. To ensure the consistency and accuracy of the data, the interviews were recorded with the participants’ permission. The first author who conducted the interviews transcribed them verbatim, and prepared field notes during and immediately after the interviews. There were no repeat interviews.

Data analysis

An inductive content analysis was used for our data analysis[20]. The researchers read each verbatim transcript several times to obtain an overall understanding of the content and gain a sense of the whole [21]. The meaning units in the interviews related to nurses’ reasoning process were identified and coded. The codes were sorted into subcategories based on similarities and differences [22]. Depending on the relationships among subthemes, a larger number of subthemes can be organized, or combined, into a smaller number of themes [22]. After assessments across subcategories, overarching themes were derived. When discrepancies in coding occurred, the researchers of this study discussed and resolved them through consensus. The process was repeated until the content of each interview was compared with the content of all other interviews. Through the process, emerging findings could be identified and comparative commonalities could be extracted. This series of analyses methods were performed by three researchers. Two of them are nurses with experience of working in hospitals; the other is an occupational therapist with experience in medical practice. All three are experienced in qualitative research.

Study rigor

Rigor was confirmed following Lincoln and Guba’s criteria [23]. The credibility of the research findings was established using member checking and peer debriefing. Transferability was ensured via detailed descriptions of the research process. Dependability was achieved by checking the consistency of the findings. The first author, who conducted the interviews, did not have a prior relationship with the participants, which helped participants to freely provide their opinions and perceptions, which were accurately transcribed to promote authenticity.

Ethical considerations

This study followed the guidelines set out by the 1975 Helsinki Declaration (2008 version). The study was approved by the Hokkaido University Graduate School of Health Sciences Ethics Committee and the ethics committee of the study site (13–51). When briefing potential participants, the researchers explained the purpose and requirements of the study, participants’ right to withdraw at any time without consequences, and possibility of the authors publishing the results. They were informed that personal information would be managed appropriately, and that colloquial and written data would be discarded at the end of the study. The above aspects were explained verbally and in writing, and written consent was obtained. After this, the researchers began to schedule interviews.

Common practice

The decision to disinfect or not was influenced by perceptions and responses of the people who received care. One reason for skin disinfection before administering subcutaneous injections was that it is common practice. Participants worried that omitting this step would not be acceptable, and would instead induce anxiety in the patient. They also reported that they would agree to omit skin disinfection if it became a common practice with injection patients among the general public. Thus, disinfection was carried out owing to participants’ perception that it is a current common practice.

Presumed merit of omitting disinfection

Some merits of omitting skin disinfection before subcutaneous injection as part of standard care were mentioned. These included the economic benefits of reducing the cost of purchasing cotton for disinfection and disposing of waste, reduction in labor by skipping one of the steps involved in administering injections, and avoidance of unnecessary irritation to the skin caused by disinfectant solutions. Although these are small benefits, they can aid in elevating the patients’ comfort level. As described above, the participants recognized the specific benefits of omitting skin disinfection before subcutaneous injection.

Adherence to hospital norms

Hospitals have standards that staff must follow to provide patients with a certain quality of care. Participants said that, because they worked in a hospital, they followed hospital norms. Even if they personally believed that skin disinfection was unnecessary, the hospital rule was to disinfect the skin before administering every injection. Hence, they had no option to skip the step of skin disinfection. Thus, one of the reasons nurses used skin disinfection before subcutaneous injection was adherence to hospital norms.

Avoiding persistent suspicion of infection

Participants were concerned about the risk of infection when skin disinfection was omitted before subcutaneous injection. They reported that the purpose of alcohol disinfection before administering subcutaneous injections was to remove bacteria from the skin and prevent infection. Disinfection may not completely prevent infection, but it is practiced on the assumption that the risk of infection can be reduced. Participants recognized that omission of skin disinfection before subcutaneous injection was unlikely to cause infection based on literature demonstrating that skin disinfection prior to subcutaneous injection was unnecessary and knowledge of subcutaneous anatomical physiology. However, they were still concerned about infection, and it was difficult for them to actually introduce the practice of omitting disinfection before subcutaneous injections. If omitting disinfection of the skin before subcutaneous injection became the standard, it was feared that disinfection might be omitted even in situations where disinfection was necessary. To avoid persistent suspicion of infection, the nurses continued the practice of skin disinfection before subcutaneous injection.

No detrimental effect

One reason considered by the participants for continuing disinfection was that it posed no significant harm to the patient. Although problems owing to exposure to alcohol could occur, they were not considered a significant disadvantage compared with many other infection control issues in hospitals. Participants perceived that it was not necessary to actively consider omitting the practice of disinfection prior to subcutaneous injections, as it is not detrimental for patients if continued.

Ingrained custom

The nurses were taught that disinfection before subcutaneous injection was necessary from the time they were students, and there was no opportunity to reflect upon the necessity of the practice even after they had started work. Nurses routinely administer injections after skin disinfection without questioning its scientific basis. Thus, it has become a deeply ingrained practice. They felt that it would be difficult to change this convention because it had become a custom. Another reason for performing skin disinfection before subcutaneous injections was that it was perceived as an ingrained practice.

Tacit approval for not disinfecting in home care settings

Participants believed that skin disinfection may not be necessary for patients at home because it places an extra burden on patients. When patients require injections in home care settings, it is important to ensure that the required dose is injected, and skipping skin disinfection is not considered a problem. In home care settings, nurses give tacit approval to the omission of disinfection because there are priorities over adhering to the norms of skin disinfection before subcutaneous injection.

Reasoning for disinfecting before subcutaneous injection

Seven themes emerged from the data examined in this study. Fig 1 shows the reasoning of the CNIC for disinfection skin before administering subcutaneous injections. Patients expect skin to be disinfected before a subcutaneous injection because it is “common practice.” Before administration, there was “presumed merit of omitting disinfection,” such as reduced patient burden for self-injection and streamlining and efficiency for nurses. However, because disinfection does not harm the patient, nurses continued the precedent to avoid any possible risk of infection; this concept was categorized as “ingrained custom,” “no precise effect,” and “avoiding persistent suspicion of infection.” In the hospital, CNIC, as hospital staff, must “adhere to hospital norms” and, thus, do not have the choice of omitting the practice of skin disinfection. Outside the hospital, on the contrary, CNIC are not obliged to follow these norms, and the need for skin disinfection was determined based on the priorities of individual self-injecting patients. Thus, there was “tacit approval for not disinfection in home care settings.”

Fig 1

Reasoning process for disinfecting skin before subcutaneous injection.

The seven themes identified in this study are enclosed in squares. “Common practice” includes six other themes because they were based on common practice. The decision on whether to disinfect the skin before subcutaneous injection was made by going back and forth between the four themes: a positive theme of “presented merit of omitting disinfection,” and three other negative themes on the omission of said practice. In considering them, the decision was made in the presence of patients and/or injection providers. In the case of a hospital, the decision went through “adherence to hospital norms,” and then “always perform skin disinfection”; and if the patient was at home, it went through “tact approval for not disinfecting in home care settings,” and finally, “it depends on the patient’s situation.”

Limitations

The results of this study suggest that nurses have different reasoning for skin disinfection in home care settings than in hospitals. The participants in this study were experienced nurses who worked in hospitals. However, nurses who work in home care settings may have different reasoning on this issue. Further studies should consider the latter group to more deeply explore why nurses disinfect skin before administering subcutaneous injections. A quantitative survey will be required to clarify the actual status of skin disinfection before subcutaneous injections in home care settings when developing guidelines.