The burden of infections in dialysis facilities continues to rise worldwide. Due to the invasive procedures associated with haemodialysis (HD), patients undergoing HD in dialysis facilities are at high risk of acquiring bloodstream-related infections.
The present study explored the practices of dialysis practitioners regarding the prevention of HD bloodstream-related infections at selected dialysis facilities in the City of Tshwane, Gauteng province, in South Africa.
An exploratory-descriptive contextual qualitative study was conducted in five dialysis facilities utilising semi-structured interviews. Purposive sampling was conducted until data saturation was reached from 10 in-depth semi-structured interviews conducted with dialysis practitioners.
Data analysis was conducted concurrently with data collection using a qualitative thematic analysis approach, whereby Tesch’s eight-step method was used to analyse the data. One theme, infection prevention challenges of dialysis practitioners, emerged with three subthemes: (1) in-service training, (2) shortage of resources and (3) colleagues’ behaviors and practices.
A lack of staffing, training and resources hinders the implementation of infection prevention and control (IPC) to ensure optimal care in dialysis facilities. These findings suggest that enhancing training programmes and promoting a culture of compliance with IPC protocols are crucial for improving patient safety and outcomes in dialysis settings.
This study highlights contextual insights into the infection prevention challenges faced by dialysis practitioners in South African dialysis facilities, highlighting critical gaps in training, resources and staff compliance that inform targeted interventions to reduce bloodstream infections.
Haemodialysis (HD) is the predominant modality for kidney replacement therapy (KRT) globally,
The global burden of infections in dialysis facilities is escalating, marking infections as leading causes of morbidity and mortality in HD populations.
Amidst these challenges, multiple organisations have recommended approaches and programmes to mitigate risks associated with HAIs and combat antimicrobial resistance.
The high burden of HAI in sub-Saharan Africa (SSA) varies between regions.
Given the complex dynamics between patients and healthcare providers in dialysis facilities, where multidisciplinary collaboration is essential, it is vital to explore the challenges healthcare workers encounter in adhering to IPC measures. There is a paucity of studies focusing on the challenges faced by dialysis healthcare workers in complying with and adhering to IPC measures in the City of Tshwane. This study explored practices of preventing catheter-related infections amongst dialysis practitioners at five dialysis facilities in the City of Tshwane.
A qualitative, exploratory-descriptive and contextual research design
Dialysis nurses and clinical technologists were chosen for this study due to their critical roles in managing patients undergoing haemodialysis. These professionals possess first-hand experience and expertise in managing dialysis vascular catheters, which are essential components of the treatment process. Their involvement directly impacts patient safety and outcomes, particularly concerning the prevention of infections associated with these catheters. By focusing on this specific group, the study aimed to gather in-depth insights into their practices, challenges and strategies regarding infection prevention and control (IPC).
Using a purposeful sampling method, 10 HD practitioners were selected, recruited and interviewed using semi-structured interviews. This segment of the study represents the second phase of the overarching research project. Participants were selected based on their voluntary consent to engage in the study. Additionally, the researchers verified each participant’s years of experience in the dialysis field to ensure a comprehensive representation. By purposefully including both highly experienced and relatively less experienced HD practitioners, a nuanced array of insights and perspectives was obtained from the participants.
Participants were recruited after their involvement in the quantitative phase of the study, which included a survey of HD practitioners across five HD units in the City of Tshwane. Individuals who expressed interest in participating further were invited based on their willingness and professional experience. The aim was to include a diverse sample of HD practitioners, from those new to the field to those with extensive experience. The recruitment process emphasised voluntary participation, providing candidates with clear information about the study’s objectives and procedures. Ten HD practitioners were selected to provide rich qualitative data on IPC practices related to dialysis vascular catheters.
This helped facilitate the collection of rich qualitative data regarding the practitioners’ experiences, challenges and perspectives on HD practices.
The researchers itemised audiotapes and read transcripts to gain a deeper understanding of the recorded interviews and further familiarise themselves with the collected data. All data were transcribed verbatim. Data analysis involved multiple steps, including reading notes, identifying emergent themes and clustering insights into subthemes. Two researchers independently coded the transcripts using descriptive thematic analysis following Tesch’s methodology.
Approval was obtained from the Tshwane University of Technology’s Research Ethics Committee (REC Ref#: 2020/02/004), with gatekeeper permissions secured from all participating HD facilities. Participants were fully informed about the study’s purpose and procedures before the commencement of data collection. Informed consent was obtained, ensuring confidentiality and anonymity using pseudonyms. The study specifically targeted HD practitioners who actively connect and disconnect patients from HD machines and other dialysis-related activities. Data collection occurred across five HD facilities to capture a wide range of experiences.
Data were collected from participants working across all five selected HD units. Participants had voluntarily agreed to participate in the semi-structured interviews from the online survey by providing their email addresses. Semi-structured interviews were conducted between June 2021 and September 2021, spanning 4 months.
Demographics of participants.
| Pseudo name | Years working in nephrology | Highest qualification | Professional status |
|---|---|---|---|
| P1 | 19 | Postgraduate Diploma in Nephrology Nursing | Nurse |
| P2 | 13 | Postgraduate Diploma in Nephrology Nursing | Nurse |
| P3 | 5 | Postgraduate Diploma in Nephrology Nursing | Nurse |
| P4 | 4 | Diploma in Nursing | Nurse |
| P5 | 9 | Postgraduate Diploma in Nursing | Nurse |
| P6 | 23 | BTech Clinical Technology | Clinical technologist |
| P7 | 5 | Diploma in Clinical Technology | Clinical technologist |
| P8 | 35 | Postgraduate Diploma in Nephrology Nursing | Nurse |
| P9 | 21 | Postgraduate Diploma in Nephrology Nursing | Nurse |
| P10 | 8 | BTech in Clinical Technology | Clinical technologist |
P, participant.
The participants were predominantly nurses, with qualifications primarily in Nephrology Nursing, including several with postgraduate diplomas. The ages of the participants ranged from 28 years to 57 years, indicating a diverse range of perspectives and maturity in the field. Notably, the years of experience in nephrology varied significantly from 4 years to a substantial 35 years, suggesting a range of practical knowledge and expertise amongst the group. In terms of qualifications, the majority had pursued advanced education in nursing, reflecting a commitment to specialised training in nephrology. Additionally, clinical technologists were represented in this cohort, with backgrounds in clinical technology, enhancing the interdisciplinary nature of nephrology care across HD units. This composition of professionals underscores the importance of both nursing and clinical technology in managing kidney-related health issues and highlights the varied yet complementary roles these experts play within the healthcare system. Such diversity in age, experience and educational background was deemed to contribute to a well-rounded approach to patient care in nephrology.
This section explores a central theme of the study: the challenges faced by HD practitioners. Accompanying this theme are three significant subthemes that provide deeper insight, namely a lack of in-service training, the nuances of staff behaviour and practices in various situations and the implications of staffing shortages. These elements provide a comprehensive picture of the respondents’ challenges in HD unit environments.
Theme, subthemes and categories.
| Theme | Subtheme | Categories |
|---|---|---|
| 1. Infection prevention challenges for dialysis practitioners | In-service training |
Lack of in-service training Infrequent training opportunities |
Shortage of resources |
Shortage of personnel Shortage of supplies for IPC |
|
Colleagues’ behaviours and practices |
Impact on infection control practices Effects of situational factors |
IPC, infection prevention and control.
Participants were asked about the in-service training they received regarding the prevention of dialysis catheter-related infections, infection prevention in HD facilities and strategies that could be effectively implemented to mitigate infection risks. Many cited a significant lack of training and resources as critical factors contributing to deficiencies in practice. Whilst participants acknowledged having undergone some training related to IPC at various points in their roles, there was unanimous agreement on the pressing need for more comprehensive and frequent training sessions in HD facilities. Insights from the participants reflected their experiences as quoted below:
A participant expressed a concern:
‘We do not have in-service training anymore, when we did, it was at least once a month, but I can’t even recall the last time I received such training.’ (P6)
This sentiment was echoed by a participant who reminisced about their initial onboarding, saying:
‘I only got training when I came for orientation; after that, there has been nothing.’ (P8)
In contrast, a participant, who has been working in acute dialysis for just 2 months, lamented:
‘I have not yet received any training related to infection prevention this year. Last year, at the chronic facility, we also received no training in this vital area.’ (P1)
Participants collectively underscored the importance of in-service training as essential for promoting IPC, advocating that it could significantly improve adherence to protocols in dialysis facilities.
A participant said:
‘The training at my workplace is scheduled, but this year I didn’t attend. I don’t remember the last time I last had one [
The perceived inadequacy of training was also a critical factor influencing staff practices.
Furthermore, participants reported varied experiences regarding the frequency of training, revealing inconsistent schedules and attendance of training related to IPC in their work environment. A glaring disparity emerged amongst HD practitioners regarding the intervals of such training. The comments provided below revealed this gap.
Some participants said:
‘I only got the training when I came for orientation, then after that, no.’ (P8)
‘The last training I attended, I think, was six months ago; no, it’s been eight months now.’ (P4)
‘People forget … maybe they do not realise the significance of infection control. They often focus solely on connecting and disconnecting patients without following the necessary steps.’ (P9)
‘Training is not conducted frequently at work because we are considered competent. I would say ongoing training occurs every three [
These insights underscore the critical need for systematic and regular training in IPC to ensure that all practitioners in HD facilities are knowledgeable and consistently follow best practices.
Participants noted that a shortage of human resources and supplies is increasingly compromising their ability to adhere to infection prevention precautions for dialysis vascular catheters, ultimately affecting the quality of patient care. As highlighted by participants, these shortages create an environment where healthcare workers often find themselves overworked and unable to effectively perform their duties.
A participant reflected on the frustrations expressed by many when they noted that such conditions can prevent compliance with IPC measures:
‘Sometimes you find that we are working, and we are short-staffed, so on those days we are doing the wrong way, most of the time.’ (P10)
Another participant added that:
‘I think it is because of the shortage of staff, like when we are short-staffed, let me say we have 12 patients, then you’re three staff members.’ (P4)
Moreover, P3 emphasised that inadequate staffing and limited resources not only hinder the proper execution of infection prevention procedures, but also contribute to a cycle of stress and inefficiency amongst personnel. This persistent issue, echoed by various participants, calls for urgent attention and action to ensure that healthcare professionals are adequately supported in their roles.
One participant highlighted that:
‘We are mostly short-staffed because you don’t get enough chance or enough time to do the whole procedure properly, sometimes there are not enough supplies, so you think people are not doing the right thing, but sometimes it’s because of shortage of staff or shortage of supplies.’ (P3)
Participants expressed that they envision a situation where they combat non-compliance, which may be better if given enough staff and supplies.
A participant alluded that:
‘They must just provide us with enough staff ’cause sometimes we become overworked, and you know when you become overworked you struggle to do your job to the fullest ability, so staffing is a challenge as well as supplies.’ (P3)
Regarding the shortage of supplies a participant said:
‘Sometimes you find people running around with aprons from this patient to another patient in the ward and, people will tell you that there is shortage, but at some point, now with this COVID thing, we are really short of PPEs, am sure it is shortage, shortage of staff has been a problem for years and years.’ (P1)
This subtheme reveals significant insights into the behaviours and practices of HD practitioners regarding the prevention of HD catheter-related infections. Multiple key practices and staff behaviours that emerged from the participants’ responses include inadequate hand hygiene, a tendency to take shortcuts and the impact of situational factors on compliance with infection control protocols.
Several participants expressed concerns about their colleagues’ practices, specifically regarding hand hygiene.
For instance, a participant said:
‘Sometimes it becomes a bit difficult because we are mostly short-staffed ’cause you don’t get enough chance or enough time to do the whole procedure properly. Sometimes in between patients we don’t wash our hands.’ (P3)
In addition, a participant stated that the challenge of non-compliance is common with all members of the multidisciplinary team and cited that:
‘There are times when nurses do not follow the steps as set out in the policy. Then in that regard then there are gaps that needs to be filled in that regard. And the doctors, only few would spray or wash their hands in between patients during their rounds.’ (P2)
A participant recalled and remarked on her experience of a lack of thorough hand-washing amongst staff, indicating a potential risk for infection transmission.
Another participant further said that:
‘I have worked with someone who doesn’t wash hands accordingly, so because we’ve got this screening thing, connecting a catheter needs an aseptic technique, you need to wash your hands, very thoroughly, so they just pulled the screen on, go wash hands like your social hand washing or something go behind the screen, they’ll be touching all over.’ (P1)
Similarly, a participant expressed doubts about their colleagues’ commitment to implementing appropriate IPC measures, highlighting a collective sense of discomfort about the standards maintained within the team:
‘I think people tend to get comfortable, and then they do not follow procedure all the time. That is why it is good to always have in-service training to remind one another about the importance of following the correct procedure to avoid those kind of things where people tend to fall into the trap of being too relaxed.’ (P2)
The participants’ narratives indicated that situational factors significantly impact adherence to guidelines. Whilst busy periods detract from strict compliance, calmer times allow staff to follow procedures diligently. A recurring sentiment amongst the participants was the inclination to take shortcuts due to workload, particularly in high-pressure situations.
A participant openly shared an experience of prioritising speed over compliance due to a busy environment, confessing that:
‘I don’t wanna lie, we tend to take the shortcut because we busy, we want to cover many patients as we want, so some they will not even put the sterile gloves, but it depends with the situation, when it is a calm situation and we not busy, we go through the procedure because we try to avoid infection … [
This statement underscores how work pressures related to extreme workloads can compromise infection control practices.
Participants also remarked on how the fast-paced dialysis environment can sometimes lead them to bypass the infection prevention measures due to wanting to meet the demands. In this regard,
A participant highlighted that:
‘We have a tendency again of not wearing a mask when attending to the patient, or wearing goggles when attending to the patient, and sometimes when we feel like it’s a minor challenge, it is also easy for us to attend to it without gloves. Like swapping your lines maybe from your arterial to the venous or from the venous to arterial. We sometimes do that without wearing gloves. That is also very common in dialysis.’ (P6)
This study explored IPC practices and challenges amongst dialysis practitioners at five dialysis facilities in the City of Tshwane. Staff behaviours and practices regarding the prevention of HD catheter-related infections illustrate a complex interplay between individual diligence, situational pressures and training inadequacies. It is crucial to prevent harm to patients, healthcare professionals and visitors due to infections in healthcare settings to achieve quality care, patient safety and healthcare security, and to decrease HAIs and antimicrobial resistance.
Shortages of staff and a lack of supplies emerged as contributing factors to non-compliance with optimal IPC practices in the HD facilities. These findings of barriers concur with other findings in developing countries, where suboptimal provision of supplies in dialysis settings has been reported.
Despite the importance of staffing in HD settings, staffing and its importance in optimal patient care has been noticeably overlooked. In the current study, HD practitioners reported that dialysis facilities are short-staffed, which affected their adherence to IPC measures, as in a study from Northern Nigeria.
It is unclear whether there was a lack of IPC training in HD facilities in the current study or whether practitioners did not attend training when it was organised. A descriptive cross-sectional study conducted in HD centres in Sudan revealed low levels of training attendance in training courses about IPC in HD.
In this study, multiple key practices and staff behaviours emerged from participants’ responses, including inadequate hand hygiene, tendencies to take shortcuts and the impact of situational factors on compliance with IPC protocols. This is supported by a Vietnam study,
Haemodialysis practitioners face multiple challenges that hinder effective, optimal IPC practices and compliance. Corresponding with the current study’s findings are studies from Vietnam and South Africa, which highlight significant challenges that HD practitioners face in adhering to hygiene protocols.
This study’s findings cannot be generalised because they are contextual. Only five HD facilities were involved; therefore, the reality of other HD facilities might differ. The study was also conducted at the peak of the coronavirus disease 2019 (COVID-19) pandemic. Another notable limitation of this study is the absence of detailed operational data regarding the participating HD units. Information on key facility characteristics, including public versus private-sector distribution, hospital-attached versus standalone configurations, unit occupancy rates, nurse-to-patient staffing ratios and vascular access profiles (proportion of patients dialysing via arteriovenous fistulae versus central venous catheters), was not systematically collected. These contextual factors may significantly influence infection rates and HD staff practices, potentially limiting the generalisability and transferability of our findings to other HD settings. Whilst the South African Nephrology Society (formerly the South African Renal Society) recommends a staff ratio of one nurse or clinical technologist per four patients for dialysis facilities, in the current study, staff ratios were not measured.
Whilst the current study focused on nurses and dialysis technologists as frontline personnel with direct catheter care responsibilities, the exclusion of nephrologists represents a notable limitation. Though nephrologists have less frequent patient contact, they critically influence infection risk through key decisions on vascular access, antimicrobial prescribing and catheter management once infection occurs. These clinical decisions directly shape the situational pressures and contextual factors examined in this study. Future research would benefit from incorporating nephrologists’ perspectives to capture the complete decision-making pathway influencing dialysis catheter-related bloodstream infection rates in HD settings.
To enhance IPC compliance in dialysis facilities, several key recommendations can be implemented. First and foremost, comprehensive in-service training programmes focused on IPC protocols should be established for all dialysis practitioners. This will ensure that ongoing education and awareness of best practices are prioritised, allowing staff to stay informed about the latest guidelines. Furthermore, addressing staffing shortages is critical. Facilities can hire additional personnel or optimise task delegation to reduce the workload on existing staff, which will enable them to concentrate more effectively on IPC measures. Alongside staffing changes, it is essential to provide practitioners with adequate resources, including sanitation supplies and equipment. This support will facilitate compliance with IPC guidelines. Establishing a culture of safety within dialysis units is equally crucial. In such an environment, adherence to protocols should be prioritised and recognised, reinforcing the importance of IPC compliance amongst all staff members. Finally, conducting further research is necessary to identify specific barriers to effective IPC practices. This research will help develop tailored interventions that meet the unique needs of practitioners, particularly in regions such as the City of Tshwane.
In conclusion, this is the first study to explore the challenges dialysis practitioners face in IPC in the City of Tshwane. Significant gaps, such as a lack of staffing, training and resources in the HD units, hinder the implementation of IPC measures to ensure optimal care in dialysis facilities. These challenges reveal a pressing need for better staffing, formal and informal training and resources to promote positive adherence and compliance and prevent dialysis-related vascular catheter infections. These implementations will improve patient safety and outcomes in dialysis settings. Addressing these deficiencies requires targeted interventions and heightened awareness amongst healthcare providers. Additionally, further investigation into the impact of staffing on infection rates is essential to inform clinical practice guidelines and policies regarding optimal dialysis staffing.
We would like to acknowledge the support of the Adelaide Tambo School of Nursing Science, Faculty of Science and the Tshwane University of Technology. Without prejudice, we thank and acknowledge the HD facility authorities and participants for participating in the study.
This article is based on research originally conducted as part of Siyanda A. Ngema’s master’s thesis titled ‘Knowledge and Practice of Haemodialysis Practitioners on Intravenous Infection Prevention and Control at 5 selected HD Units in the City of Tshwane’, submitted to the Faculty of Science, Adelaide Tambo School of Nursing Science, Tshwane University of Technology in 2022. The thesis is currently unpublished and not publicly available. The thesis was supervised by Thabiso A. Bale and Tendani S. Ramukumba. The thesis was reworked, revised and adapted into a journal article for publication. The author confirms that the content has not been previously published or disseminated and complies with ethical standards for original publication.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Siyanda A. Ngema: Conceptualisation and Writing – original draft. Thabiso A. Bale: Conceptualisation and Supervision. Tendani S. Ramukumba: Conceptualisation and Supervision. Livhuani Nezingahe: Formal analysis, Validation and Data curation. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication and take responsibility for the integrity of its findings.
The data that support the findings of this study are not openly available due to restrictions on ethical approval and are available from the corresponding author, Siyanda A. Ngema, upon reasonable request.
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings, and content.