Jessica Swain, MBA, MLT, director of infection prevention and control at Dartmouth Health in Lebanon, New Hampshire

Jessica Swain, MBA, MLT, CIC, IHI

Have you ever felt like you're doing the work of 3 people, but the numbers say you're only 1? In the years following COVID-19, the role of the infection preventionist (IP) has become increasingly complex, with programs consistently asked to do more with less. 

For 2 infection prevention system directors, we lamented how the demands on our time kept growing, making it challenging to make a convincing business case for more staff. What started as a chat among 2 friends became a magazine article and a major article in the 

AJIC). To better understand how other IPs experience their workload, we went directly to our peers with a survey. Our goal was to gather a national snapshot of how organizations are supporting their infection prevention programs to inform practical staffing decisions.

When we set out on this journey, our goal was to get a real-world snapshot of the IP landscape. We chose a survey-based approach, which gave us the flexibility to reach IPs across the country, but it also came with some inherent limitations. For starters, a major strength of any study is its sample size. While we were thrilled to receive 128 initial survey responses, the final group we analyzed was 91 acute care facilities. While this was enough to give us a clear picture of some national trends, a larger sample would have made our findings even more robust. We relied on professional social media platforms like LinkedIn and email networks for recruitment, which might have led to self-selection bias, meaning the people who responded were likely those who felt most passionate about staffing.

Finally, while our survey provided incredible insight, it primarily showed correlations, not causation. We found, for example, that IPs in the West worked the most hours and that certain facilities shared staff more than others. We can offer interpretations of why these things are happening, but the survey itself doesn't definitively prove a direct cause-and-effect relationship. It’s a starting point for the next phase of our research.

Our research revealed surprising insights into IP staffing, challenging long-held assumptions. We found a strong statistical connection between the number of IP full-time equivalents (FTEs) and a facility's licensed inpatient beds (

 < .001) as well as its geographical region (p<.001). This presents a more complex picture than a simple one-size-fits-all model. The most significant finding was the reality of the IP workload. A substantial majority of IPs (59%) reported working more than 40 hours per week, with the average workweek extending to 43.6 hours. This holds true regardless of facility size, hospital complexity, or geographic location, highlighting a profession that persistently works excessive hours. The drivers of workload appear to be less about hospital complexity and more about the essential functions of the IP role, such as surveillance and regulatory reporting, which are universal and demand significant time.

The survey also shed light on the heavy burden carried by IP leaders, who reported working even longer hours than their teams, averaging 51.7 hours per week. Additionally, 78% of leaders reported taking calls outside of regular business hours, underscoring the 24/7 nature of their roles. These findings have profound implications, creating significant patient safety vulnerabilities for undersourced IP programs. When IPs are overworked, their ability to conduct critical prevention activities is compromised, which can lead to higher rates of health care-associated infections (HAIs). The persistent excessive hours also contribute to burnout and attrition, which in turn compromise patient safety. Beyond the clinical impact, underresourced IP programs expose facilities to significant financial and reputational risks.

After conducting this study and reflecting on our findings for nearly 2 years, the data paint a disheartening picture. It is disappointing that IPs, who are predominantly salaried staff, are consistently working more than 40 hours a week, with some working as many as 50 or more hours. This highlights the passion and dedication of our field but also reveals a concerning reality about the impact on our personal and professional well-being. Years after the pandemic ended, infection prevention programs are still struggling to meet the demands placed on them without the staffing support they need.

IPs have reached out to us, letting us know they have used findings from our manuscript to support their staffing proposals to advocate for additional staff to help balance the workload. While there has been considerable research on providing reasonable staffing ratios, we still have work to do. Our findings make it clear that the current demand on IPs requires a dynamic, adaptable staffing model, not a one-size-fits-all approach. Looking ahead, we believe further research can build on our work toward a dynamic staffing model through 3 key areas:

 Our study highlights the importance of insourcing and outsourcing as a solution to workload demands. Data shows that facilities with more integrated services have the highest staff sharing, enabling IPs to balance their core responsibilities with cross-functional tasks. We've seen this provide a tangible blueprint for other facilities, with specific roles like quality and medical directors insourced and data analysts and epidemiologists outsourced. This provides IP leaders with a way to strategically advocate for additional resources without directly requesting new FTEs.

 We are in an era of AI, and we believe there is an untapped opportunity to leverage this technology in an innovative, forward-thinking way. The integration of AI moves beyond traditional, static tools and enables customizable staffing models based on "real-time workload fluctuations." These inputs may include seasonal variations (e.g., during the respiratory season), changes in infection rates, new hospital initiatives, or regulatory requirements. An AI-driven tool could help bridge the gap between workforce demands and resource availability.

: We hope to see additional research to define the current scope of work for infection prevention programs. By strategically allocating IP skills and expertise, organizations can enhance their programs while reducing burnout.

A Clear Call for Action: Prioritizing IP Mental Health and Retention

The findings from our study paint a clear and frankly, concerning picture of the modern IP workforce. The persistent excessive hours, leadership burdens, and systemic under-resourcing are not merely operational challenges; they are a direct threat to the mental health and sustainability of this profession. The chronic stress, the expectation of being on-call 24/7, and the constant pressure to do more with less are driving IP burnout and attrition, creating a cycle of high turnover that critically weakens our ability to protect patients.

Our work has highlighted the ongoing personal and professional human cost of working as an IP. We must advocate for dynamic, data-driven solutions that prioritize the well-being of the IP and go beyond the need for additional staff. By implementing models that provide real-time staffing adjustments and by leveraging innovative tools like AI to manage workload, we can begin to bridge the gap between demand and resources. We can strategically message to our leadership the cost of IPs taking on more and have informed crucial conversations on how to align IP resources with IP workload expectations.

This is a clear call to action for health care leadership. We must understand the human cost of consistently expecting more from infection prevention programs without adequately staffing them. As our study demonstrated, IPs consistently work excessive hours in an ongoing attempt to meet the growing demands. While this speaks volumes about their passion and dedication, IPs have a breaking point. 

Providing a healthy work-life balance isn't just a matter of doing the right thing; it is a critical strategy for patient safety, financial stability, and, most importantly, for retaining the dedicated professionals who serve as the last line of defense against infection. The time to stop asking our IPs to do the work of 3 people is long past due; the future of a safe and resilient health care system depends not just on what we build, but on how we support the people who protect it.

Articles

This 6-part series will chronicle the journey of 2 infection prevention 
leaders, Brenna Doran, PhD, MA, ACC, CIC; and Jessica Swain, MBA, MLT, CIC, IHI, as they partnered to research and shed light on
the critical issue of infection prevention staffing in the current health care landscape. From the initial spark of an idea to the publication of an impactful article, a research manuscript, and a podcast, this series will offer an insider’s view of their collaborative process and the profound implications of their findings. This third article in the series will focus on...


From Concept to Impact: The Findings Unveiled—A Snapshot of IP Realities

This 6-part series will chronicle the journey of 2 infection prevention and control (IPC) leaders, Brenna Doran, PhD, MA; and Jessica Swain, MBA, MLT, as they partnered to research and shed light on the critical issue of IP staffing in the current health care landscape. From the initial spark of an idea to the publication of an impactful article, a research manuscript, and a podcast, this series will offer an insider's view of their collaborative process and the profound implications of their findings.

This second article in the series will focus on the art of the survey.

The field of infection prevention has become increasingly complex, with evolving demands and persistent challenges that were magnified by the COVID-19 pandemic. Facing similar obstacles on opposite sides of the country, we recognized that this was not a regional issue, but a national one. We felt that existing staffing recommendations were inadequate and did not reflect the full scope of our work. This fueled a shared frustration that became the catalyst for our study, which started as a magazine article for Prevention Strategist and later grew into a major article in 

American Journal of Infection Control (AJIC)

, a publication we believe has helped bring greater visibility to the infection prevention workload.

To address this critical gap in the literature and move beyond frustration, we decided to survey our peers.This would allow us to collect insights from front-line infection prevention leaders to help inform how the field of infection prevention could leverage the current work environment of infection preventionists (IPs) and infection prevention departments to inform practical staffing decisions. Designing this survey required balancing curiosity with what was feasible.

In this month’s second installment of “From Concept to Impact,” titled "Designing the Research Inquiry: The Art of the Survey," we will share our journey. We will discuss how we strategically narrowed our initial 2 pages of questions and found a balance in a survey tool that could collect impactful insights without overwhelming our fellow IPs and tanking our response rate. Finally, we will share how we distributed our survey widely to capture the experiences of as many IPs as possible. This article details the collaborative process, strategic decisions, and challenges we faced in designing a survey that would ultimately contribute to a broader conversation about how infection prevention staffing is defined and resourced nationwide.

Brainstorming the Survey: Narrowing Down Questions and Direction

Our first step was to tackle the central question: What do we want to know? As researchers, we began with a long list of potential topics, requiring a balance between our curiosity and what we could reasonably accomplish. Each new idea led to another, forcing us to constantly weigh which questions would provide the most meaningful insights without overwhelming our respondents. We began by reviewing prior studies to understand what had already been explored and identify the gaps. We found that much of the existing research didn't fully account for the increased complexity of modern health care organizations. This allowed us to narrow our focus to critical but underresearched factors, such as the number of licensed hospital beds, hospital complexity, regional differences, and various staffing models. We then explored a range of free online survey tools and determined that an online survey would be the most feasible and far-reaching option for our target audience. We chose Qualtrics due to our prior experience and comfort with the platform. When crafting our questions, we included a mix of categorical and open-ended questions to gather both hard numbers and nuanced, qualitative insights.

Below is a list of common free online survey tools and some pros and cons of each as you consider what survey tool you may want to use for your research topic. 

The survey was structured into 4 distinct sections to gather comprehensive data. The Organizational Demographics section contained a mix of open-ended and categorical questions about the organization's structure, including the number of licensed hospitals, inpatient beds, facility types, and the number of ambulatory centers covered by the IP program. 

The Department-Related Staffing section focused on personnel, asking open-ended questions about the number of full-time equivalent (FTE) employees in the IP department, their average weekly hours, and the number of FTEs with dual roles. This section also explored the roles of any external support staff. The Program-Related Inquiry section included a simple "yes/no" question. 

To analyze this mix of data, we used a variety of methods. We employed the Chi-square test to compare frequencies and examine relationships between categorical variables, such as inpatient beds and facility types. For comparing our 5 main geographic regions, we used the Kruskal-Wallis test because the data distributions were nonparametric. For our qualitative, open-ended responses, we performed a descriptive and inductive content analysis to identify and track recurring themes. Data analysis can feel overwhelming at first, but with the right resources and guidance, it becomes far more approachable. This dual approach allowed us to collect both hard numbers and valuable contextual information, resulting in a truly comprehensive survey.

When designing a survey, think carefully about the types of questions you choose. Aim for those that will yield the most useful data, while balancing the time it will take for respondents to complete the survey.

To help you refine your choices, we recommend drafting a few variations to identify the style that is simplest for participants to answer. Remember that questions requiring a simple click take less time and energy than writing a full response. Your survey tool may provide an estimated completion time. If not, consider timing yourself to get an accurate sense of time commitment.

Finally, once you feel confident with your question types and wording, consider asking a few colleagues to review or take a sample survey. You may be surprised how terminology that is standard to you may not be common in other areas. Ensuring your survey uses terms and language that are generalizable to your chosen participant pool is a critical final step

 Survey questions and pros and cons of each.

Anticipating Survey Impact and Overcoming Hurdles

What began as a hope for academic insights evolved into a vision for driving practical and policy changes, and this broader vision was the primary driver of our survey design. We specifically designed questions that would provide the most insight into the current realities of IP programs and their alignment with the increased complexity of modern health care organizations. For instance, we focused on gathering data about organizational demographics and detailed staffing metrics. This deliberate effort to collect actionable data could be used to strengthen national tools, such as the APIC Staffing calculator,

 to better reflect the current challenges faced by IPs today.

Equally important were the decisions about what not to include. While questions related to budget allocations or clinical outcomes were tempting, we recognized that adding them would complicate the survey and likely reduce participation. By focusing on a smaller set of high-yield variables, we struck a balance between research depth and feasibility.

Rolling out our survey presented a series of challenges we had to overcome to ensure the integrity and representation of our data. While our initial distribution via professional networks was encouraging, we quickly realized we lacked a nationwide reach, as illustrated by gaps in the Midwest and Southern regions. To overcome this hurdle, we launched a targeted outreach strategy that involved sending our survey directly to Association for Professionals in Infection Control and Epidemiology (APIC) chapter presidents in those states, which helped us achieve responses from nearly every state. 

Once the responses were collected, we faced the critical task of managing and preparing the data for analysis. Of the 128 total responses, we carefully reviewed each submission, excluding 15 due to duplication, missing data, or misclassification. This left us with 98 responses from acute care facilities that met the study's inclusion criteria. A final challenge involved managing the small dataset from critical access hospitals. Due to their limited representation, we made the decision to exclude this data from the analysis to avoid introducing skewed results. By proactively addressing these challenges, we were able to successfully gather reliable and representative data for our research.

Our analysis uncovered several key findings about IP staffing. First, we discovered a significant relationship between the number of IP FTEs and both the number of licensed inpatient beds and the facility’s geographic region. Second, our research also revealed that IPs are consistently overworked, with participants reporting an average of 43.6 hours per week, which is well above a standard 40-hour workweek. This highlights that IP departments across various health care settings are generally understaffed. Finally, we found that the practice of cross-sharing IP FTEs becomes more common as the complexity of health care services increases, with these professionals most frequently supporting the Quality department.

Based on our findings, we concluded that IPs are regularly working more than a standard week, and their staffing levels are directly impacted by the number of inpatient beds, hospital complexity, and geographic location. Looking ahead, we believe that artificial intelligence (AI)-driven tools could offer a transformative solution by dynamically adjusting staffing models in real-time to meet fluctuating workloads.

In this installment, we shared our journey of designing and executing a national survey to inform a broader conversation about IP staffing. Through a collaborative process, we strategically narrowed our focus to collect high-yield data, leveraged an online survey tool for broad distribution, and selected question types that balanced our need for both quantitative data and qualitative insights. In doing so, we successfully navigated the challenges of survey design and rollout, including overcoming geographic limitations in our responses and making difficult decisions about data inclusion to ensure the integrity of our findings. The many conversations, shared insights, and strategic decisions made throughout this collaborative phase were crucial to transforming our initial academic curiosity into a data-driven resource that will inform policy and practical changes across the country.

R. Bartles, A. Dickson, O. Babade. A systematic approach to quantifying infection prevention staffing and coverage needs 

https://apic.org/apic-staffing-calculator/

To read more about our publications and work on this topic:

"Post-COVID Learnings from an Infection Prevention Staffing Survey"

This article offers key insights from a survey on infection prevention staffing in the post-COVID era.

Prevention Strategist (APIQ) - Spring 2024 - Post-COVID Learnings From an Infection Prevention Staffing Survey

"Quantifying the Progressing Landscape of Infection Preventionists: A Survey-Based Analysis of Workload and Resource Needs"

 Brenna Doran, Jessica Swain, and Shanina Knighton 

Dive deeper into the research that quantifies the workload and resource needs of infection preventionists today.

https://www.sciencedirect.com/science/article/pii/S019665532500104X

"Burnout, Beds, and Budgets: The Hidden Reality of IP Staffing" (Podcast Episode No. 46)

 Hosted by Nikki Shore and Jessica Swain 

American Journal of Infection Control: Science Into Practice

Listen to this podcast for a candid discussion on the challenges and realities of infection prevention staffing, including burnout and budget constraints.

https://ajicscienceintopractice.org/episode/46-burnout-beds-and-budgets-the-hidden-reality-of-ip-staffing/

Designing a survey is both art and science. In this installment of From Concept to Impact, we share how we shaped questions to capture meaningful insights without overwhelming respondents.

From Concept to Impact: Designing the Research Inquiry – The Art of the Survey

Brenna and Jessica meeting to discuss this research idea 

Part 1: The Spark: Unmasking the Hidden Workload

The field of infection prevention has always been dynamic, but the past few years have brought unprecedented challenges to the forefront, particularly regarding staffing and workload. In this inaugural piece of our 6-part series for 

, we, Brenna Doran and Jessica Swain, will take you behind the scenes of our journey to quantify the evolving landscape of infection preventionists (IPs). This is the story of how a shared frustration ignited a collaborative research effort, leading to an impactful article, a comprehensive research manuscript, and even a podcast, all aimed at shedding light on the critical issue of IP staffing in modern health care.

Inception of the Idea: When Frustration Fuels Research

Our personal inspiration for delving into the demanding world of IP workloads stemmed from a place of shared experience and mounting frustration. As infection prevention system directors, we frequently found ourselves lamenting the myriad challenges posed by our current staffing levels. The conversations often revolved around how our dedicated teams managed to accomplish their extensive work, a feat that often felt herculean. It became clear to both of us that existing staffing recommendations were grossly inadequate and failed to account for the breadth and depth of what was being asked of us daily.

The struggle is real: How do you justify the need for additional full-time equivalents (FTEs) when the work prioritized for you already consumes more hours than there are in a standard workweek? We felt the weight of this disconnect daily, as we championed the efforts of our teams while simultaneously grappling with the systemic under-resourcing of our infection prevention programs.

The COVID-19 pandemic, while highlighting the critical role of IPs, also exacerbated these issues, pushing many IPs to work well beyond normal hours, including evenings, weekends, and holidays, simply to keep patients and staff safe. This emergent work piled onto an already extensive list of standard duties, from regulatory preparedness and construction risk assessments to surveillance of health care-associated infections (HAIs) and continuous committee work. This personal experience of trying to keep up with the demands while feeling perpetually understaffed was the initial spark.

The "Aha!" Moment: From Regional Lament to National Crisis

What began as a lament between 2 colleagues soon culminated in a profound "aha!" moment. Through our ongoing conversations, we recognized that the critical issue of inadequate IP staffing transcended our individual regions and states; it was, in fact, a national challenge. The increasing demands placed on IPs, while presenting both similar and distinct facets across different organizations, universally led to unmanageable workloads.

The existing body of literature, we observed, simply wasn't adequately addressing the increased expertise IPs were expected to provide, nor the expanded scope of work they were responsible for. We realized that if 2 IPC leaders, deeply embedded in the field, were experiencing such acute staffing pressures and feeling unheard, then countless other IPs across the country were likely facing similar, if not identical, struggles. This revelation transformed our shared frustrations into a collective understanding: our common experience needed national input from other IPs and empirical data to truly illustrate IPs current state.

The pandemic had unmistakably brought to light the impact of insufficient IP staffing, particularly in long-term care facilities, which suffered disproportionately from COVID-19-related mortality and morbidity due in part to inadequately staffed infection prevention programs. However, even as the need for IPs soared, hospitals faced severe financial strains, with many operating with negative financial margins and experiencing higher labor expenses and lower patient volumes.

 This created a tricky dynamic: Hospitals were required by regulation to have IP programs, but these programs were not revenue-generating, making it difficult to justify additional staffing despite their proven ability to reduce healthcare-associated infections and generate cost savings. This growing disconnect between the essential nature of IP work and the financial realities of health care organizations cemented our belief that this was a critical issue demanding investigation.

Diverse Perspectives, Shared Purpose: Shaping the Study's Direction

Our collaboration brought together different perspectives and roles, which ultimately enriched the direction and scope of our study. We engaged in passionate discussions about the practical realities of how our respective teams approached their work and what the organizational expectations were for their involvement. This wasn't just about the "what," but also the "how" – how the work was done in our organizations, and equally important, how that work was supported, and by whom.

We expanded our discussions to include how the field of infection prevention has evolved over time, sharing insights into how we approached the work in prior organizations. We also actively connected with a range of colleagues and peers working in various IP roles to gather additional, diverse insights. This broad outreach allowed us to paint a more comprehensive picture of the challenges and nuances faced by IPs across different settings and career stages. We took all the valuable information we had gleaned from these conversations and meticulously considered what a national-level study might look like. Our goal was to design research that was both inclusive of diverse IP experiences and representative of what the average IP was truly experiencing within their organization, ensuring the study reflected the real-world demands and complexities of the role.

Key Questions from the Outset: Guiding Our Initial Inquiry

From the very beginning, our primary goal was clear: to understand how infection prevention departments are staffed to meet the complex needs and expectations of their organizations. We specifically wanted to investigate how all organizations, regardless of size or complexity, address the fundamental core infection prevention work. This includes critical duties like surveillance of HAIs, outbreak management, policy development, education, and regulatory compliance.

Beyond this core, we were deeply curious about how infection prevention programs adapt their approaches as their organizations grow in size and complexity. For instance, in a smaller, less complex organization, a solo IP might function as a generalist, handling a broad spectrum of responsibilities. But how do larger, more intricate academic facilities with their broader scope of services, higher patient acuity, and greater service complexity meet these expanded needs through a team of IPs? Do these teams specialize, and if so, how is that specialization structured within the department?

We also examined whether IPs concurrently work in other roles, such as employee health. This question was critical to understanding the true workload and potential for role diffusion within organizations. Finally, a key inquiry was to understand how other organizational departments support the infection prevention program. This explored the concept of "insourcing" and "outsourcing" of IP functions, shedding light on the collaborative dynamics and resource sharing within healthcare institutions. These core questions formed the bedrock of our initial inquiry, setting the stage for a research endeavor that would ultimately unveil the hidden workload of IPs across the nation.

Conclusion: Volunteering to Create the Path Forward

The start of this journey, in the summer of 2023, led us to volunteer to write an article for the 

magazine. As editorial panel members, our conversations made it clear we weren't alone in our questions or in the relentless struggle to keep pace with an ever-growing workload. We offered to write an article because we suspected many of you are experiencing the same pressures. While we still needed to figure out how we were going to collect the voices of other IPs, and narrow down the questions we had, we were energized and excited.

Jessica Swain, MBA, MLT, CIC, IHI

Articles

From Concept to Impact: The Findings Unveiled—A Snapshot of IP Realities

From Concept to Impact: Designing the Research Inquiry – The Art of the Survey

From Concept to Impact: A Collaborative Journey in Infection Prevention Staffing