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Airborne infection prevention and control implementation: A
positive deviant organisational case study of tuberculosis and
COVID-19 at a South African rural district hospital
Helene-Mari van der Westhuizen
a
, Sarah Tonkin-Crine
a
, Rodney Ehrlich
b
, Chris C. Butler
a
and Trisha Greenhalgh
a
a
Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK;
b
Division of Occupational
Medicine, School of Public Health, University of Cape Town, Cape Town, South Africa
ABSTRACT
There are many examples of poor TB infection prevention and control
(IPC) implementation in the academic literature, describing a high-risk
environment for nosocomial spread of airborne diseases to patients and
health workers. We developed a positive deviant organisational case
study drawing on Weick’s theory of organisational sensemaking. We
focused on a district hospital in the rural Eastern Cape, South Africa and
used four primary care clinics as comparator sites. We interviewed 18
health workers to understand TB IPC implementation over time. We
included follow-up interviews on interactions between TB and COVID-
19 IPC. We found that TB IPC implementation at the district hospital
was strengthened by continually adapting strategies based on
synergistic interventions (e.g. TB triage and sta health services),
changes in what value health workers attached to TB IPC and
establishing organisational TB IPC norms. The COVID-19 pandemic
severely tested organisational resilience and COVID-19 IPC measures
competed instead of acted synergistically with TB. Yet there is the
opportunity for applying COVID-19 IPC organisational narratives to TB
IPC to support its use. Based on this positive deviant case we
recommend viewing TB IPC implementation as a social process where
health workers contribute to how evidence is interpreted and applied.
ARTICLE HISTORY
Received 7 September 2023
Accepted 12 July 2024
KEYWORDS
Tuberculosis; COVID-19;
infection prevention and
control; case study;
implementation
SUSTAINABLE
DEVELOPMENT GOALS
SDG 3: Good health and well-
being; SDG 10: Reduced
Inequalities
Introduction
In high tuberculosis (TB) burden countries, the airborne spread of TB in healthcare facilities places
both health workers and patients at risk, and disproportionally aects those most vulnerable to devel-
oping severe disease (Uden et al., 2017). This hazard is extensive: in South Africa TB has been the
leading cause of death, with health workers falling ill with TB disease at a three times increased
rate compared to the general population (Department of Statistics South Africa, 2020; Uden et al.,
2017). During the COVID-19 pandemic, as airborne precautions became an increasingly important
part of the pandemic response, there was an opportunity to consider airborne infection prevention
and control (IPC) implementation as a multi-disease intervention combining the emergency
COVID-19 response and ‘routine’ care for diseases such as TB (van der Westhuizen et al., 2022).
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
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article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
CONTACT Helene-Mari van der Westhuizen helene.vdw@phc.ox.ac.uk Nuffield Department of Primary Care Health
Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford University, Oxford OX2 6GG, UK
GLOBAL PUBLIC HEALTH
2024, VOL. 19, NO. 1, 2382343
https://doi.org/10.1080/17441692.2024.2382343
Implementation of TB IPC across health facilities in South Africa and in other high TB burden
countries is generally described to be poor (Colvin et al., 2021; Engelbrecht et al., 2018; Farley
et al., 2012; O’Hara et al., 2017). This failure may be due to TB IPC requiring multiple com-
ponents of an eective airborne IPC programme to be implemented simultaneously. This
includes administrative controls (triage and the use of isolation and respiratory hygiene for
people with TB symptoms or disease, as well as prompt initiation of eective treatment), environ-
mental controls (ventilation and upper-room germicidal ultraviolet systems) and use of personal
protective equipment (World Health Organization, 2019). These components interact to inu-
ence the risk of nosocomial airborne disease transmission making this a complex intervention
(van der Westhuizen et al., 2022).
Arakelyan and colleagues argue that TB IPC eorts should move beyond using a checklist
approach to monitor implementation, and instead incorporate ethnographic methods (Arakelyan
et al., 2022). Their research focussed on six primary healthcare clinics in KwaZulu Natal, South
Africa, and described how dimensions of the ‘enabling environment’ such as infrastructure,
resources and organisational constraints interact. They noted that while some of the system hard-
ware components (such as IPC protocols, committees and champions) were available in principle,
they were not implemented in a meaningful way. One clinic was the exception, where they noted the
inuence of supportive senior management and good working relationships between sta in facil-
itating TB IPC improvements.
Kallon and colleagues explored the contribution of organisational culture to mask-wearing prac-
tices for TB in six primary healthcare facilities in South African (Kallon et al., 2021). They found
that mask-wearing was impacted by perceptions during social interactions, that health workers
tended to normalise TB risk and viewed it as an individual risk rather than collective responsibility.
In this case study we develop this organisational focus further by predominantly focussing on a dis-
trict hospital.
The setting for this research is the rural Eastern Cape of South Africa, which has the highest
annual TB disease incidence rate in the country at 692 per 100,000 people (Kanabus, 2021). The
local municipalities are some of the most deprived areas in South Africa, with only 8.5% of the
population over 15 years employed and 72% of the population needing to collect water from a
river (Wazimap, n.d.). While many descriptions of the rural areas in South Africa draw strongly
on measures of deprivation, there are also conceptualisations of how rural areas may develop
resilience through using relationships to identify, recruit and utilise resources (Ebersöhn & Fer-
reira, 2012). Ebersohn and colleagues researched rural schools in South Africa and proposed
viewing relationships as discs of systemic strength, like a honeycomb, that enable agency that
can challenge the depiction of rural areas as ever-widening circles of deficit (Ebersöhn & Ferreira,
2012).
In this study, we develop an in-depth understanding of an organisation where TB IPC as a bun-
dle of interventions was implemented well, an example of what Flyvbjerg calls a ‘positive deviant’
case study (Flyvbjerg, 2006). While Arakelyan and colleagues briey discussed a positive case
example of a primary care clinic in their study, this approach has not received in-depth focus in
TB IPC research (Arakelyan et al., 2022). Flyvberg’s method examines in-depth context-dependent
knowledge – what allows people to become virtuoso experts in a field rather than knowledge based
on rule. Flyvbjerg argues that focussing on a deviant provides rich information that could deepen
understanding useful in dierent settings and demonstrates that positive deviation from the usual is
possible.
We use Weick’s theory of organisational sensemaking as it starts from the premise that organ-
isations have environments that are in ux, and that organisational narratives reect interpretations
of this environment, but also help to shape or ‘enact’ the environment (Weick, 1995). Our research
aims are to explore: (1) How organisational sensemaking theory can help to explain a positive devi-
ant case of TB IPC implementation at a health facility. (2) How implementing TB IPC prepared the
organisation for the early stages of the COVID-19 pandemic.
2 H. VAN DER WESTHUIZEN ET AL.
Methods
Study design
The study design used an organisational case study approach, drawing on the interpretive case
study method of Stake, with detailed, naturalistic and longitudinal observation of events and
relationships, including thick descriptions and narrative extracts (Stake, 1995). Our primary unit
of analysis is a rural district hospital – it includes the infrastructure, the sta and patients who
use the hospital and local policies that inuence the hospital’s way of work. We also conducted
interviews at four primary care clinics based in the same area, to contrast dierent IPC organis-
ational practices in the same geographic area, while keeping our focus on the district hospital. Pseu-
donyms for the health facilities are used to promote confidentiality.
Context
Mamele hospital was selected as a positive outlier for good TB IPC practices based on provin-
cial audit data. It delivers services to a catchment area of approximately 130,000 people and has
150 beds. The hospital delivers outreach support to 14 primary healthcare clinics in the sur-
rounding area, of which four were comparator study sites for this research (Aphiwe, Camago,
Fassi and Khumbula clinics). Key dierences between the district hospital and primary care
clinics are size and organisational structure: the district hospital has a CEO and clinical man-
ager, with a multi-disciplinary team of health professions including allied health workers,
doctors and nurses. The primary care clinics are nurse-run, have between 6 and 12 sta mem-
bers, and ranged from having newly renovated facilities to old infrastructure. The primary
healthcare clinics were selected for maximum variation (considering distance from district hos-
pital, physical infrastructure, patient load and TB incidence based on number of TB referrals
sent to hospital).
Data collection
Data sources include in-depth individual interviews with 18 health workers conducted between
2019 and 2020 which lasted between 30 and 90 min each. We also used fieldnotes, policy document
reviews and reviews of IPC audits. During 2021 we approached all participants for remote follow-up
interviews and conducted this with the six health workers who expressed interest, all were based at
the hospital. Sampling was purposive, specifically including health workers who played key roles
over time in developing TB and COVID-19 IPC systems in the hospital. Interviews were audio
recorded and conducted in isiXhosa or English, transcribed and translated into English where
applicable, and checked for accuracy by the research team. This study formed part of a broader pro-
gramme of research that also included interviews with patients and a specific focus on stigma and
IPC, which will be reported elsewhere.
Data analysis
Initial analysis was guided by Braun and Clarke’s reexive thematic analysis, using line-by-line cod-
ing with NVivo software (Braun & Clarke, 2006). We then looked to develop an understanding of
how the organisation made sense of airborne IPC as an intervention over time, using narrative sum-
maries of key informants and creating a narrative overview.
We draw on Weick’s theory of organisational sensemaking as theoretical approach to under-
stand TB IPC implementation (Weick, 1995). Weick recommends a literal definition of sensemak-
ing – referring to a process that is both an individual and social activity of making sense. When
applied to organisations, it refers to the way members of an organisation interpret their
GLOBAL PUBLIC HEALTH 3
environment in and through interactions with others, which then leads to collective action (Weick,
1995). We use the seven properties of sensemaking (in italics below) that Weick described and apply
it to TB IPC implementation in these facilities.
The seven properties include how organisational sensemaking is grounded in identity con-
struction, which involves establishing and maintaining identity. We approached this component
by considering – what do health workers perceive a ‘good’ professional should do with regards
to TB IPC implementation in their setting? Sensemaking is retrospective, which involves
occasions for sensemaking that interpret events and processes that could either support or hin-
der TB IPC implementation. Examples would be what health workers view the results of their
TB IPC actions or lack of action to be. Sensemaking is enactive of sensible environments, mean-
ing it shapes the environment and the way health workers think about TB IPC as intervention.
This includes how they conceptualise ‘eective’ TB IPC for their context. Sensemaking is social,
meaning it is inuenced by the opinions of others and constructed between people in a way that
may be contested and negotiated. Sensemaking is ongoing, which implies that for our in-depth
case it would be important to gauge how the process of sensemaking has adapted over time.
Sensemaking involves using extracted cues, and looking at how these are interpreted at an organ-
isational level. We draw on this when sharing what participants felt key milestones were in TB
IPC implementation. Sensemaking is driven by plausibility rather than accuracy. With this,
Weick means that accuracy (for example, the most eective place to target TB IPC measures)
is helpful but not necessary for sensemaking. What is more important is to get some interpret-
ation to start with, instead of waiting for ‘the’ definitive interpretation to arrive. We selected this
theoretical approach to help understand the social processes of TB IPC implementation that are
distinctive to the positive deviant organisational case study and contrast examples of guided
organisational sensemaking where there is a unitary rich account, with fragmented sensemaking
(Maitlis, 2005).
The research team was led by HvdW, a clinician-researcher who had previously worked in the
facilities, with co-investigators bringing expertise in occupational health (RE), primary care (CB
and TG), behavioural science (STC) and sociology (TG). A research assistant familiar with the
area received two days’ training in qualitative research methods and mentorship during the
study. She supported recruitment and led the isiXhosa interviews.
Ethics
The study was approved by the research ethics committees at the University of Cape Town Faculty
of Health Sciences (HREC REF: 259/2019) and the University of Oxford (Oxtrec number: 541-19).
It received institutional permission from the Eastern Cape Department of Health (EC_201907_010)
and local permissions from health facilities.
Results
We start by introducing TB IPC implementation narratives at the comparator primary care clinics
and consider why these did not lead to comprehensive TB IPC implementation. We then introduce
our positive deviant case study of the district hospital with additional details about the rural context
and six key milestones that sta identified as important in their collective sensemaking. We present
an in-depth narrative from the clinical manager, who played a key role in this process, which we
describe as leadership sensegiving. Finally, we look at how organisational sensemaking was dis-
rupted by the COVID-19 pandemic, and how these new disease transmission narratives can trans-
late to TB IPC.
For a summary of participant characteristics, including the number of health workers inter-
viewed at primary care facilities compared to the district hospital, see Table 1.
4 H. VAN DER WESTHUIZEN ET AL.
TB IPC implementation narratives at primary care level
The following four primary care facilities show fragmented narratives of organisational sensemak-
ing of TB IPC implementation. They represent narrow approaches that focus on a specific subcom-
ponent of TB IPC. Our impression was that their activities aimed to demonstrate some compliance,
at times at significant resource costs, but that TB IPC did not seem to have substantive broader
value for the organisations and therefore implementation fell short.
Organisational narrative 1 based on Aphiwe Clinic: In this facility health workers decided
not to use masks or respirators for TB as they felt patients experienced this as stigmatising.
The health worker’s bare face was seen as a visual manifestation that they do not find patients
‘disgusting’ and did not need a protective barrier. This links with identity construction of pro-
fessional norms for what a ‘good’ health worker should do, which in this context they interpreted
as avoid making patients feel stigmatised. The TB service was run by a nurse who previously had
TB, which the other health workers felt meant he could relate more closely to the patients. The
risk of recurrent TB for this health worker was not considered. They did not routinely open win-
dows. Their overarching narrative about TB IPC was that it was not practical as they were
thwarted by poor facility infrastructure (comprised of a temporary prefab structure and hut)
which led to overcrowded, poorly ventilated indoor waiting areas when patients had to wait inside
when it rained. They felt that unless they received a new facility, TB IPC implementation was
beyond their inuence.
Organisational narrative 2 based on Camago Clinic: This facility has been recently renovated
and had purpose-built coughing booths for sputum collection and windows that can open widely.
Their main TB IPC focus was to fast-track people with positive TB laboratory results. The desig-
nated TB and HIV nurse would alert the facility administrator that a person’s TB diagnosis was
positive, give a surgical mask for the patient when they arrived at the facility and let them skip
the queue. The health workers did not use respirators, arguing that they had managed to avoid fall-
ing ill with their current practices thus far, an example of retrospective sensemaking. Their over-
arching narrative about TB IPC was that it should be targeted towards people with a positive TB
diagnostic test but who had not yet started treatment.
Organisational narrative 3 based on Fassi Clinic: This facility rotated their TB focal nurse
every three months to share the TB risk sta faced. The facility’s IPC eorts were targeted towards
separating patients who had been diagnosed with TB. There was an important visual manifestation
Table 1. Participant characteristics.
Age (years)
Median 33
Range 22–56
Sex
Male 6
Female 12
Health worker profession
Doctor 5
Nurse 10
Allied health professional 2
Support staff (translator) 1
Health facility
District hospital 11
Primary care clinic 7
Years of work experience
0–10 12
10+ 6
Previous TB disease
Drug sensitive TB 2
Drug resistant TB 0
Total participants 18
GLOBAL PUBLIC HEALTH 5
of TB IPC, where TB patients used a separate area of the clinic: they had a separate waiting area,
vital signs room, and medication dispensing pathway. This reected a deeper shared assumption
that known TB patients posed the infection risk. However, sta did not apply this to the use of pro-
tective equipment. Masks and respirators were only viewed as needed for patients with drug resist-
ant TB, who were rarely seen at the clinic. Respirators which had been out of stock for three months
would appear in time for audits to avoid a negative evaluation. This incongruent response, localis-
ing infection risk to known TB patients through having a separate patient ow system but health
workers not using respiratory equipment, could reect a fatalistic approach to the TB risk to health
workers or a belief that drug-sensitive TB was not as severe.
Organisational narrative 4 based on Khumbula Clinic: During the site visit, two junior
nurses were working on their own. The location was isolated with very poor road infrastructure
and limited mobile reception. They described receiving an instruction from their clinic manager
that all patients visiting the facility, irrespective of symptoms, should receive a mask and the
nurses should also wear surgical masks as PPE. Yet there were no surgical masks in stock at
the facility for health workers or patients. They felt the only tool they could use was to ask
patients to cover their cough with a scarf or their hand. They felt that the power relations
with the clinic manager meant that they feared engaging their manager about the implications
of the mask directive and did not have inuence over stock-outs. One of the junior nurses (par-
ticipant 27) summarised their overall work experiences as: Things are not happening here. The
narrative of the nurses around TB IPC in this facility was that despite junior sta having signifi-
cant organisational responsibilities, it was yet another requirement they had insucient support
to execute.
These organisational narratives describe a patchwork of TB IPC measures. The starting point for
this is that the bundle of TB IPC measures did not always convince health workers of its relative
advantage over not implementing it. Where TB was not considered a significant threat to the health
of health workers, or if health workers were fatalistic about their TB risk, IPC measures were less
persuasive. This scepticism may also be due to the outcomes of poor TB IPC implementation being
less observable since it could take two years or longer for a health worker to fall ill with TB after
being exposed. A health worker may also choose not to disclose this to their colleagues, which
would omit this from the organisation’s narrative. This results in fewer cues for organisational sen-
semaking on the importance of TB IPC. These focussed conceptualisations of what TB IPC
implementation entailed in each primary care setting were incomplete, and seldomly accompanied
by a strategy to progressively expand implementation.
A positive deviant case for sensemaking on TB IPC implementation
As an introduction to the district hospital, Box 1 describes the rural setting and process of being
screened for TB.
Box 1. A visit to Mamele hospital.
‘Mamele hospital is easy to spot – it is the biggest conglomeration of buildings for kilometres, with huts dotting the
surrounding hills. Taxis speed past, hooting at goats, chickens and sheep to clear the way. The hospital entrance is a large,
well-ventilated atrium with wooden benches. Patients slowly shuffle their way through one queue to the administrative
clerks to collect their hospital number. They then shuffle down the next queue to have their vital signs taken. Blood pressure,
heart rate, temperature, oxygen saturation. Then the next queue shifts to a different line of benches, this time to discuss their
presenting problem with a nurse. If someone is visiting the hospital for emergency care, they receive a triage colour. This is
the point where the nurse also screens for TB symptoms. If a patient is coughing, has night sweats and is losing weight, they
go directly to TB Point, instead of queuing to see the doctor. At TB Point, the TB nurse directs them to the corrugated iron
coughing booth outside to take a sputum sample that is sent to the on-site laboratory. Then it is time to wait. First for the TB
results, then to see the doctor, then to collect medication. Amagwinyas [deep fried fat cakes] are for sale at the tuck shop
across the road. On the grassy embankment next to the hospital entrance, gogos [elderly women] unfurl the blankets that
they wear around their waist and use head wraps as pillows to prepare for a nap. A hospital visit starts early and can take the
whole day.’ – Description of a Mamele hospital visit, field work journal 2019
6 H. VAN DER WESTHUIZEN ET AL.
The organisation placed a strong emphasis on core values for the clinical team of doctors, allied
health workers, and nursing staff. These values were developed by the hospital’s leadership and
introduced to new members of the healthcare team during orientation. These include prioritising
patient care, respectful relationships with colleagues and ‘a hopeful attitude’. They explicitly grapple
with the tension between striving to provide high quality care amidst the resource constraints
inherent in rural healthcare.
The narratives among health workers and patients about generally providing good patient care
also included TB IPC, with participants describing how they score ‘green’ on audits. This corre-
sponded with our fieldnotes: in general, patients visiting the facility were screened for TB, surgical
masks were oered to people with a cough. There were rosters for opening windows in dierent
hospital areas and the waiting area had large doors on either side that were kept open, cross venti-
lating the most crowded area in the hospital. Health workers obtained particulate filter respirators
distributed through the pharmacy, and frequently used them in the wards and in the out-patient
department.
At Mamele hospital, in contrast to the primary care clinics, the process of TB IPC organisational
sensemaking was guided by the organisation’s leadership (using training sessions for sta, and for-
mal policies to support TB IPC) and through peer inuence (for example by seeing the practices of
other health workers in the same team), while adapting the process based on iterative feedback.
Health workers at Mamele hospital described TB IPC implementation as an unstructured ‘journey’
mirroring the 15-year trajectory of improving care at the facility.
Prior to developing a deliberate strategy to implement TB IPC, the organisation focussed on
strengthening the TB care that was provided to patients:
TB had become this thing that we wore as a badge of pride as South Africa – the highest rates – something that
was part of life. And then suddenly it was something that we should probably do something about. That’s as
simple as the change was at first. – participant 12, Mamele hospital, manager
What followed was described as a series of sensemaking milestones – some related to organisational
services, others to interpretation of key events or access to new technology – which supported a
series of emergent actions supporting the implementation of TB IPC. A depiction of this is provided
in Figure 1.
Milestone 1: Dedicated organisational resources earmarked for TB through ‘TB Point’
A consulting room, called TB Point, was set up where a member of the nursing sta coordinated all
components of TB care. This provided dedicated resources within the organisation for TB, and later
TB IPC. Since 2007, TB Point had been led by a nurse who had developed occupational TB herself.
She described her organisational role as champion for TB:
They [the health workers] must change their attitudes. They must like TB, just like any other disease. I know all
my patients. Because I like TB very much as I like myself. Don’t treat people as if [they’re] not a human being.
The sister from one hospital said, “ I don’t like this TB. They just put me [there] because there is no one [else].” TB
is not like that. [Where] you stay, you walk, we must speak of TB. You must love it. – participant 13, Mamele
hospital, nurse, previous TB
Having a local champion that would disseminate TB information and dedicated organisational time
and resources to TB, likely helped prepare the organisation to be receptive to further TB inno-
vations and disrupt prior sensemaking that viewed high risk of TB transmission as unavoidable.
Milestone 2: A clear relative advantage becomes evident for TB IPC
A treatment programme for drug-resistant TB at Mamele was initiated by the hospital at the begin-
ning of decentralised management of drug-resistant TB in South Africa in 2011 (South African
National Department of Health, 2011). The clinical manager described how the success of the
drug resistant TB treatment programme depended on using TB IPC to reduce the risks of infection
and allay sta and community fears about its transmission. The tension for change for introducing
GLOBAL PUBLIC HEALTH 7
TB IPC grew as the value proposition focussed on preventing drug-resistant TB infection. This
likely shifted perceptions of the relative advantage of TB IPC. TB IPC was also combined with
drug-resistant TB care as a new manifestation of identify construction for health workers –
where a ‘good health worker’ strives to provide more comprehensive care at the district hospital,
instead of referring patients to a distant specialist TB hospital.
Milestone 3: Tension for change reaches a critical level
When one of the health workers at Mamele developed occupational TB, the clinical manager viewed
this as an observable consequence of inadequate TB IPC at an organisational level, not an individual
error attributable to the health worker. They used it as a cue for further action:
When we got our first audiology booth, we’d test the hearing of our drug resistant TB patients. And the next thing
our audiologist had TB. But she wore a mask. What we hadn’t appreciated was that the booth wasn’t ventilated.
If there was a moment she didn’t have a mask on, at the point of opening the booth, that was really where it was
going wrong. We thought we were doing infection control and then realised, hold on a moment [there are gaps]. –
participant 12, Mamele hospital, manager
This again inuenced the organisation’s receptiveness to TB IPC, adding to the tension for change.
It demonstrates the impact of peer inuence – where health workers observed that someone work-
ing in the same environment fell ill and therefore interpreted TB IPC as being applicable to them
too.
Milestone 4: TB IPC becomes normalised
Several health workers described a gradual change in the organisational norms at Mamele hospital,
from seeing very few health workers wearing a respirator, to one where most health workers would
wear a respirator when providing TB care – initially most often in the TB wards:
Figure 1. Key milestones in TB IPC organisational sensemaking.
8 H. VAN DER WESTHUIZEN ET AL.
I remember the first two years people really were not really thinking about [TB]. And a lot of nurses didn’t wear
masks. But we did a lot of health education and support. As part of the orientation programs, we tried to get
people to wear masks. For the last five years I honestly cannot remember when last I told a healthcare provider
“where’s your mask?” – participant 4, Mamele hospital, doctor
Participants described dierent types of inuence and communication, from promoting awareness
of the importance of TB IPC through hierarchical approaches to implementation (a doctor moni-
toring respirator use by nurses) to peer inuence (through organisational norms) that supported
the use of respirators. The spread of this practice was likely strengthened by the visual component
of wearing a respirator that served as a cue to other health workers, especially as it was associated
with certain areas in the health facility initially. A health worker entering a ward and finding
another health worker wearing respiratory protection could be prompted to also wear one. Looking
at TB IPC more broadly, several participants referred to the hospital’s induction programme (a typi-
cal occasion for sensemaking) as a way in which organisational norms and priorities around TB IPC
were communicated to new sta.
Milestone 5: TB IPC becomes further embedded, and aligned with new interventions
Participants described three interventions that were introduced to improve overall quality of care,
that were then aligned to TB IPC. Firstly, access to novel molecular diagnostics at the on-site hos-
pital laboratory reduced the turnaround time for TB test results from multiple days to six hours.
This made it feasible to isolate people with potential TB until their diagnostic result became avail-
able. Prior to this the hospital would not have had sucient isolation space. Using TB diagnostic
tests for timely IPC decisions required negotiating about when specimens were taken from the hos-
pital to the laboratory to facilitate this faster turnaround and how TB tests were prioritised by lab-
oratory personnel.
Secondly, a triage system for patients visiting the outpatient department was introduced to
dierentiate between people requiring routine or urgent care. Screening for TB symptoms was
added to the triage form that was used for all patients, which helped identify patients who may
pose a risk of TB transmission to others in the general waiting areas:
Initially we didn’t have a triage system. Everyone used to walk in and it used to be first come first serve – unless
you were an emergency. Everyone used to sit in line – we used to just say ‘next’ and then whoever came in, came
in. We introduced a triage system and TB symptom screen – sending people through TB Point. People had been
pre-identified and removed [from the general queue]. It was better for the patients in the line. And it was better
for us because someone walked in with a mask and you’re like ‘okay this is TB’ and then you could put your mask
on straight away. They’d usually already had a GeneXpert so you could check for results. – participant 33,
Mamele hospital, doctor
Health workers described how TB screening and emergency triage were two processes with
dierent aims: while emergency triage aimed to identify life-threatening symptoms (not a
cough), TB screening aimed to identify a symptom that required action to prevent a longer-
term adverse outcome. Participants also described unintended negative eects of the new TB
screening system, especially for patients presenting with a cough not due to TB who would
then be triaged to receive a TB test and wait for diagnostic results before seeing a health
worker.
The third synergistic intervention was the development of a dedicated sta occupational health
clinic. This provided organisational resources to screen sta for TB. At the facility, baseline and
then annual chest X-rays was oered through the sta health clinic. This likely also contributed
to awareness among health workers that they were at risk of occupational TB.
These three examples describe an organisational context for change that was receptive to the
introduction of dierent innovations. It required viewing TB IPC implementation as an ongoing
process that required finding linkages beyond the core elements of TB IPC, and oered scope
for adapting the intervention as the broader system also underwent changes.
GLOBAL PUBLIC HEALTH 9
Milestone 6: There is a continually developed, shared understanding of TB IPC among sta
At a clinical team meeting in 2018, the clinical manager presented research that showed people with
TB became rapidly less infectious after 48 h of eective TB treatment (Dharmadhikari et al., 2014).
The study used TB rates in guinea pigs: one group was exposed to air from rooms of patients with
TB before treatment was started and another group was exposed to air from the rooms of patients
after TB treatment was started. The guinea pigs exposed to patients who were already on eective
treatment had much lower rates of TB. At the team meeting, health workers discussed the appli-
cation of this finding to who poses the biggest risk of infection in the facility and decided to isolate
the patients most likely to do so (for example waiting for a TB test result not yet on treatment)
instead of TB patients already on treatment for multiple weeks.
Well, who’s actually the dangerous patient? … Sometimes you just need to get enough momentum. I think our
high-risk coughing room was that. … We’d been talking about it for a while, but there was pushback. There were
[health workers who said,] “No, we’re scared of TB”. And it took a while before people [shifted from]: we are
scared of TB. That’s good. But who’s got TB [and poses an infection risk]?” Suddenly - once that penny dropped
- it was amazing. … The idea that you could have a TB patient in the general ward [who is still on treatment but
not infectious any longer] and not have nurses up in arms about it is incredible. The crucial dierence is this
change from ‘TB is bad’ to ‘infection risk is bad’. That understanding of infection control has helped. – partici-
pant 12, Mamele hospital, manager
This milestone describes the implementation of TB IPC as an ongoing, social process: involving
health workers in developing a new protocol for isolating potentially infectious patients and creat-
ing a shared meaning of what infectious TB refers to. Collaboratively, the TB ward was renamed and
repurposed to become the High-Risk Coughing Room. During interviews, four participants
referred to the guinea pig study – at times challenging the use of animal model evidence, and
other times citing it as key reference for changing the organisation’s TB IPC focus. This shows
how knowledge of the specific study was ‘made social’ – it started circulating in interpersonal net-
works where health workers would engage with and challenge the evidence. Focusing on developing
a shared understanding of what TB IPC implementation would entail for that specific context, with
its available resources, was the outcome.
The role of ‘leader sensegiving’ in TB IPC organisational sensemaking
Box 2 provides an in-depth reection from the facility manager about the process of TB IPC
implementation.
Box 2. Key stakeholder reflective summary on initiating a similar process of implementing TB IPC in other facilities.
‘I’ve often described what we’re trying to do here as starting the conversation around X, Y or Z. There are multiple role players
and different opinions. It’s a process of changing head knowledge into belief. Realising there isn’t a quick fix. It becomes part
of the way you do things. If you’re wanting to address TB you need to start to talk about TB and develop a consensus – but
also just find the people who are interested. There are a couple of people who will [it] find academically interesting, or
they’ve got a relative who had TB. And once you’ve got a couple of people you’re having a conversation and you’re not just
the town crier. Once you’re getting momentum, then the question is – what small things can we do better? Because it is a
journey, change management isn’t about arrive, sing and dance, fireworks, leave and it’s all fine. No. Even when you do it
carefully, when you stop, it starts to regress. Everything we do is about continual education of ourselves, our colleagues and
our patients. Find what are the small things that you can do better. Just opening windows – that’s a big one. It’s easy to do
and it’s difficult to start. Just focus on opening the windows because – once the windows are open you’ve done two things:
1) you’ve opened the windows, but 2) you’ve created enough awareness to have the windows open. And then you’re
thinking – what’s next? Can we order N95’s? Yes okay. When should we wear them? Who should wear them? How long
should you wear them? Then do a bit of education. Make sure patient flow in your facility is right and that’s the undiagnosed
patients, but also the TB patients who are coming back. And then education. Staying up to date with what’s happening and
generating some enthusiasm around it. I think if TB’s left to that old burnt-out [medical officer] or the nurse who’s been here
forever and it happens in the dark corner office – then it doesn’t move forward. But now TB is dynamic. There’s never been a
better time to be interested in TB. I often say pick your battles wisely. What do you have the capacity for? How long are you
going to be around? Some changes take years. Don’t pick a year’s kind of change when you’re only going to be [at the
facility] a couple of months, because you won’t achieve it. And then you’ll feel disillusioned.’ – participant 12, Mamele
hospital, manager
10 H. VAN DER WESTHUIZEN ET AL.
This demonstrates a rich understanding of introducing change into an organisation with rec-
ommendations for similar initiatives in other settings. This could be conceptualised as guided
organisational sensemaking – described by Maitlis as a form of sensemaking where leader and sta-
keholder sensegiving is consistent and helps to produce a unitary rich account (Maitlis, 2005). It
does not involve stiing disagreement, but rather using conversation and even conict in a pro-
ductive way to reach a mutually acceptable consensus.
The clinical manager spoke about the process of introducing an innovation as ‘starting or chan-
ging the conversation’ around TB IPC. By changing the conversation, the way people think or feel
about TB IPC is slowly inuenced, which in this case study, contributed to a receptive environment
for TB IPC. It also embraces the social component of sensemaking, where a shared meaning of what
eective TB IPC would entail is constructed between people.
In 2020, the COVID-19 pandemic brought a major shift in how TB IPC was implemented at
Mamele hospital. The following section presents insights on how IPC changed in 2021.
COVID-19 IPC as an example of fragmented organisational sensemaking
Participants described how the COVID-19 pandemic challenged Mamele hospital in unexpected
ways, testing the core values of the organisation. Health workers described a heightened sense of
isolation when the referral hospital stopped their outpatient clinics, ambulances were slower to
respond to calls, and social grant oces closed causing severe economic hardship and impacting
patients’ ability to aord transport to visit the hospital.
There was a breakdown in trust between colleagues, trust in the leadership of the organisation
and trust in the ability of guidelines to protect health workers. This became a traumatic time for
many health workers at Mamele, with one commenting, The strengths that we had before were
lost … [Hopeful attitude] imploded, exploded. – participant 30, Mamele hospital, doctor.
While these health workers worked in a health system that was under chronic strain prior to the
COVID-19 pandemic, the acute strain of COVID-19 heightened uncertainty and fear. Many dis-
agreements focussed on IPC:
The tension in this hospital was palpable. It was heavy. It was everywhere. It was permeating. Cloth masks
became the symbol of this stress. There were definite lines drawn amongst dierent groups. There were factions
in the hospital … The mask became a uniform of one of the teams and the bare face became the uniform of the
other. – participant 30, Mamele hospital, doctor
While some of the disagreements were about whether cloth masks were eective in reducing the
spread of COVID-19 (for example, whether it could filter out small viral particles), it was also
about symbolism. Some of the health workers felt they were important role models for broader
use of cloth masks also in community settings and should wear cloth masks in areas where they
would have previously worn no masks. Others argued that wearing a cloth mask would give sta
a false sense of protection, as they did not meet protective quality standards. This is an example
where multiple, conicting narratives did not produce a broadly compatible account. When con-
trasted with TB IPC sensemaking, where team discussions on about evidence had a productive
element, this was conict that fragmented organisational sensemaking. Later in the pandemic,
there was further conict about the type of PPE oered:
At Mamele hospital during that time we had massive [nursing and general worker] strikes - the worst we’ve ever
seen - over PPE - the whole [hazmat] suit. There was just a heightened awareness and anxiety and fear, but it
almost made people really illogical. – participant 4, Mamele hospital, doctor
The strikes and disagreements about PPE were not simply about equipment, but also about its sym-
bolic meaning – whether sta felt safe at work and whether they felt valued in the organisation.
Our journey was really dicult: from an organisational culture point of view, from a trust point of view with
sta, for me personally, politically within the hospital environment, and in my role as clinical manager. Suddenly
GLOBAL PUBLIC HEALTH 11
it felt like nobody trusted anybody and there were wild rumours about all sorts of things including the virus itself,
but also what the agenda of management was. Suddenly everyone wanted to wear PPE as if they were going to the
moon and rational thought left the building. – participant 12, Mamele hospital, manager
This mistrust in the leadership likely also contributed to the fragmented sensemaking, where the
prior contributions of leader sensegiving were sidelined. Yet the changing or contradicting IPC
guidelines also made health workers distrustful of whether guidelines were protecting them, and
whether the organisation could be trusted to protect health workers.
COVID-19 providing new organisational IPC narratives useful for TB
At the time of the follow-up interviews in 2021, health workers identified many opportunities to
integrate COVID-19 and TB prevention and care, including testing patients presenting with a
cough for both diseases. COVID-19 also led to the repurposing of TB resources: the drug-resistant
TB ward was converted into a COVID-19 ward, and all the drug-resistant TB patients were dis-
charged home. This also had symbolic meaning – the most feared infectious disease, drug-resistant
TB, was being replaced by COVID-19.
Sta described how, during the first year of the COVID-19 pandemic, the focus of the entire
organisation had shifted to COVID-19, deprioritising TB and not linking the two illnesses together:
One of the great ironies of COVID in South Africa is that, because it’s been a pandemic and it has implications
for developed economies, we paid a lot more attention to COVID than we’ve ever paid to TB. I’m not sure that it’s
been a better experience, but it’s bizarre that we’ve poured so much money into PPE for COVID, managing
spaces and trying to identify patients early. It’s not scientifically justifiable really. … given that TB kills so
many people in our country … TB had that journey– trying to highlight TB as something that was both poten-
tially dangerous to sta and preventable. That was a mindset shift. COVID on the other hand was going to kill
everyone dead 10 seconds after it arrived in South Africa and the level of panic and fear was completely insane. –
participant 12, Mamele hospital, manager
Yet by 2021, possibly due to more time elapsing that supports retrospective sensemaking, health
workers described two examples of new organisational narratives that COVID-19 can oer TB
IPC sensemaking.
The first new narrative was the use of airborne IPC measures for people with no symptoms of illness:
COVID is TB’s twin, but with a dierent set of rules. Let’s forget what you know [about TB]: that in order to be sick
you have to lose weight and then wear a mask and to be identified [as someone with TB] through the mask. Let’s
just say anyone can have it and then what will we do?. – participant 31, Mamele hospital, allied health worker
The ‘new rules’ introduced by COVID-19 meant viewing asymptomatic people as posing a risk to
others, instead of reserving masks for the use of symptomatic sick patients. This is a dierent per-
spective on airborne infection control, and as a follow-on to this, it would be important to question
whether asymptomatic transmission is plausible for TB as well. This could then draw on the organ-
isational experience during COVID-19.
The second new narrative was that universal mask-use in health facilities was feasible. Partici-
pants described that initially mask availability was a challenge – the increase in demand could
not be met through hospital provision of masks to all patients, health workers and visitors. As
time passed, more patients brought their own cloth masks, eventually leading to a situation
where everybody in the hospital setting would wear a cloth or surgical mask.
It continually blows my mind that within the hospital every single person is wearing a mask. You know, all our
patients. How powerful is continuous messaging? It’s amazing. We used to look to Asia where mask wearing for
pollution was common. And just think, how would we ever adapt to that? And then here we are. – participant 12,
Mamele hospital, manager.
Several health workers commented on how this universal use of masks changed its associated sym-
bolism and would be helpful for TB as it didn’t stigmatise a specific group. It would be valuable to
12 H. VAN DER WESTHUIZEN ET AL.
consider incorporating these new organisational understandings of IPC from COVID-19 into TB
programmes.
Discussion
This organisational case study examined TB IPC implementation at a rural district hospital in South
Africa as a positive deviant case and included experiences of the COVID-19 pandemic. We found
that TB IPC implementation was approached as a multi-year process, continually adapted based on
available resources, drawing on perceptions of the relative advantage of using TB IPC and other
synergistic interventions (such as triage processes and sta occupational health). This was strength-
ened by viewing implementation as a social process, where health workers could contribute to how
evidence is interpreted, valued and applied.
As Flyvberg describes, a positive deviant case firstly shows that the intervention is possible, and
then helps to generate insights that could inform positive case examples in other settings (Flyvbjerg,
2006).
In Box 3 we consider which insights may be transferable from our positive deviant case findings.
Box 3. Recommendations to support TB IPC implementation based on Weick’s seven properties of organisational
sensemaking.
1. Look for opportunities where TB IPC can be aligned with the organisational identity being constructed, for example TB
IPC being part of providing higher quality services.
2. Create occasions for sensemaking that interpret key events (a health worker getting organisational TB) and processes
(naming of an isolation cubicle) that could support TB IPC implementation.
3. Focus on ‘starting or changing the conversation’ around TB IPC. This is likely a more productive approach to changing
IPC practices, compared to viewing health workers as passive recipients to be ‘filled’ with the correct knowledge.
4. View TB IPC as a shared, social practice, where effective TB IPC for that setting needs to be negotiated between people
by discussing key pieces of scientific evidence.
5. Existing ways in which TB IPC is conceptualised, can change. Implementation strategies should account for this.
6. TB IPC prioritisation often centres around health worker perceptions of occupational TB risk, which could be one
extracted cue for sensemaking.
7. The process of TB IPC implementation should be an ongoing conversation, where the aim is to reach a shared
understanding driven by plausibility.
As part of the sensemaking process, critical questions that the organisation engaged with were:
Where should IPC resources be directed? Where are high risk areas for transmission? How should
occupational risk to health workers be communicated? These questions have been raised in dier-
ent settings, with little detail on how they may be resolved (van der Westhuizen et al., 2022). Kallon
and colleagues used organisational culture as guiding framework and described primary care set-
tings in the Western Cape, where health workers chose to localise risk to certain clinical areas in
the facility where patients known with TB were attended to, neglecting patients who may have
TB but were not on treatment (Kallon et al., 2021). Our case study describes how this was overcome,
through a shift in how health workers came to think about risk as present anywhere in the health
facility. While this approach was still contested by dierent health workers, there was sucient con-
sensus to facilitate a shift in how TB IPC resources were being used.
Kallon and colleagues also described how mask-wearing was seen as individual choice, informed
by a health worker’s perception of risk and assumption of responsibility should they fall ill with TB
(Kallon et al., 2021). This contrasted with a stronger emphasis on organisational responsibility in
this district hospital dataset. When a health worker fell ill with TB, the cause was sought in their
working environment and not blamed on the individual. There was a collective approach to induct-
ing new members into accepting the organisation’s TB IPC norms, and TB IPC was linked to sta
health programmes.
Existing research about supporting TB IPC implementation has included participatory theatre as
educational tool (Parent et al., 2017), personal narratives of HCWs aected by TB (van der
Westhuizen et al., 2015), and educational games and TB awareness campaigns (Haeusler et al.,
GLOBAL PUBLIC HEALTH 13
2019). Our findings have a dierent emphasis – on TB IPC as a process of collective organisational
sensemaking – which has implications for TB IPC training for health workers. Instead of covering
content that emphasises adherence to guidelines and the use of checklists to audit implementation,
training should include discussions about organisational values, negotiating complexity and indi-
vidual versus collective responsibility.
The social component of IPC implementation was also prominent during the COVID-19 pan-
demic. At the time of the interviews, opportunities for achieving synergy between COVID-19 and
TB IPC were not taken up. Participants mentioned uncertainty due to changing guidelines, an
atmosphere strikingly similar to the experiences of the COVID-19 pandemic globally, including
as described in Australia (Broom et al., 2022).
In this case study, strong TB IPC implementation was not sucient preparation for COVID-19
IPC, as the fragmented sensemaking of COVID-19 IPC contrasted with the guided sensemaking of
TB IPC that was characterised by a series of broadly compatible actions. This raises questions for
pandemic preparedness. If a pandemic strains critical resources for resilience, such as relationships
between health workers and organisational trustworthiness, what could be put in place as prep-
aration? How can uncertainty around transmission, debates about supporting evidence and changes
in IPC guidelines be managed in a more supportive way? And how can TB IPC programmes incor-
porate new sensemaking from COVID-19 IPC, particularly around managing asymptomatic trans-
mission through universal mask wearing? This would be valuable to explore in future IPC research.
Our study had important limitations. A case study of a single organisation enabled us to provide
in-depth insights but does not provide a representative overview of TB IPC implementation in all
district hospitals. Our data collection from the primary care facilities had smaller numbers of par-
ticipations per facility and did not have a similarly in-depth focus. Further observational and eth-
nographic work would have strengthened this study. This was planned but limited by the COVID-
19 pandemic. As the sample of follow-up interviews during the COVID-19 pandemic was small and
limited by a lack of observational data and to one facility, it can provide only provisional insights.
Conclusion
This organisational case study represents a positive deviant: a facility that, over a multi-year jour-
ney, developed successful strategy for TB IPC implementation. By drawing on Weick’s work on sen-
semaking in organisations, we identified features of this process that could support TB IPC eorts
in other organisations. This would involve viewing TB IPC, and IPC more broadly, as a process of
organisational sensemaking, where implementation is a social process and health workers can con-
tribute to how evidence is interpreted and applied. Due to the strain on relational resources within
the organisation, COVID-19 IPC posed significant implementation challenges at this site, but also
presented new narratives on IPC implementation which could be utilised for TB IPC in the future.
Acknowledgements
The authors would like to thank the following people who supported the research: Ncumisa Somdyala, Dr Karl Le
Roux, Dr Nadisha Meyer and Catherine Young. We deeply appreciate the contributions of the health workers who
participated in this study.
Disclosure statement
No potential conict of interest was reported by the author(s).
Funding
This publication is part of HvdW’s doctoral research which was funded by a Rhodes Scholarships. She received sup-
port for fieldwork from the Africa Oxford Initiative, Murrey-Speight Fund from the Rhodes Trust, Newton Exchange
14 H. VAN DER WESTHUIZEN ET AL.
Fund and Green Templeton College’s fieldwork funding. TG’s research is funded from the following sources:
National Institute for Health Research (BRC-1215-20008), Economic and Social Research Council (ESRC) (ES/
V010069/1), Wellcome Trust (WT104830MA) and Health Data Research UK (HDRUK2020.139). STC is funded
by the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare
Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health
England (PHE). CCB acknowledges part support as Senior Investigator of the NIHR, the NIHR Community Health-
care Medtech and In-Vitro Diagnostics Co-operative (MIC), and the NIHR Health Protection Research Unit on
Health Care Associated Infections and Antimicrobial Resistance and was a Part-time salaried general practitioner
for the Cwm Taf Morgannwg University Health Board. The funders had no role in study design, data collection
and analysis, decision to publish, or preparation of the manuscript.
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