Exploring head nurse leadership at multiple levels to prevent MDROs in ICUs: a multi-centre grounded theory approach...

Managing healthcare-associated infections due to multi-drug-resistant organisms (MDROs) in intensive care units (ICUs) is a critical challenge. Although infection prevention and control (IPC) practices are essential to reduce risk, differences in infrastructure and behavioural barriers often limit their effectiveness. Head nurse leadership is crucial for overcoming these obstacles, fostering effective pathways and improving patient outcomes.

A grounded theory approach was used to develop a theoretical framework from the experiences of 34 professionals, including head nurses, nurses, nurse assistants, and physicians, from two hospitals. Participants were selected through theoretical sampling. Data were collected via non-participant observation and semistructured interviews, then analysed using constant comparative methods.

Effective MDRO management is significantly shaped by head nurse leadership operating across multiple organisational levels. Four themes emerged: creating a safe organisation, leading through flexible and contextual strategies, fostering belonging via relational dynamics, and modulating professional behaviours. These themes informed the BRIDGE-IPC framework (Behavioural oRganIsation Dynamics for Governance and lEadership in Infection Prevention and Control), linking macro-level policies, meso-level leadership, and microlevel team and individual behaviours. The framework highlights how head nurses transform individual knowledge into shared, robust IPC practices within a 'landscape of opportunities'.

Multi-level head nurse leadership in ICUs shapes MDRO management by integrating professional competencies with individual attributes, nurturing, authoritative, resilient, reassuring or remissive. Acting as system mediators and relational facilitators, they create 'virtual knowledge bridges' that foster tacit knowledge exchange, support adaptive practices, and maintain team motivation. Internalising IPC as a core value enables them to serve as credible role models, reinforcing staff engagement and adherence, improving patient safety, and shaping training and policy interventions.