Prevention of Hospital-Acquired Norovirus Outbreaks Using a Complexity Theory-Based Model Integrating Organisational Management, Staff Behaviour and Technology
Ian K Hosein1,2*, Rosie E Madeloso3
1Department of Medical Microbiology, Midlands Regional Hospital Tullamore, Republic of Ireland.
2Department of Microbiology, University of the West Indies, St Augustine, Trinidad & Tobago.
3Strategy and Partnerships Department, Barking, Havering and Redbridge University Hospitals NHS Trust, UK.
*Corresponding Author: Dr. Ian K Hosein, Consultant Medical Microbiologist, Midlands Regional Hospital Tullamore, Arden Road, Tullamore R35 NY51, Republic of Ireland.
https://doi.org/10.58624/SVOAMB.2026.07.004
Received: Mach 16, 2026
Published: April 02, 2026
Citation: Hosein IK, Madeloso RE. Prevention of Hospital-Acquired Norovirus Outbreaks Using a Complexity Theory-Based Model Integrating Organisational Management, Staff Behaviour and Technology. SVOA Microbiology 2026, 7:2, 37-45. doi: 10.58624/SVOAMB.2026.07.004
Abstract
An organisation with two hospitals in England experienced significant norovirus outbreaks in the winter periods between 2008–2011. Outbreaks occurred despite organisational educational efforts to improve staff hygiene practices and audits of hygiene compliance. In July 2012, to identify underlying drivers of these outbreaks and to develop related interventions, a mixed-methods research approach was undertaken, examining the organisation from a complexity theory perspective. Quantitative data on environmental cleaning, staff hygiene, hospital-acquired infections, and hospital bed availability were extracted from hospital databases. Qualitative data were obtained from semi-structured individual staff interviews and focus groups. The quantitative data demonstrated limited adherence to hygiene protocols with high rates of infection among patients and staff. Staff interviews revealed a minimal depth of understanding of norovirus transmission mechanisms and a perception of outbreak inevitability. Interviews also highlighted a lack of cross-professional team ownership with prevention of outbreaks being considered a problem for nurses. To address the drivers simultaneously, interventions were made using a complexity-based model integrating Organisational Management Accountability, Staff Behaviour Modification and, Technological issues such as equipment decontamination (OBT Model) with Leadership as the key underpinning all other drivers. Rapid interventions over a 2-week period began in late October 2012. Cross-disciplinary staff groups were trained together to foster shared ownership of infection prevention. Mobile handwashing sinks were introduced at ward entrances to augment handwashing sinks in patient bays; environmental and equipment cleaning were intensified and assured by use of washable ultraviolet markers on key surfaces such as commodes. The microbiology laboratory provided rapid PCR results on Norovirus from testing of faecal samples. Following this two-week implementation phase in October 2012, there were substantial reductions in infected patients (−66%), staff (−66%) and bed-days lost (−78%) from norovirus infection that winter (2012/2013). These reductions occurred during one of the worse years for norovirus infection in the UK at that time with strain G11.4 Sydney 2012. Further reductions continued the following winter (2013/2014): infected patients ( 83%), staff (-86%), and bed days lost ( -94%) as compared to the period 2011/2012. The Organisational Behavioural-Technological model also resulted in a sustained transformation in organisational culture, with improved teamworking and hygiene practices.
Keywords: Hospital-Associated Infection; Norovirus Outbreaks; Mixed-Methods Research, Complexity Theory, Organisational-Behavioural-Technological Model (OBT)
