© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Objective The aim of this study was to explore how infection prevention and control (IPC) guidelines are used and understood by healthcare professionals, patients and families. Design Ethnographic study with 59 hours of non-participant observation and 57 conversational interviews. Data analysis was underpinned by the Normalization Process Theory (NPT) as a theoretical framework. Setting Four hospitals in Ireland. Participants Healthcare professionals, patient and families. Results Five themes emerged through the analysis. Four themes provided evidence of the NPT elements (coherence, cognitive participation, collective action and reflexive monitoring). Our findings revealed the existence of a 'dissonance between IPC guidelines and the reality of clinical practice' (theme 1) and 'Challenges to legitimatize guidelines' recommendations in practice' (theme 3). These elements contributed to 'Symbolic implementation of IPC guidelines' (theme 2), which was also determined by a 'Lack of shared reflection upon IPC practices' (theme 4) and a clinical context of 'Workforce fragmentation, time pressure and lack of prioritization of IPC' (theme 5). Conclusions Our analysis identified themes that provide a comprehensive understanding of elements needed for the successful or unsuccessful implementation of IPC guidelines. Our findings suggest that implementation of IPC guidelines is regularly operationalised through the reproduction of IPC symbols, rather than through adherence to performance of the evidence-based recommendations. Our findings also provide insights into changes to make IPC guidelines that align with clinical work.