Participants
Two hundred RACF staff participated in the survey. Of these, 123 participants answered all questions. Most of the participants were IPC Leads (Table 1), largely employed by public (n = 93, 47.2%) and not-for-profit (n = 83, 42.1%) RACFs. Participants were mostly located in the state of Victoria (n = 84, 42.2%) followed by New South Wales (n = 34, 17.1%) with comparable representation of metropolitan (n = 61, 31.1%), regional (n = 74, 37.8%) and rural (n = 61, 31.3%) facilities.
There were 29 participants across the five focus groups. Participants with different positions and from different facility types were spread across the focus groups, with IPC Leads (n = 13, 44.8%) and IPC Consultants (n = 9, 31%) being the most common roles. Participants were largely from RACFs in the state of Victoria (n = 20, 69%), and from not-for-profit (n = 13, 44.8%) or public (n = 10, 34.5%) facilities. Three participants (10.4%) were within 5 years of graduating from their qualification, while most of the participants were more than 20 years post-graduation (n = 16, 55.2%).
Survey and focus group results
The survey results offered an insight into the operations of RACFs and their capacity for surveillance, including an initial understanding of some key barriers for staff participation in surveillance. Table 2) The focus groups had an average length of 44 min. Common themes emerged by the third focus group, and data saturation was evident following the fifth focus group. There was a high level of concordance between EW and LD’s coding and identification of major themes.
Themes are described below and are identified as barriers and enablers to participation in infection and antimicrobial use surveillance in RACFs, within each of the COM-B domains.
Complete survey results are provided in Additional File 2 and key quotes for each theme can be found in Table 3.
Infection surveillance not widely understood by RACF staff (Capability—Barrier)
Participants reported that RACF healthcare staff who do not have direct involvement in entering surveillance data often lack an awareness of what surveillance is and how to apply guidelines and enter appropriate data.
This was supported by the survey, with respondents indicating that a lack of expertise in surveillance and limited skilled personnel were common barriers to participation in surveillance programs (Table 2).
Previous experience with infection surveillance improves understanding (Capability—Enabler)
Participants in the focus groups were all involved directly in infection surveillance. All had an understanding of infection surveillance principles and felt comfortable with their knowledge.
Previous participation in infection surveillance, including Aged Care NAPS, improved understanding of surveillance and ability to identify and report infections.
Difficulty engaging staff and doctors to complete proper documentation (Opportunity—Barrier)
Participants reported that RACF staff and visiting doctors often do not provide enough detail in their documentation of infections. In particular, it was reported that doctors fail to engage in elements of antimicrobial stewardship, providing only minimal detail of why antibiotics have been commenced. This resulted in concerns that surveillance “doesn’t get reported as well as it potentially could” leading to “adequate surveillance” rather than “best practice surveillance” (Quality Manager 1, FG1). A third of survey respondents reported having more than 6 primary care physicians visit their facilities (n = 60 34.9%).
While a small number of participants reported the need to follow up with primary care physicians about pathology results, the survey showed that most participants have direct access to pathology results for individual residents (n = 141, 86%) and/or a simplified summary of results (n = 118, 72.4%) for those residents who had pathology specimens taken. Access to data and pathology results for these residents were not commonly identified barriers (Table 2).
Surveillance is time consuming and there is insufficient resourcing to complete it (Opportunity—Barrier)
RACF nursing and IPC staff have large workloads and are “inundated … with just providing the most basic of care” (IPC Consultant 3, FG2), which impacts on their ability to participate in surveillance. Participants felt that surveillance is time consuming and that they have little time to dedicate to it. Similarly, survey participants indicated that the considerable time commitment required for surveillance was the most common barrier to participation (Table 2).
These high workloads were compounded by insufficient resources to fill positions and complete tasks, with one participant noting that “staffing is just an ongoing daily issue for all of our aged care facilities” (IPC Consultant 7, FG4).
Electronic medical records improve documentation (Opportunity—Enabler)
Most survey participants (82.8%) stated that their facility currently uses electronic medical records (EMR). Most participants reported that their EMR programs capture details of infections (n = 119, 93%), vaccinations (n = 115, 89.8%), medications (including antimicrobials) (n = 100, 78.1%) and pathology results (n = 95, 74.2%). Focus group participants discussed how EMR has improved entry of surveillance data, with paper charts being “time consuming” (Pharmacist 1, FG1) and an “absolute nightmare” (IPC Consultant 4, FG2), whereas EMR have streamlined and simplified processes.
Shared responsibility for surveillance (Opportunity—Enabler)
IPC leads and consultants were most frequently responsible for entering surveillance data. However, surveillance was seen as a shared responsibility for healthcare staff in RACFs, with some participants highlighting the importance of all staff understanding surveillance methodology to allow for redundancy if specialist staff are unavailable. Equally, staff with specialist knowledge and training were also seen as vital for guiding surveillance and helping to train staff and implement correct data collection. Almost all RACFs have access to an IPC lead, with only 6.2% (n = 11) reporting they currently have none in their facilities. In addition, 44.9% (n = 75) of survey respondents reported having an IPC coordinator available through their provider group or health service.
Improved education will benefit all staff (Opportunity—Enabler)
Participants felt that the current education about surveillance and antimicrobial stewardship was not sufficient and it emerged that improved education would increase participation in surveillance activities.
Participants felt it was important to have resources specific to aged care and tailored information for all levels of RACF staff to allow them to be more involved in surveillance. Topics nominated by participants included infection prevention, infection surveillance in aged care, and case studies. Surveyed respondents reported a preference for education regarding surveillance methodology, interpretation of surveillance reports and principles of antimicrobial use. Most respondents preferred on-line modalities of education, with webinars, on-line resources and self-guided on-line training being the most popular.
Staff are tired and stressed from the COVID-19 pandemic (Motivation—Barrier)
Participants expressed that they and their colleagues were tired and stressed, particularly after managing the COVID-19 pandemic in their facilities. They felt that “COVID’s pretty much taken over our world in a lot of ways” (NUM, FG4) but there are still high expectations of what staff in RACFs must undertake on a daily basis. One called for an “understanding of what is reasonable and what isn’t” (Quality Manager 1, FG1) for RACF staff.
Surveillance is not a priority for staff (Motivation—Barrier)
Participants revealed that provision of clinical care is the highest priority for them and other RACF staff, and that they often have a number of other (non-surveillance) time-sensitive tasks to complete. Frequently, surveillance activities are pushed lower on their task list each day. This was supported by survey results, which identified competing priority tasks as the second most common barrier to participation in surveillance (Table 2).
Utilising data for practice change (Motivation—Enabler)
Participants revealed that it was important for there to be a purpose to collecting surveillance data. They explained that this was to ensure that the time commitment and effort required from staff to complete it was regarded as worthwhile.
Results from Aged Care NAPS and internal audits are commonly used by RACF staff to bring about practice change and improvements, to compare performance against previous years, and to train staff. The site-specific data from surveillance provides unique evidence to support initiation of these activities by IPC staff. Participants appreciated the importance of participating in surveillance when there was a practical, known use for the data.
Similarly, survey findings revealed that staff use surveillance data, with 75.4% of respondents saying that infection and antimicrobial use reports are fed back to a multidisciplinary committee for review, and 74.5% of these respondents saying the committee finds it helpful if the reports enable benchmarking.
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