Identifying barriers and enablers to participation in infection surveillance in Australian residential aged care facilities

Abstract

Background

Infection surveillance is a vital part of infection prevention and control activities for the aged care sector. In Australia there are two currently available infection and antimicrobial use surveillance programs for residential aged care facilities. These programs are not mandated nor available to all facilities. Development of a new surveillance program will provide standardised surveillance for all facilities in Australia.

Methods

This study aimed to assess barriers and enablers to participation in the two existing infection and antimicrobial use surveillance programs, to improve development and implementation of a new program. A mixed-methods study was performed. Aged Care staff involved in infection surveillance were invited to participate in focus groups and complete an online survey comprising 17 items. Interviews were transcribed and analysed using the COM-B framework.

Results

Twenty-nine staff took part in the focus groups and two hundred took part in the survey. Barriers to participating in aged care infection surveillance programs were the time needed to collect and enter data, competing priority tasks, limited understanding of surveillance from some staff, difficulty engaging clinicians, and staff fatigue after the COVID-19 pandemic. Factors that enabled participation were previous experience with surveillance, and sharing responsibilities, educational materials and using data for benchmarking and to improve practice.

Conclusion

Streamlined and simple data entry methods will reduce the burden of surveillance on staff. Education materials will be vital for the implementation of a new surveillance program. These materials must be tailored to different aged care workers, specific to the aged care context and provide guidance on how to use surveillance results to improve practice.

Background

Infection prevention and control (IPC) activities are essential for the safety of residents, carers and staff in residential aged care facilities (RACFs) [1]; these facilities provide access to personal care, nursing and health services to older adults. Residents in RACFs are particularly vulnerable to infections [2, 3]. One cohort study found infections accounted for one quarter of all overnight hospitalisations from South Australian RACFs [4].

The Australian Aged Care Quality Standards outline how a RACF might demonstrate the minimization of infection-related risks; this includes the use of ‘data to monitor infections and resolution rates and the effectiveness of an IPC program’ [5]. Monitoring and reporting of infections in healthcare and RACF settings has been shown to reduce risks for acquisition and burden of infection, through support for quality improvement activities [1, 6, 7]. Use of standardised surveillance methods improves validity of data and allows RACFs to benchmark and evaluate internal performance over time [1, 8, 9].

In Australia, there are two main surveillance programs configured for the monitoring of infection and antimicrobial use in RACFs – the Aged Care National Antimicrobial Prescribing Survey (NAPS) and the Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre Aged Care Infection Indicator Program (ACIIP). Facilities which are publicly managed in the state of Victoria are required to participate in the VICNISS ACIIP. Aged Care NAPS is available to all RACFs nationally, but is not mandated [6, 10, 11]. Mandating participation in quality improvement activities in the aged care sector can motivate staff and lead to improved quality of care [9, 12].

The benefits of a national, standardised and mandated surveillance program are well recognised in Australia and internationally [13, 14]. Development of a National Infection Surveillance Program for Aged Care (NISPAC) for Australian RACFs is now underway. This program aims to deliver a standardised surveillance system, leveraging from the two currently available surveillance programs, in addition to newly developed surveillance modules (e.g. respiratory infection surveillance, including COVID-19). The current study will contribute towards the development of NISPAC through an evaluation of the merits and limitations of the two existing surveillance programs in Australia. This evaluation will ensure that NISPAC is developed and implemented in accordance with current resources, emerging risks and stakeholder needs, and is therefore implemented in a sustainable manner.

To date, no in-depth qualitative evaluation of either program has been performed. There is also limited international data on user attitudes towards similar programs [15]. This study aimed to assess barriers and enablers to participation in infection surveillance in Australian RACFs, to understand whether existing programs are acceptable to staff and to identify potential improvements for future program development.

Method

This was a mixed methods study using a survey and focus groups in order to capture the views of healthcare staff employed in Australian RACFs. Michie et al.’s Behaviour Change Wheel (BCW) [16] was used as the analysis framework. The BCW outlines three key domains of behaviour – capability, opportunity and motivation, also referred to as COM-B.

This study received ethical approval from the Royal Melbourne Hospital Human Research Ethics Committee (HREC) (HREC/82249/MH-2022).

Setting

Australia’s aged care system is managed both publicly through government-owned facilities, and privately through for-profit and not-for-profit facilities. There are approximately 805 approved aged care service providers in Australia, managing more than 2,600 RACFs [17]. Aged Care NAPS officially commenced in 2016 and is optional for most of these facilities; 568 RACFs participated nationally in 2019 [18]. Aged Care NAPS is an annual survey that allows users to conduct surveillance of antimicrobial use and infections (urinary tract, respiratory tract, skin and soft tissue, eye and ear) in their facilities.

The 179 publicly-operated RACFs in Victoria are required to participate in both Aged Care NAPS and the VICNISS ACIIP [11, 19]. The VICNISS ACIIP, commenced in 2017, allows users to conduct continuous surveillance of significant organism infections (Methicillin Resistance Staphylococcus aureus, Vancomycin Resistance enterococci, Clostridioides difficile), and point prevalence surveillance of staff influenza vaccination and resident influenza, herpes zoster and pneumococcal vaccination status.

As of October 2020, Australian RACFs have been required to employ a clinical lead with specific training in IPC (IPC leads) [20, 21]. IPC Leads, IPC Consultants (employed across multiple facilities to assist with IPC activities), Quality Managers and pharmacists are the workforce involved in infection surveillance in RACFs. Doctors are based offsite from RACFs, and those who visit residents are mostly primary care physicians (general practitioners). Personal Care Assistants (PCAs) are also employed by RACFs to assist with the care of residents, however they do not have the required qualifications to undertake surveillance.

Participants

Purposive sampling was used to recruit participants who were currently employed by a RACF and who held registration with Aged Care NAPS and ACIIP. These staff included IPC Leads, IPC Consultant, Quality Managers and pharmacists. Email invitations were sent to mailing lists comprising 1852 registered users, noting it was unknown how many were still employed at their registered RACF(s). These mailing lists are hosted internally by the two programs, who granted permission for this research to take place in accordance with maintenance of privacy under the ethics agreement.; Invitations for the survey and focus groups were sent separately, with the survey invitation sent several months prior to the focus group invitations, due to delays in ethics approval. Survey participants were asked to complete an electronic consent form before gaining access to the survey. Those interested in participating in the focus groups completed an electronic consent form, eligibility form and provided preferences of availability for the focus groups, they were then contacted by a researcher and allocated to their preferred time or were placed on a waitlist if there were more participants than needed. Each focus group aimed to have 5–7 participants, approximately 9 were allocated to each account for potential fall out of participants, which was expected due to the busy schedules of RACF staff.

Focus groups

Five focus groups were hosted in September 2022 online (Zoom® Video Communications Inc., San Jose, California, USA). One researcher (EW) facilitated the discussions using a semi-structured focus group guide (provided in Additional file 1), a second researcher (AA or NB) observed and wrote field notes during the focus groups. The focus group interview guide was developed based on the Capability, Opportunity and Motivation for Behaviour (COM-B) framework, and refined based on the results of the survey [16]. All focus groups were audio recorded and transcribed using the Zoom® automatic transcription function, the transcripts were then corrected by two of the researchers (EW and AA).

Five groups were arranged, with capacity for more if data saturation was not reached.

Survey

Survey questions were primarily based on the Centers’ for Disease Control Updated Guidelines for Evaluating Public Health Surveillance Systems [United States of America (USA)] [22]. Questions were multiple choice, with some optional open-ended questions. The survey comprised of questions regarding infection surveillance resources at the participants’ RACFs and was divided into several sections. Results from 17 items from the following survey sections will be presented in this paper: Demographics, Human Resources (Infection Prevention and Control), Pathology, Information technology, Surveillance and Education. Participants were also questioned specifically about the ACIIP and Aged Care NAPS program.

Surveys were conducted on-line using REDcap electronic data capture tools hosted at Melbourne Health [23, 24]. The survey was open for a four-week period (May 2022), two reminder emails were sent during this period.

Data analysis

Focus group transcripts were uploaded to NVivo®, version 12 (QSR International Pty. Ltd., Burlington, Massachusetts, USA) [22]. Transcripts were analysed thematically using a process of open, axial coding. Deductive coding was used to identify domains from COM-B, with concurrent inductive coding used to identify sub-themes categorised to each of the COM-B domains [16]. Coding of all transcripts was undertaken by one researcher (EW), with 20% independently coded by a second researcher (LD). Both researchers met to discuss coding and discrepancies.

Descriptive analysis of the survey data was performed using STATA®/SE 14.2 (StataCorp LLC., College Station, Texas, USA) to determine frequencies of responses [25].

The focus group and survey data were analysed separately. Triangulation was used to determine where results converged, were complimentary or contradictory [26]. Survey results were mapped to the themes identified from the qualitative data. Mapping of survey results enhanced the identified themes by providing more detail or contrasting to the focus group results.

Results

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.

Table 1 Positions of survey participants

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.

Table 2 Barriers to participation in an Infection and antimicrobial use surveillance program identified from the survey

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.

Table 3 Major themes and quotes from the focus groups

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.

Discussion

This study aimed to identify the barriers and enablers to participation in infection surveillance in Australian RACFs, to improve development and implementation of a national, standardised infection surveillance program. This is the first time that an in-depth qualitative analysis of the two currently available surveillance programs has been conducted from a staff perspective.

Audit and feedback of data is well-recognised as a motivator for behaviour change in the healthcare sector [27, 28]. Specifically, infection surveillance allows RACFs to audit their progress against previous performance and benchmark with other facilities to encourage participation in surveillance [8, 9]. Participants in our study noted the benefits of receiving surveillance reports for initiating practice change and educating staff. Creating change and having a positive outcome from program implementation can improve confidence of staff and encourage participation despite other barriers [29]. It is important that all RACF staff understand the benefit of collecting surveillance data to ensure it is collected with purpose. Implementation of NISPAC would be strengthened by clear, easy to understand reports and education for staff regarding the interpretation and use of data to improve local practices.

Participants in the survey and focus groups felt that knowledge among RACF staff and education about infection surveillance and related topics was lacking. Previous studies engaging IPC staff, including in Australian RACFs, have similarly found an absence of access to IPC education, with one study reporting no education programs about infection surveillance provided in surveyed facilities [30,31,32]. Consistent with prior studies, our study found that IPC staff are most often responsible for infection surveillance activities in RACFs [30]. IPC staff are now required by the Australian Government to complete specific IPC training [20]. However, focus group participants highlighted that there is a need to educate other RACF staff to complete surveillance so that the responsibility can be shared, and ensure that surveillance processes can be completed in the absence of IPC staff. Workforce shortages are an ongoing issue in Australian RACFs and this was compounded during the height of the COVID-19 pandemic, which highlighted a lack of staff skilled in infection control [33, 34]. Implementation of a new surveillance program with education modules that are applicable to all levels of RACF healthcare staff may help to ease workloads by creating shared responsibility.

The COVID-19 pandemic greatly impacted RACFs in Australia, particularly in the state of Victoria where a majority of the focus group participants were located [35]. The COVID-19 pandemic was raised by participants as a barrier to conducting surveillance, due to increased stress and high expectations placed on staff. Staff in RACFs experienced work-related stress, exhaustion and higher workloads due to the pandemic [36]. COVID-19 outbreaks are still regularly occurring at Australian RACFs, and it is likely that the added workload from these will continue to impact RACF staff into the foreseeable future [37].

Similarly, staff reported the time needed to complete surveillance and other clinical priorities as barriers to surveillance activities. Time constraints, competing priority tasks and workloads have been identified as barriers to participating in infection surveillance programs internationally, and in other quality improvement initiatives in Australia and overseas prior to the pandemic [9, 32, 38,39,40,41]. These are important considerations for development of NISPAC. Implementation of NISPAC must streamline surveillance activities into usual workflows and keep the time required by staff to participate to a minimum. Similarly, surveillance data must be consistent with data already captured via EMR systems, therefore a synergy between EMR and surveillance may need to be explored to reduce duplicity and increase efficiency.

A lack of engagement from clinicians can hinder implementation of quality improvement programs in the aged care setting [38, 42]. Poor understanding from clinicians of the importance of detailed documentation led to difficulty for staff in successfully entering surveillance data in this study. Engagement from clinicians may improve uptake of surveillance in aged care through demonstrating to RACF staff the benefit of participation and by improving quality of patient data. Some facilities reported having many individual primary care physicians visiting, which may make engagement difficult. Previous studies have also noted difficulties in engaging offsite primary care physicians in IPC activities and reviewing antimicrobials [32, 43]. Future studies may be needed to understand physician attitudes to surveillance in RACFs, and to understand how best to report surveillance findings to this stakeholder group and support their engagement with surveillance.

Potential study limitations include the fact that although an online medium was used to provide a convenient tool for focus group participants across Australia, the platform was not always conducive to fluency and continual dialogue by participants. Prompting by the facilitator was necessary to support discussion. The consistency on most topics between the survey and focus groups results indicates that the impact of this was minimal. Further, the studied cohorts may represent a select subset of staff, rather than being truly representative of all Australian facilities. However, we note individuals from multiple jurisdictions across Australia participated, and a range of different experience levels were noted across the survey and focus groups.

Conclusion

This study identified several barriers and enablers to participation in two infection and antimicrobial use surveillance programs in Australian RACFs. It is vital that the perspectives of staff are considered in the development and implementation of future surveillance initiatives, particularly in light of significant impacts of the COVID-19 pandemic upon workforce and workload of staff. This study has identified that workloads and pressure on staff must be considered, and that staff are eager for tailored education to improve participation in a standardised surveillance network. Surveillance reporting and feedback to staff is also important and can provide a basis for quality improvement initiatives. The understanding of staff perspectives gained from this study will be incorporated into implementation materials and strategies underpinning NISPAC.