Table 3 Major themes and quotes from the focus groups

Capability

Barrier

Infection surveillance not widely understood by RACF staff

“they [staff] can talk that they know what McGeer [criteria] is, but I think only the ones that use the NAPS really have an understanding of how to apply it properly” (Director of Quality and Governance, FG5)

“surveillance and understanding the McGeer [criteria] is just not a concept that is well understood in aged care. And I have got experience with this in trying to establish surveillance systems in my aged care Facilities, and some of them are not even aware of McGeer.” (IPC Consultant 3, FG2)

Enabler

Previous experience with infection surveillance improves understanding

“My understanding of surveillance is very good.” (IPC Consultant 3, FG2)

“So from my perspective Infections surveillance is looking at what type of infections have occurred in your facility, how they’ve been identified, also how they've been treated according to best practice or best guidelines.” (Pharmacist 4, FG4)

“I definitely find that staff who've completed the survey before have a better experience than those who haven't, so practice makes perfect I think” (Pharmacist 3, FG3)

“I think this will be our six year we've done it, and we get better at it every year, I have to say, and probably because our infection prevention component of our team gets better each year. … I think the useful thing that we are getting better at is probably the preparing for it, and so making sure that everybody is really clear exactly when we are going to be auditing. … Over the years, I guess we've got better at finding results, finding indications.” (Quality Manager 1, FG1)

Opportunity

Barrier

Difficulty engaging staff and doctors to complete proper documentation

“I feel like often it's [infections] not well documented either by the GPs (general practitioners) or the nursing stuff. So um it is, I often find, maybe that it did exist, the symptoms were there, they made a clinical decision under the right circumstances, but they didn't document it well, so we often fail those audits.” (Pharmacist 5, FG5)

“it's been challenging at times to get the data, but it does show that there is a lack of documentation often, um, ah, particularly from the doctors. I'd say so um, that often I might see recorded in the progress notes, um, no symptoms.” (Pharmacist 4, FG4)

“particularly doing the AMS or implementing AMS programs you when you're going through those just finding that an appreciation of what qualifies as a as an infection and what doesn't, what you see in the notes as opposed to what some of the online systems where you might not see anything. For instance, for a UTI It might just say, “Mavis feels unwell”, but then, when they have to report the infection that it sort of prompts them through a series of other symptoms that aren't mentioned in the notes, but you feel that they might be filling it in just so they're able to progress the report.” (IPC Consultant 1, FG2)

“the GPs (general practitioners) are just very quick to not provide much detail, but just, you know the standard progress note: commence on antibiotics.” (Director of Quality and Compliance, FG5)

“So I’m finding it very difficult, um, doing surveillance in our facilities, because the doctors write out the pathology requests, and the results go to them. So, I I have got access to like the clinical labs portal to be able to get the results, but if they don't um put, ah request the pathology on one of our pads we don't get the results. So that's the difficulty I’m having with surveillance at this present time” (IPC Consultant 6, FG3)

“well for me, it takes a bit of following up on things because I’m not a nurse working on the floor. So it takes a lot of following up, especially if they haven't listed all symptoms things like that, or if they haven't found out what the results of the pathology … So a lot of the time we spent chasing up the results from the doctors to find out exactly what pathogen it is, etcetera.” (IPC Lead 1, FG1)

Barrier

Surveillance is time consuming and there is insufficient resourcing to complete it

“Well, I've taken part in the [AC] NAPS, and it was time consuming, um having to go through all the, you know, documentation, trying to find doctor's notes, how they've documented looking at the infection reports, looking at pathology. Um. A lot of, I guess prep work before you could input the data.” (IPC Lead 5, FG2)

“Well, this is my first year working with [AC] NAPS so I found was a little bit time consuming to put all the data, I was spending about three days, we have thirteen facilities” (IPC Specialist 1, FG4)

“I'm panicking a bit, because some I believe it took five days and three practitioners [to complete Aged Care NAPS]” (Pharmacist 1, FG1)

“And like everyone's saying, everyone's just so time poor” (Pharmacist 4, FG4)

“I think the big, biggest barriers um for our staff doing that um Aged Care NAPS is staffing and availability, and the um protected time for infection control. Most of our nurses are registered nurses who have, are supposed to have some protected time, and that doesn't always happen when you have acute or unwell patients in the residential aged care facility.” (Pharmacist 3, FG3)

“The difficulty in that is that it's still got to be resourced and there's still going to be the ability for them to have the capacity outside of their normal job to actually have time to actually do that as well. So that's the difficulty, especially with the IPCs in aged care that we’ve found, is it's fine to have some trained and sitting there and saying “that’s that, tick that box” but it’s been the resourcing of that role, and getting the ability for them to have time to actually put into that role that has been the biggest challenge.” (IPC Consultant 2, FG2)

“the more staff the better. So, I'm not based at any site, but I must have done ten sites’ [AC] NAPS, or at least assisted with them just because we don't have enough staff” (IPC Consultant 5, FG3)

Enabler

EMR improves documentation

“We are very fortunate to have an electronic medical record and an electronic medication system. So it means that um, the infection control can, or infection surveillance can be done virtually or remotely, which makes it very easy for a lot of facilities distributed geographically, separately.” (Pharmacist 3, FG3)

“we do have an electronic care system. I mean, we all thank God for that every day, and we have built in an infection reporting log into our system” (Quality Manager 1, FG1)

“I think as more facilities come on to um electronic medication charts, which there's a big push over the next couple of years for that to happen, some some, but not all, of the systems, you can do Antimicrobial stewardship reports, and that will make it a lot easier, I think, for you know, on-site nurses to actually to complete the AMS surveillance” (Pharmacist 2, FG2)

Enabler

Shared responsibility for surveillance

“[surveillance]'s part of everybody's role. It's everyone's responsibility” [Pharmacist 1, FG1]

“we have the IPC coordinators, then we have the IPC leads, and a further down IPC support role which we have introduced at facilities, because obviously these IPC leads are, uh, they have to be the EN's or the RNs, but given the shortage of them we are, we are also encouraging our other AHPRA registered staff, such as the Allied health, and other staff members to actually uh, go through the [IPC] course and be as a support person to actually ensure that the IPC practices are done correctly, and this is actually helping us in outbreaks, because, instead of just having one person where you run the risk of them, not being able to work for many reasons. You have a team who actually goes into work. So for us we are thinking, so far it has worked” (IPC Lead 8, FG4)

“I think it ultimately should be an IPC um job role, so they can actually um monitor the infections in their, especially in their own villages or their own sites, and then roll out some education to go with it, because you’ll find some sites have different infections to others, and sometimes you could find, you know, lead back to a cause and um monitor it from that, and do some education to the staff.” (IPC Lead 4, FG2)

“we've done some pharmacy-based education to infection control nurses and um offered support if they have questions, or and I feel like having a point of contact with a pharmacist has been really beneficial, um, someone they can reach out to and ask questions rather than reaching out to the NAPS team.” (Pharmacist 3, FG3)

Enabler

Improved education will benefit all staff

“I think that the education in aged care in general has just not been there around infection prevention… it would be useful to have some standardized guidelines that we will all agree to following” (IPC Consultant 4, FG2)

“The Aged Care Quality Commission put out some resources late last year on urinary tract infections which I think were quite good… those kind of templates, particularly not just for nurses around surveillance, but actually the information that gets you to that point around, you know, should you be dipsticking urine… I think that would be really useful, and perhaps not just pitched at registered nurses, but perhaps pitched at you know, in that other space, particularly with the changes to aged care funding because we're going to see a shift in our in our staff and our workforce.” (Quality Manager 1, FG1)

“having seen what we've seen with COVID and with the IPC leads, and the requirement for them to complete education, that perhaps wasn't targeted specifically to the needs of the aged care facility, that if there is going to be development of a surveillance module that it really needs to be targeted obviously to aged care.” (IPC Consultant 3, FG2)

“I think more education around [antimicrobial stewardship] would be really beneficial, and just to you know, for me its wanting to understand it, but then to be able to like have the other RNs understand that, the other nurses, you know the Team Leaders, you know that when I’m not here, they’ll be faced with that so how do they, you know, what do they know about their knowledge and how will they manage that. So I think that would be beneficial.” (IPC Lead 5, FG3)

Motivation

Barrier

Staff are tired and stressed from the COVID-19 pandemic

“Everyone's getting quite stressed because their roles are just growing bigger and bigger.” (IPC Lead 4, FG2)

“increase infections and just tiredness that goes with that. Just so, I guess, and accept an acceptance that it's here. There's infections, and it's quite hard to keep track of other things when everything is COVID related. You know it's hard to keep track of your MRSAs and your VREs when your, and you know, your life revolves around Covid.” (Quality Manager 1, FG1)

“I think it's because aged care staff are going through so much at this time, with staff shortages, it's been a lot with the COVID situation, and I think they're just a bit worn out more than anything else, staff in aged care. That’s what I found anyway.” (IPC Lead 6, FG3)

“with COVID and everything they're just feeling snowed under, and sometimes just let them get on with their day to day jobs is what they're asking to do. But there's more and more getting expected of them all the time.” (IPC Lead 9, FG5)

Barrier

Surveillance is not a priority for staff

“in the grand scheme of things they [staff] have to do in a day, you know it's [surveillance] not at the top of their list, so there are occasions, I think, where it gets missed” (Quality Manager 1, FG1)

“it's just not necessarily on people's priority list. Um, you know they're running around answering phones, they're picking people up off the floor, they're trying to get documentation done, following up on, and obviously talking to relatives. So um trying to add that in when it's just kind of easily dropped off their radar, I think, is problematic for us” (Quality Manager 2, FG5)

“think sometimes the infection control just is low down on the list. Like it gets done if it gets done, and we're all happy if it gets done” (IPC Specialist 1, FG4)

Enabler

Utilising data for practice change

“we have to be careful not to be collecting data for the sake of collecting data…It’s what you do with the data which is really important. And how does that data inform practice change to make improvements to care.” (Pharmacist 4, FG4)

“We started doing NAPS, we've been doing it for three years now, and we're using that as our springboard to making continuous improvement strategies around issues that are identified in each individual home through that survey process.” (IPC Consultant 4, FG2)

“I find that report really useful as well in education, whenever we give education to nursing staff to have data that's local to us and not just presenting it as this is happening, it's like this happens here as well as everywhere else, that can be really valuable when the pictorial graphs et cetera, can be useful for the staff to see that in a visual” (Pharmacist 5, FG5)

“I was just going to say surveillance programs, I find they work best when when, you know, because you're collecting data, and it's what you use with the data, and I've found it quite beneficial when you actually can report back to prescribers.” (Pharmacist 2, FG2)

“the end result was really good, um like, you know, for benchmarking purposes to see, you know where your facility is sitting, um, and yeah you can compare previous um surveys as well, so you can see how you’re tracking if the usage is increased or decreased, um, you know, looking at your trends, you know prescribing trends. Are there patterns picking up on areas that “okay, this is happening repeatedly, um, you know, right, what can I do about it?” So it gives you a good idea, about your position, and you know where you're sitting.” (IPC Lead 5, FG3)

“every year we do participate in the NAPS and then we run an organization-wide report. From there onwards we actually do run improvement projects at our facility, at a facility like for this year we did identify a bit of an increase in the skin infections and then we combine that NAPS surveillance data with our internal monitoring analysis and then we actually found that “ah!” there was actually a correlation between COVID outbreaks and skin infection. So, at the moment we are actually on the phase one of our Improvement project so hopefully by the end of the year we will see a reduction in that” (IPC Lead 8, FG4)