Table 4 Factors influencing the implementation of recommended procedures

Capability: Psychological capabilities

Awareness and knowledge of CPE and relevant procedures

Facilitator/barrier

• I feel like I went from never hearing of it to maybe now having a basic knowledge of what we do and things and tests and things like that. (General frontline staff 19)

• The toolkit is raising awareness at ward level so that people should be making this assessment for – well suspected cases of where there’s been a hospital admission in the last twelve months. (IPC frontline staff 20)

Competing demands

Barrier

• CPE is competing against all these other national agendas. (General frontline staff 14)

• From an infection control point of view, we’ve got to keep services running and we’ve got to balance the need to manage people safely but also be able to keep services going so that they get the treatment they need in a timely fashion. (IPC frontline staff 4)

Uncertainty about CPE risk factors/effectiveness of screening

Barrier

• I think the other thing that comes up that can be slightly confusing is about which people have been in which hospitals, it’s quite loose isn’t it. (IPC frontline staff 12)

• Well I mean they are, you know really motivated and quite dynamic in many areas but I think they have looked at other trusts like the [name of neighbouring trust] for instance and maybe they don’t think you pick enough up to warrant it so they’re doing a different risk assessment. (IPC frontline staff 11)

Information overload

Barrier

• Sometimes these things are sent and you look at them and you think very good, there is an attachment and you don’t read it and you move onto the next email and off you go. It’s like most emails that I get, I don’t get time to read them. (…) We get an awful lot of documents and you have to be selective in what you think is the most relevant to your area or the most appropriate. (General frontline staff 3)

• There was lots of it [communication]. There was lots of it and infection control did kind of a lot of roadshows and lots of sessions to talk about CPE. I’m not sure the general staff on the ward, if you were to ask them, would still be able to tell you what CPE was. (General frontline staff 11)

Embedding CPE procedures into routine practice

Facilitator

• And also I think sometimes easier to make it a part of their job, so on and so forth possibly. (General frontline staff 1)

• It’s embedded yeah but the other wards - the low risk wards - they know about it, they know what it means and if they’ve got a question or they need to call us then they get hold of us and we talk to them about it. With the high risk wards they’re so… It’s just engrained in their practice now. (IPC frontline staff 13)

Opportunity: Social influences

Multidisciplinary, trust-wide and across-trusts efforts and knowledge sharing

Facilitator/barrier

• If the patient’s been transferred through one of the normal wards we would make sure to have proper communication, proper handover to the team, make sure that we phone them. If they need to be isolated, that they need a side room and make sure that the nursing staff there will know and again, communicate to the whole team, to the doctors, to the porters and to the cleaners, to the nurses, to the HCs [home carers] so everyone knows what they are doing. So as a hospital we are working together to try to prevent it spreading. (General frontline staff 7)

• If they are going into another care provider or district nursing or there is a lot of concern over looking after a patient who is CPE-positive in the community, and what that means to how those staff respond and react to that particular patient. (General frontline staff 20)

Dedicated IPC staff

Facilitator

• Infection control on here, they come every morning so they guide us as to when we need new samples. (General frontline staff 21)

• We contact the ward. We sort out the cleaning, the isolation, when they are screened, so we actually advise them step by step what to do and I think they do follow it. (IPC frontline staff 6)

Supervision and leadership

Facilitator

• I think it’s partly about leadership in that if you demonstrate to your colleagues that you are adhering to this Trust policy, Trust procedure, as a senior doctor, they will then do the same. I can’t tell people to roll their sleeves up if my sleeves are down. (General frontline staff 3)

• So yes, if medics get involved in implementing a policy, then it works more, it becomes more effective as well as nurses and healthcare assistants. When it is coming from the top, I feel it becomes more effective and people listen more. (General frontline staff 1)

Management support

Facilitator

• Actually, the one thing I will say is they’ve [trust management] been incredibly supportive. They required costings but not a formal business case. It was more a case of, ‘Tell us how much this is going to cost so we can budget for it,’ as opposed to, ‘You submit a business case and we’ll see if we approve it or not.’ (IPC frontline staff 1)

• I think what the toolkit did for us is it helped to focus the board, the board of directors on the importance of CPE and how we manage it and as a result of that the trust made a big investment in the CPE plan, programme. (IPC frontline staff 8)

Social comparison

Facilitator

• We’ve heard of some Trusts as becoming so familiar with the CPE they’ve got as to almost become blasé, as to say, ‘Well, we’ve got it. We’re not gonna get rid of it.’ We haven’t reached that point. It’s still something we control; it’s still something we are aiming to isolate and prevent transfer. (General frontline staff 17)

• From trusts in the region which obviously I can’t name I’m not sure whether they’re taking it as seriously as what we do. (IPC frontline staff 19)

Patients’ lack of awareness and collaboration

Barrier

• I think it is that privacy and dignity of where you’re putting the swab, and people weren’t comfortable with that to start with, so that took a little bit of work. (General frontline staff 20)

• We just have to explain it to them. I have encountered one who is just refusing to get it done because it’s per rectal. (General frontline staff 8)

Opportunity: Physical environment

Encountering CPE

Facilitator/barrier

• Obviously, infection control generally has a reputation for, one, potentially being a bit overzealous, I think, about something that clinicians don’t always see as a problem, but once they saw the nature of the resistance and the potential issues that we could have, I think it got them on-board fairly quickly. (IPC frontline staff 1)

• If CPO was becoming a problem, I can imagine everyone knowing about it much more. (…) It would take a problem to get a robust procedure in place unfortunately. (…) I think it has to be recognised that we’re in the situation with the number of cases that we have that we’re certainly beyond the UK national guidelines by a long way. It’s not designed... It’s not fit for purpose, really, for us. (IPC frontline staff 23)

Lack of side rooms

Barrier

• One thing that we found in our team quite difficult was the fact that the guidance was to isolate all suspected cases and I don’t think any acute hospital in England or the UK has enough side rooms to properly do that so I find sometimes we’re having to risk assess and then act upon that risk assessment. (IPC frontline staff 10)

• What I thought of the toolkit? I mean I thought that we’d have a problem because there would be a lot of patients answering yes to the risk assessment and we are short of side rooms at the best of times. (…) So I did have concerns whether we could actually deliver that and implement it within the Trust. (IPC frontline staff 17)

Availability of resources and financial investments

Facilitator

• I think we’ve got the resources we need. We do our audits. We do our meetings and we do our training. (General frontline staff 7)

• Having an in-house laboratory I think is key, otherwise I think we would have not been so on top of the game. (IPC frontline staff 12)

Age, layout and location of hospital

Facilitator/barrier

• I think in the new building it’s easier to isolate patients because all the side rooms are ensuite. The hospital that I cover is a very old building and not all the side rooms are ensuite. (IPC frontline staff 19)

• So you can pop that up and get to all the data cables, all the water pipes and the services. Other trusts will have sealed ceilings. (IPC frontline staff 5)

Staff shortage and high staff turn-over

Barrier

• We have a high turnover of staff particularly amongst doctors you know they change every six months. They might not always come across CPE in other trusts so we have a lot of education, do a lot of education with them. (IPC frontline staff 8)

• We’re an area that often or frequently experience shortages in staffing. Therefore, it kind of leaves us heavily dependent upon agency and bank staff who maybe aren’t as robust, shall we say, in their procedures. (General frontline staff 11)

Time pressure

Barrier

• Because people are busy so people don’t have time for teaching sessions. So yeah, I think that’s it really just ad-hoc teaching on wards so you capture the nurses. (IPC frontline staff 7)

• I think it is probably because the medical staff is too stretched at the moment, and you know any additional responsibility given to them, I think you know makes it more difficult. (General frontline staff 1)

CPE as part of wider IPC and AMR plan

Facilitator/barrier

• I think initially we went straight with a CRO, CPO protocol and actually it needs to fit more with gram negatives and then with a bit on CPO so it’s more embedded and less alien and less scary. (IPC frontline staff 19)

• Before the CPE toolkit came out we had a general MDRGMB policy and I think the first iteration… let me get this right… I think we tried to incorporate the CPE guidance into that and it did two things really, it made the policy rather long which I think some people found inconvenient but certainly the feedback that we got from nurses, including the infection control nurses, was that it was too complicated and they wanted a separate CPE policy. (IPC frontline staff 22)

Motivation: Reflective motivation

Optimism, beliefs about CPE consequences and confidence in capabilities to manage it

Facilitator

• I am confident in my colleagues and I am confident the way the nurses observe their infection control management I think is very commendable, very good, they take on board what they are trained to do. I think the medical staff do a much better job than they used to. There is always some room for improvement, but there is definitely, there is definitely an improvement. (General frontline staff 3)

• I do find it interesting because it’s just the fact that we are kind of leaning towards a post antibiotic era is quite scary prospect you know and how we can and what we can do and how we can do as part of the frontline I suppose to stop that and reduce that while we can. We’re not going to get completely rid of it but to reduce it down to you know manageable levels. (IPC frontline staff 14)

Prioritising CPE

Facilitator

• It’s on the naughtiest list. (…) We manage them higher precautions than MRSA, the CPE, yeah. (General frontline staff 12)

• We’ve got to make it clear to them that the CPEs are not the same as MRSA or something like that you know, they’re a different level of risk altogether. But at the same time I don’t want them to go away from that meeting or training session thinking, ‘Oh it’s alright we can just slip in MRSA patients anywhere because they’re not the CPEs. (…) I would certainly intend to have a zero tolerance to CPEs so we will do whatever we need to do to contain them and we’ll consider any intra-hospital transmissions unacceptable. (IPC frontline staff 22)

Continuous improvement efforts and lessons learnt

Facilitator

• We developed, or relooked at our action plan for the management of CPE and by June we had extended our screening programme. July, August we opened up CPE isolation wards because we weren’t able to cope with the amount of patients. (IPC frontline staff 8)

• I think it’s good to have those channels of communication and to feedback when things have gone well if you’ve had a complicated patient in and feeding that back, maybe doing an after action review, learning from what’s happened, what we can do better because I really think, one of the things we bring back in these after action reviews is that this is the future. (IPC frontline staff 10)

Doubts about evidence base and practicality of recommended procedures

Barrier

• So we have moved away from the Public Health guidance document, because it hasn’t been updated for quite a while, so we’ve taken it that we will screen everybody from abroad. (General frontline staff 20)

• I don’t know whether the toolkit’s really helpful if we actually have a problem in terms of the cluster or an outbreak. (IPC frontline staff 17)

CPE prevention, management and control part of social professional role and identity, specifically to protect patients

Facilitator

• Being the deputy in charge most of the time I’m in charge of the unit so I do need to be aware of it. It’s part of my role to be aware that you can at any time get patients with CPO. (General frontline staff 7)

• I’m the lead for the infection control team so responsibility to make sure that we educate staff and that we make sure they’re doing the right things in terms of CPE. (IPC frontline staff 4)

Taking initiative and ownership of CPE prevention, management and control efforts

Facilitator

• Basically, we took ownership of our own problem and tried to deal with it rather than just relying on rules and regulations that were around the rest of the hospital. (General frontline staff 16)

• We actively screen for it, and we’ve made a decision that we are going to do that. We’re not going to sit back or wait and see. (IPC frontline staff 21)

Motivation: Automatic Motivation

Concerns about CPE, its consequences and management

Facilitator/barrier

• I spoke to a colleague who happened to come here on a CPE accreditation inspection of the lab and they said that they were in a Trust where they had no idea how the CPE got out of control. That was really worrying to hear. He said that it just crept up on them and they couldn’t reduce the numbers despite multiple outbreak meetings and so on, so we are very proactive when we have multi-resistant organisms. (IPC frontline staff 23)

• In one way there’s not the fear, so that’s quite good, you know, people aren’t scared, if they get it they aren’t scared of it. But maybe if there was that awareness raising about CPE then it might encourage better compliance with hand hygiene or, you know, things that we can do to prevent it. (General frontline staff 11)