3.1 Baseline characteristics
Three of the seven clinics were included in the focus groups. Two focus groups were hosted – one included staff from two clinics that implemented the full protocol, and the other focus group included staff from the clinic that implemented the CHG sponges only. Each focus group consisted of four to five participants lasting between 47–57 minutes online over Zoom. Two surgeons from two different clinics was interviewed lasting 19–20 minutes. Our total sample size was 11.
The baseline characteristics described in Table 1 include all participants that consented to our interviews and focus groups. However, 4 participants were unable to participate due to last minute scheduling conflicts at their clinic and did not withdraw their data. Data were anonymized upon collection, so we were unable to remove the 4 participants from the baseline characteristics data and they are included in Table 1.
Table 1
A summary of baseline characteristics of participants who consented to participation in from the focus groups and semi-structured interviews.
Characteristic | Frequency | Percentage |
Age (years) <30 30–40 41–50 51–64 | 3 4 2 6 | 20 27 13 40 |
Clinic role: Surgeon Registered Nurse Administration/Management | 2 8 5 | 13 53 33 |
Time worked in clinic (years) <5 5–10 11–20 >20 | 7 2 4 2 | 47 13 27 13 |
Gender Man Woman Non-binary | 2 12 1 | 13 80 7 |
3.2 Categories
Through the analysis process, the core category of clinic knowledge and understanding emerged. Seven different subcategories led to the core category of clinic knowledge and understanding. Subcategories included: 1) patient knowledge, 2) clinics requiring further development/planning, 3) clinic knowledge, 4) cost, 5) number of sponges, 6) provincial care pathway, and 7) MO prescription (Fig. 1). All subcategories were chosen based on relevancy from axial coding and are connected to the core category. Subcategory definitions are listed in Table 2.
Table 2
A summary of subcategory results from qualitative data collected from focus groups and semi-structured interviews.
Subcategory | Description |
1. Patient knowledge | Knowledge transfer between registered nurses (RNs) and patients resulting in patients’ knowledge in using a decolonization strategy and its importance. |
2. Clinics development/planning | Knowledge transfer central to clinics resulting in further development and planning to deliver a decolonization strategy for certain circumstances. Also includes current strategies that were useful. |
3. Clinic knowledge | Knowledge transfer between educators and clinical team members resulting in clinics knowledge in using a decolonization strategy and its importance. |
4. Cost | Cost effecting clinics motivation for the permanent implementation of a decolonization strategy. |
5. Number of sponges | Knowledge transfer between educators and RNs extending to knowledge transfer between RNs and patients. Often resulting in clinics and patients preferring 1 CHG sponge over 3 sponges. |
6. Provincial care pathway | Knowledge transfer gaps between the province and clinics. |
7. MO prescription | Knowledge transfer gaps between clinics and pharmacists. |
3.3 Core category: knowledge and understanding
The majority of positive and negative implementation activity traced back to the core categories of knowledge and understanding. Specifically, information and knowledge transfer points between clinics, patients, and stakeholders were the places and moments where understanding and so successful implementation was or was not achieved. The process of knowledge transfer consists of sharing collected knowledge with individuals, so they have access to utilize information necessary to succeed (10). When knowledge transferred successfully into an understanding of the decolonization strategy, it was a facilitator of implementation. Missing, or incomplete information of knowledge transfer, conversely, acted as a barrier to implementation. In the paragraphs that follow we describe the facilitators and barriers that participants experience at a range of knowledge transfer points from the top-down effect of the clinical care pathway. When knowledge and understanding amongst stakeholders had gaps or insufficiencies, barriers came forth in a variety of areas. These barriers and facilitators within the core category are explained through our subcategories.
3.4 Subcategories
3.4.1 Patient knowledge
Clinic staff felt some patients were confused by the decolonization strategy or chose not to comply. Confusion included clinics switching from one CHG sponge prior to this study, to then three sponges during the study period. Furthermore, clinic staff suggested that patients feel overwhelmed by the amount of information given during pre-operation teaching, and adding further education in the form of a decolonization strategy worsened this problem. Knowledge transfer between RNs and patients was inadequate at times when patients felt confusion from over sharing. At other times, knowledge transfer did not matter as patients did not follow through with the decolonization strategy regardless of what the RNs had said. Quotes from staff below describes this:
It's very overwhelming the amount of information they do get in preparation for surgery. And now you're throwing three sponges and asking them to add Mupirocin in their nostrils twice a day for five days leading up to surgery, I think it was overwhelming for a lot of patients.
“I do know some patients, when I would ask the questions at the two-week appointment, told me Yes, yes, I used everything. But then, if they came up for a second joint and then I would give them the sponges and say, You're going to do what you did last time. I had a few patients say, Oh yeah, I didn't use three sponges. Or, I didn't get the Mupirocin ointment. I just skipped that."
3.4.2 Clinics requiring development/planning
Clinics need more direction and planning on how to deliver decolonization strategy to patients in homecare, patients receiving second surgeries but only coming in for one education class, and during COVID-19 outbreaks. Overall, clinics wanted to give patients the decolonization strategy for these situations but could not figure out an effective way to do so. Each clinic develops their own protocols for implementing the decolonization to patients and this is knowledge transfer central to clinics. An example is outlined below:
I had the 89-year-old lady come in for hip replacement, who had home care to bath twice a week, who had somebody give her medication. I just made the decision not even to give her the ointment for the Mupirocin and just give her the one sponge, at least the home care nurse could help with the one sponge either the night before or the morning. So, those circumstantial patients where I just made the call to say, you know what, let's not even worry about this part of your pre-op and your preparation, let's just do the one sponge and be good with that. So, that was another barrier too.
Clinics came up with strategies to efficiently deliver the decolonization strategy. For example, in staffs down time they would prepackage CHG sponges with instructions inside. Clinics felt the prepacks made the decolonization easier for patients and aided in facilitating the decolonization strategy. The quote below explains the process:
We took the three sponges in a plastic package that was sealed with the instructions and stuff and we faxed the prescription right to their pharmacy to make that ease of ensuring that step was done and they weren't responsible for that at least. And I think that made it fairly easy for the patients that they had what they needed, and all they had to do was go pick up the ointment, and they had the checklist and everything as well.
3.4.3 Clinic knowledge
Surgeons stated that they have read the existing literature on a decolonization strategy but, clinical staff such as RNs or administration staff did not read the supporting literature. The knowledge transfer between educators and RNs or administration may have differed from the education surgeons received. Staff was given a one-page information sheet on the decolonization strategy as part of the implementation; however, staff members stated they could not recall what was on the sheet. Some clinic staff felt less motivated to deliver or support a decolonization strategy because they had not read the supporting evidence. While clinic staff understood a decolonization strategy reduced SSIs, staff made statements about not wanting to continue a full decolonization strategy without seeing compelling evidence as it is more time consuming and expensive. The concept is illustrated in the quotes below:
So, I think it would probably be effective if somebody had an existing issue, but I think it's maybe... I don't know. I didn't review the literature. I don't know how many people would come into surgery with pre-existing infection. So, I'm not sure it's cost effective.
I don't think we had any formal education, either information on what to anticipate with the study, to be honest. And to just elaborate on that, I'm still getting questions from surgeons. I actually got a phone call from one of our internists just recently who does a lot of the pre-op consults asking me why we're using the ointment. So yeah, he had no idea why the patients were having that done.
3.4.4 Cost
Clinics felt decisions that are made which effect cost, need to be evidence based in order to support the additional cost. Staff felt a decolonization strategy is cost effective and saves money if it reduces the incidence of infections but not all staff members were convinced a decolonization was cost-effective for their clinic. Among clinic staff there were mixed opinions on whether a decolonization strategy was worth the cost. For example:
“So again, that comes down to the economics of who supplies these things. And it's a little bit complex, right? It's not like we function like a private hospital, for example, where the hospital supplies all this because they don't want to see infection. Right. We have to convince AHS or whatever to supply these things to our patients, I believe. And then they have to, you know, that's where, because ultimately of course it benefits us, but there's just some economics of how the clinic runs. I think that also might be a factor in, in how this is, or why it may or may not roll out, I think.“
3.4.5 Number of sponges
Prior to this decolonization strategy, interviewed clinics were using one CHG sponge. Staff did not see the difference between one and three sponges or how three sponges would be more beneficial. This is an issue of knowledge transfer between educators and clinic staff. Staff also felt that it was more difficult to use three sponges versus one and that it was more difficult for the patients as well. Therefore, the issue of knowledge transfer between RNs and patients applies as well. Clinic staff were more motivated to use one sponge rather than three as demonstrated in the quote below:
“I would go with the one just because we don't have to prep the three packages. I believe it's easier to explain to the patient because then it's like, "Hey, use this scrub the night before or morning prior," versus the three. "Okay, you have to use this three days leading up to your surgery," because there is older people out there that get confused off of the littlest things. So, remembering to use the three leading up is probably a lot more confusing than, "Okay, you just have one scrub. Please use it either the night before or the morning prior, whichever is easier for you." So, my vote is the one is probably the best, unless there was some type of evidence that, "Yeah, okay. The three is better. It's preventing infection better than versus the one."
3.4.6 Provincial care pathway
There clearly were gaps between clinics knowledge of the care pathway and what the care pathway is currently recommending. This left clinics feeling confused on what strategy to use once the study was completed meaning there is a lack of communication and knowledge sharing between the province and clinics. Alberta’s clinical care pathway had made changes in 2020. While some clinics stated they were following the care pathway, they had incorrect information on what the pathway was. Other clinics had not known there was a change in the pathway at all. The following quote illustrates this:
Well, because as I said before, I think that we agreed to be part of the decolonization study, and I was not aware that it actually had been put into the care path, right? So, to me, care path is, this is the way we should be doing this work. But to me there was no discussion or even, I think shared decision making on that being part of the care path because it does affect our bottom line, right? And so, I actually went after the fact after we'd started because I wanted to see what does the care path say? And all of a sudden, it was in the care path that this was what we were supposed to be doing for prepping our patients pre-operatively.
3.4.7 MO prescription
The knowledge transfer between clinics and pharmacists needs improvement. Problems arose with MO prescriptions such as pushback from pharmacists giving the prescription to patients as pharmacists may not be familiar with this type of decolonization strategy. Staff reported that some patients did not pick their MO prescription up and various methods of giving patients prescriptions were used in each clinic. Some clinics called and ordered the MO prescription ahead of time for the patient, so the patient only had to go pick it up from the pharmacy. Staff felt this made it easier for the patient. Other clinics provided the MO prescription simultaneously with the CHG sponges. The quote below highlights some issues the clinics faced with patients obtaining MO prescriptions:
“Just to elaborate a little bit more on what […] said, that's exactly what happened to us as well, and that's why we had to generate it through our EMR and fax it for the patient as well. And then of course, we had to specify on the prescription that it was used for decolonization study because some pharmacies would call us and go, "Well, we don't usually, typically administer this ointment in nostrils," so we need to specify that. So, that was a bit of a barrier of our end too that we had to generate through our EMR as well.