Discussion

This is the first known study to assess the feasibility of a patient-facing CHG skin treatment educational video. Patients found the video helpful and were comfortable watching the video. Most patients (n = 77, 65.8%) responded that they were “extremely likely” to participate in CHG skin treatments after watching the video.

Unlike other interventions (e.g., printed educational material, escalation pathways, scripting for staff), ^{Reference Destine, Capes and Reynolds9,Reference Engel, Meyer and McNeil13,Reference Charles14} our study did not see an improvement in CHG documentation compliance or patient refusal rates. In contrast to prior evidence, our study observed a significant increase in the rate of documented patient refusals following implementation of the video. This may be because documentation rates do not always equate to what is occurring in practice (i.e., a CHG skin treatment may have occurred but not been documented) or because the study heightened awareness of CHG skin treatments, leading to improved documentation, rather than a behavioral shift. Another consideration for the paradoxical increase could be because informed patients may feel more empowered to refuse. While the purpose of the video was to decrease patient refusals, it is worth noting that informed refusal is ethically preferable to uninformed compliance; this public health tension is highlighted by these findings. Additionally, as no patient identifiers were collected, it is unknown if the patients who viewed the video are the same ones who refused the CHG skin treatment; as such, interpretation of this contradictory result is challenging. As only an estimated average of 29.7% admitted patients viewed the video each month, it is reasonable to consider that the refusals stemmed from patients who did not view the video.

While there were no improvements in CHG documentation, there was a 27.2% decrease in CLABSI rates after implementing the video; although this reduction was not statistically significant, it is clinically meaningful. It may be possible that the video contributed to this reduction as those who viewed the video and completed a CHG skin treatment may have done so in a more accurate way; however, it is difficult to substantiate this interpretation. One patient noted that the video made them realize that they had been completing some parts of the CHG skin treatment incorrectly and the video showed them the “correct things to do.” Other studies have also found clinically meaningful reductions in CLABSI rates after implementing CHG bathing patient education. ^{Reference Reynolds, Woltz and Keating10,Reference Engel, Meyer and McNeil13}

Engagement with this type of intervention proved challenging with this study, as data from 7 units randomized to the intervention were not included due to poor participation. Anecdotal feedback from nurse leaders highlighted that this type of patient education intervention was considered a low priority among nurses and that there was limited time to provide the education. This sentiment has been identified in prior evidence showing that patient education is a frequently reported missed nursing care activity due to perceived low priority and competing work demands. ^{Reference See, Chee, Rajaram, Kowitlawakul and Liaw22,Reference Gustafsson, Leino-Kilpi, Prga, Suhonen and Stolt23} Additionally, providing patient education via a laminated handout differed from typical patient education workflows and may have contributed to low uptake. As such, embedding the patient education video within the nursing workflow and the electronic health record, which mirrors similar processes for other educational videos, may enhance future use of educational videos.

Challenges encountered in this study align with domains of the Consolidated Framework for Implementation Research, an implementation research framework. ^{Reference Breimaier, Heckemann, Halfens and Lohrmann24} Indeed, poor engagement was likely the result of challenges within the inner setting (e.g., unit culture wherein other quality metrics were given high priority, the unit’s readiness for implementation); the intervention itself (e.g., inability to incorporate the video within the electronic health record; low compliance with patient education in general); the process (e.g., lack of engaged champions, champions that changed units during the study); and the individuals involved (e.g., personal attitudes regarding the video). Given these challenging limitations with engagement in this type of research, further investigation is warranted.

Conversely, nurses and leaders within the BMT unit may have been motivated to participate in the study as the unit had a high baseline CLABSI rate (inner setting—readiness for change, strong unit culture of infection prevention; outer setting—incentive to reduce CLABSI rates). Additionally, as staff care for a high-risk immunocompromised patient population, they may be more accustomed to implementing infection prevention improvements (intervention—the video was filmed on the BMT unit with practicing nurses and admitted patients which may have led this unit to be more apt to use the video; process—engaged unit champion; individuals involved—strong beliefs regarding infection prevention).

This study has several limitations. While originally designed as an RCT, poor engagement resulted in data being analyzed from only one unit. The loss of other units reduced the overall sample size and decreased power needed to detect clinically significant effects. The unit included in data analysis was a BMT unit, which may limit generalizability to other unit types. Baseline CHG documentation compliance was high and the patient survey yielded high means for all Likert-scale responses; these findings may be affected by ceiling effects and social desirability bias.

To promote broad use of the video, specific exclusion criteria to receiving the intervention were not outlined (e.g., patients who did not speak English, patients who were unable to complete their own CHG skin treatment, history of delirium or dementia, cognitive limitations, blindness or deafness) which may have impacted the patient’s ability to engage with the intervention. Further, data collected on CHG documentation, patient refusals, and CLABSI rates included all patients admitted to the unit; as such, data from patients that may not have been able to engage with the video were still included which may have skewed the data. We were not able to link documentation results with data regarding which patients did or did not watch the video (e.g., did patients who viewed the video then refuse a CHG skin treatment during their hospital stay). It is possible that individual patients may have refused the CHG skin treatment multiple days, which would skew the data. Further, as no patient identifiers were collected when patients accessed the video or survey, it is unclear if some patients may have scanned the video or survey multiple times and would have been counted separately. Future studies may consider collecting this granular patient-level data to further understand the impact of patient-facing educational videos on subsequent behavior. Further, while Slicer Dicer is a powerful tool in the electronic health record, it was used to only search for discrete documentation data points; as such, nuanced data may have been missing. Lastly, as CLABSI is a high priority among the BMT population, concurrent quality improvement initiatives may have overlapped with the study period; we were aware of only one other formal project in which a nursing team implemented standardized CHG skin treatment printed educational materials during the study. Additionally, the current study did not have an adequate sample size to be able to differentiate among different central line types or CLABSI organisms; such sub-analyses should be examined in future studies.

This is the first known study to evaluate the feasibility of a patient-facing CHG skin treatment educational video in the inpatient setting. While patient feedback regarding the video was positive, there were no meaningful improvements in CHG documentation compliance or rates of documented patient refusals. A 27.2% reduction in CLABSI rates were found, although this decrease was not statistically significant. Future research that includes more diverse patient populations is needed to better understand the long-term impact of a CHG skin treatment educational video.