Discussion

This qualitative study was conducted to understand the experience of healthcare personnel involved in the implementation of a 2-year project focused on preventing CRE infections in a vSNF. Healthcare personnel demonstrated a functional understanding of the significance and transmissibility of germs such as MDROs (theme 1), and they described self-protection routines intended to protect themselves and their families from the spread of MDROs (theme 2). Participants expressed motivation and support for infection control, but they reported structural challenges to adherence and mixed beliefs regarding the effectiveness of some infection control methods (theme 3). In particular, healthcare personnel reported that time pressures and understaffing challenged engagement with infection control measures.

vSNFs care for chronically ill residents with medical requirements, such as chronic mechanical ventilation, who are similar to patients in hospitals. Concomitantly, the risk of MDRO spread in such nursing homes has exceeded levels of risk historically associated with hospitals. ^{Reference Pacilli, Kerins and Clegg2,Reference Prabaker, Lin and McNally4,Reference Lin, Lyles-Banks and Lolans11} However, infection prevention measures developed to prevent infection need to be implemented with sensitivity to the social environment of the skilled nursing home setting. In contrast with more medicalized spaces of care such as hospitals, nursing homes aim to operate as home-like environments for residents who are perceived as “family.” ^{Reference Stone, Herzig and Pogorzelska-Maziarz12–Reference Brossard16} As such, healthcare personnel may hesitate to implement infection control measures if such measures are associated with hospital-level medical care.

Effective education in nursing homes is challenging because many frontline personnel experience high rates of job change and often do not have an extensive background in science education. ^{Reference Squires, Linklater and Grimshaw9,Reference Koo, McNamara and Lansing17,Reference Zimmerman, Gruber-Baldini, Hebel, Sloane and Magaziner18} In the context of a quality improvement intervention that featured small-group and one-on-one educational sessions focusing on the epidemiology and control of CRE, we found that front line and management healthcare personnel in vSNFs achieved adequate understanding of germ theory concepts and antibiotic resistance (eg, recognizing the threat that MDROs represent, even if the bacteria are not visible). Their knowledge manifested in elaborate personal hygiene routines that personnel independently developed to keep themselves, their loved ones, and their residents clean. Previous studies have demonstrated that healthcare personnel are concerned with the risk to themselves, ^{Reference Wolf, Lewis, Cochran and Richards19,Reference Albrecht, Croft, Morgan and Roghmann20} highlighting underlying universal fears of contagion. ^{Reference Douglas21}

Although self-protective measures were consistently described by healthcare personnel, adherence to measures to prevent infections among residents was heterogeneous. For example, healthcare personnel were instructed to perform hand hygiene before and after resident care, but they observed that hand hygiene adherence was substantially higher after resident care than before resident care. ^{Reference Lin, Froilan, Makhija and Bensen7} This pattern of hand hygiene adherence suggests that healthcare personnel are highly motivated to prevent self-acquisition of MDROs (hand hygiene after touching a resident) but less motivated to prevent resident acquisition of MDROs (hand hygiene prior to touching a resident). Taken with the data presented here, our findings suggest that self-protection is a concern and a prime motivator for all frontline healthcare personnel.

Structural challenges related to perceived lack of time, staffing, and resources further complicated full adherence to infection prevention measures. This led to work-around behaviors such as reusing gloves or deciding not to wear a disposable gown during resident interactions. The provision of adequate resources has been shown to be linked to nursing home staff satisfaction. ^{Reference Lyles, Moore and Weiner8,Reference Wolf, Lewis, Cochran and Richards19,Reference Dumyati, Stone, Nace, Crnich and Jump22,Reference Mayer, Stone and Leecaster23} Furthermore, recent descriptive studies of global nursing home care show that staff are regularly overwhelmed and have high rates of burnout and job turnover. ^{Reference Rodriguez15,Reference Yamamoto-Mitani, Saito, Takaoka, Takai and Igarashi24–Reference Jones, Krein, Harrod and Mody26} The economic drivers of nursing home care are well established, and supply shortages and high levels of staff turnover are not new findings. ^{Reference Diamond27} However, by describing the structural challenges experienced by healthcare personnel, we can see the dependent relationship between organization level challenges and individual adherence to infection control measures.

Furthermore, challenges to implementing infection control measures could reflect healthcare personnel’s mixed beliefs about the effectiveness of infection prevention interventions. For example, a persistent belief in the superiority of soap and water compared with alcohol-based hand rub or CHG wipes led to inconsistent explanations of the cleaning routines expected of frontline healthcare personnel. Although education about germ theory and MDROs appeared to be successful in improving knowledge, healthcare personnel held opinions about appropriate cleaning that likely reflect prior experience and possibly beliefs related to what residents expect in a home-like setting. Educational efforts aimed at shifting understandings of the effectiveness of alcohol-based hand rub or 2% chlorhexidine bathing compared to the use of unmedicated soap and water would benefit from acknowledging and addressing beliefs among healthcare personnel in nursing homes. ^{Reference Saint, Howell and Krein28}

This study was conducted at a single vSNF in a region with endemic MDRO transmission; thus, our findings may have limited generalizability to regions with different MDRO epidemiology. However, given that vSNFs generally care for the sickest chronically ill nursing-home residents, the experiences described by the healthcare personnel at our study vSNF are likely to reflect challenges that other vSNF personnel will encounter in combatting antimicrobial resistance.

Understanding the motivations and perceptions of healthcare personnel provides a foundation for improving infection control interventions. Although healthcare personnel in a vSNF infection control education, adherence to specific intervention measures was mixed, in part due to structural challenges with supplies and staffing. Self-protection was a strong motivator for healthcare personnel, and such insight can inform the design of future infection prevention interventions.