To the authors’ knowledge, this is the first study to have investigated factors which influence the acceptability of CPE screening and management from the perspectives of both nursing staff and the general public, using the TDF. Given the global threat of CPE, and the continued emergence of new multi-drug resistant organisms, understanding those barriers and enablers which may influence the acceptability of screening is fundamental to improving screening uptake and thereby reducing the risk of CPE transmission in hospitals. Using TDF to guide the research means that influencing factors can be mapped to specific behaviour change interventions to guide future recommendations.
Whilst regression modelling identifies specific variables found to predict the acceptability of CPE screening, of particular interest to this discussion is the influence of the theoretical domains of ‘knowledge’, ‘environmental resources’, and ‘social influences’, which were common to both nursing staff and general public groups.
For both nursing staff and the general public, knowledge and awareness of AMR in general and CPE in particular were associated with greater acceptability of CPE screening. For nursing staff, knowledge may lead to greater appreciation of the potential severity of consequences of CPE infection and possibly shape attitudes towards the acceptability of screening procedures. However, fewer than half of the nursing staff respondents agreed that the consequences of CPE would be severe. If, as we found, greater acceptability is influenced by belief in the severity of consequences, then nursing staff must be supported to develop greater understanding of the potential severity of CPE. However, providing opportunities to develop staff knowledge and awareness can be challenging. Similarly, whilst the ‘intention to conduct screening in line with hospital policy and procedure’ was an important predictor in explaining staff perceptions of CPE screening acceptability, just over half of respondents agreed they had been made aware of hospital policy. This emphasises the pivotal link between ‘environmental resources’, as an enabler, and nursing staff ‘knowledge’; resources are required to facilitate staff training about CPE policies and thus influence staff attitudes towards the acceptability of screening. This finding echoes the work of Parker et al. [20], who also report the challenges in addressing low staff awareness of CPE and providing educational opportunities across intensive care units in three New York hospitals.
Knowledge about AMR was also one of the most important factors in understanding the public’s acceptability of CPE screening. The O’Neill Report [21] highlights the ‘urgent priority’ of a global public awareness campaign as a means of tackling AMR. A recent systematic review [22] considered 54 studies and concluded that the public have an incomplete understanding of antibiotic resistance, misconceptions about its causes, and do not believe they contribute to its development. However, there is some evidence from systematic reviews that by increasing awareness and knowledge of AMR, demand for and prescription of unnecessary antibiotics shows decline [23, 24]. In the context of the acceptability of CPE screening, our results indicate that knowledge of AMR enables a broader understanding of why CPE screening, and rectal swabbing in particular, is important. Therefore, increasing public knowledge about AMR more broadly is likely to increase personal acceptability of CPE screening, and associated consequences of being cared for in isolation, for patients. Thus, the issue of public awareness of AMR, in general, requires to be addressed.
The fact that ‘careful explanation of CPE screening from a healthcare professional’ also predicts personal acceptability indicates the ‘social influence’ that nurses may have on patients’ attitudes. This finding has parallels with the recent work of Dyakova et al [14], who reported a reduction in the number of research study participants who refused to consent to a rectal swab after the explanation of the procedure had been simplified to focus on providing a consistent message around potential benefits to patients and their peers. The influence of the nurse in this situation also underlines the importance of nurses having adequate knowledge themselves, in order to explain the reasons for screening to patients. This point reiterates the link between nursing ‘knowledge’ and their capability to exert ‘social influence’ in this situation.
Other social influences are at play from both staff and patient perspectives. Beliefs regarding asking patients to self-swab also made a notable contribution to explaining the variance in CPE screening acceptability for nursing staff. Staff appear to believe that the procedure is embarrassing for patients and consequently think it would be more acceptable if those patients that were able to, self-swabbed. This is a concern, as the effectiveness of rectal self-swabbing has not yet been shown to be reliable in the context of CPE screening. A study of the sensitivity of rectal versus perineal swabs for detecting ESBL Enterobacteriaceae [14] showed that rectal swabs were around two times more sensitive than perineal swabs for detecting the organism and that staff-collected swabs resulted in higher detection rates than patient-collected swabs. Unfortunately that study gave patients the option for staff or self-swab, but did not compare staff and self-swabbing in the same patient. Further research to assess the reliability of self-swabbing in this context is required. Conversely, despite the concerns expressed by nursing staff, the general public survey demonstrated high levels of ‘strong agreement’ that rectal swabbing was acceptable.
Wider ‘social influences’ also predicted the personal acceptability of CPE screening for the public. This variable captured people’s perceptions of social responsibility regarding screening (they felt it was their and other people’s social duty to be screened). The role of such social norms in determining behaviour is debated in the literature; for example, a meta-analysis of 196 studies undertaken by Manning [25] suggests that whilst there is a relationship between injunctive norms (a behaviour perceived to be approved of by others in a social group) and actual behaviour, this is not always strong. However, our findings suggest that providing the public with information about social norms, noting that most people find screening acceptable, as well as focusing attention on ideas of collective action or the public good, may well increase the personal acceptability of CPE screening; further research is required in this area.
Whilst views from across a range of ages and geographical distribution of the public were obtained we make no claims on the representativeness of the general public sample. However, the sample sizes did meet power calculation requirements for both nursing staff and the general public. A key strength of the study is the integration of psychological theory, in the form of TDF [15], which enables the development of targeted, psychologically based interventions. Work by Mitchie et al. [26], based on the TDF, has identified a wide range of potential interventions, or taxonomy of Behaviour Change Techniques (BCTs), which can be proposed in response to identified barriers or enablers within specific theoretical domains. This means that future interventions to address the barriers and enablers to the acceptability of CPE screening (knowledge, environmental resources, social influences) can be determined on the basis of well-established behaviour change principles.