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Table 2 Themes and illustrative data

From: Understanding determinants of infection control practices in surgery: the role of shared ownership and team hierarchy

Theme Sub-theme Illustrative quotation
Knowledge and skills Lack of continuous training Q 1: So, if I do a wound care dressing as what I knew from university … all like the basics that I’ve learned from taking the degree … I don’t think this is standardised across nurses … I cannot remember that someone has shown me that this is how you should do wound care. - Critical care nurse
Lack of peer sharing Q 2: When I do the dressing no one is there, so anyone who’s checking the dressing in that closed curtains, actually in my head I don’t know how they’re doing it. Do they do it the way I do, is it my practice it is the best, I don’t also know. - Critical care nurse
Policies, guidelines, or high-quality evidence to refer to Q 3: Before that I can only suggest maybe we shouldn’t be doing this, other people can see you like, oh, smartass is coming and saying oh, we should do this or that and what is your evidence? Well, there are multiple evidence, WHO guidance from 2016, for example... - Vascular surgical registrar
Ownership Surgeon’s reputation Q 4: if you have lots of wound infections, that would look bad on you, because it suggests that there may be a problem with your technique. - Cardiac registrar
Clinical team responsibility Q 5: Everybody who the patients, along the patient’s pathway is responsible for ensuring and in, especially the patient of course themselves, but everybody that the patient comes into contact with. - Theatre personnel
Feedback Q 6: “this happens in a cyclical manner in every hospital I’ve ever worked in, but there will always be a period of time where there’s lots of wound infections … And everyone will come up with a series of steps to try and reduce that, and what will happen is, the infection will go away and everyone will say it’s because of all we’ve put in place … And actually I think it’s because everyone’s more aware of what’s going on, and when you’re more aware of what’s going on, every step is better …- Cardiac registrar
Patient related factors Q 7: The majority of the SSIs we see are those who have, like, perforate, so they have a hole in the bowel, and then faeces, and then you do a big cut, a laparotomy, and then when you close that off there’s a high rate of an SSI because it’s a contaminated wound. But that you can’t control for. - General surgery registrar
Conflicting priorities Q 8: there are times where, for example, the patient arrests in theatre which has happened, and we have opened a chest without any preparation whatsoever, you just, normal gloves which are not sterile, but that’s a different situation where the patient’s essentially dead, or, but otherwise we have to go through the steps. - Cardiac registrar
Procedure types Q 9: in … elective surgery you know you should have essentially a close to zero infection rate in the majority of patients, unless they have got some significant problem. For trauma surgery I think that’s very different because you’re starting with a, at least a contaminated wound … - Plastics consultant
Consequences for patients Q 10: Now I suspect the ones who submit really good data and take this really seriously, are the ones who, for whom consequence of infection is a real clinical issue for those patients compared to, so that’s why in cardiac and orthopaedics certainly, for them, infection’s an absolute disaster. Whereas if you’re a general surgical patient, you get a of bit wound infection, that’s normally not a big deal because you can clear it up. - Plastics consultant
The power of awareness Q 11: … this happens in a cyclical manner in every hospital I’ve ever worked in, but there will always be a period of time where there’s lots of wound infections … And everyone will come up with a series of steps to try and reduce that, and what will happen is, the infection will go away and everyone will say it’s because of all we’ve put in place … And actually I think it’s because everyone’s more aware of what’s going on, and when you’re more aware of what’s going on, every step is better … - Cardiac registrar
Culture of hierarchy Fear of offending or provoking a negative reaction Q 12: Oh, definitely. There is hierarchy … there are people who … will do their way anyway, without, whatever you tell them it doesn’t, it wouldn’t really matter. [It’s harder to challenge someone] who’s very senior, yes. Yeah, it’s harder to challenge... - Vascular surgical registrar
Challenge with tact and a non-judgemental way Q 13: they’re not upset when they do it, because they, you have to do it with tact. You can’t be rude, aggressive or loud or do things with an attitude … your body language, your tones, your attitude be of one that they would listen to … you kind of whisper little things in the ear and you make a little joke about it and you be, throw in a bit of sarcasm on the sly and things like that … it’s a personality thing … - Theatre coordinator
Staff member’s official remit or area of expertise Q 14: It’s not so much that whoever holds the knife, as you know, you have met [nurse] … [nurse] never holds the knife but holds a lot of power...is empowered to actually cause a fuss if people are doing the wrong thing … - Cardiac surgical registrar
Q 15: It depends if it’s my specialty or not. If it’s for example a simple mistake of wrong prophylaxis I will challenge that … So, I think the hierarchy is only valid if you are within the team, if you’re outside the team and if you are a consultant in another specialty, you are confident in what you are doing without obviously being arrogant. - Microbiology consultant
Q 16: Personally, I feel comfortable, but I think that’s probably because I work within that specialty. If I was a junior pharmacist on the ward, who wasn’t specialising in infection, I think I would find it difficult to challenge perhaps a consultant who was coming along on a ward round with a watch or a suit jacket on, but to me, it doesn’t really faze me to do it. I’m used to it. - Infection pharmacist
Resources – human, financial, physical Skill mix Q 17: In cardiac surgery the SSI rate, it goes up and down … I think it’s a just a problem with the team being really incredibly busy, and not having enough work force to cope with the amount of [surveillance] work. - Microbiology consultant
Q 18: There was an interview and they found a person who did tissue viability nurse’s courses and other, so she will be probably over qualified to do only dressings … - Vascular surgery
Availability of other specialist staff as a resource Q 19: Every hospital has a different policy and the policy is based on what the microbiologist feels is the current, most important bacterial infections but also we have meetings between different departments to discuss that. The microbiologist tends to give the majority of the advice with some input from clinicians, so it’s mainly the microbiologist who decides what the antibiotic prophylaxis is. - Cardiac registrar
Q 20: I think it is well organised team for surgical infection site in our trust starting from the nurses and to surgeon between, for example in our department of orthopaedic as well as the plastic surgeon and the microbiology department and as well as pharmacy. - Orthopaedic surgeon
Q 21: … the referrals that I see, I don’t get referred that many but that doesn’t mean to say that it’s not, they’re not occurring or not being reported but I know there has been a slight increase in the number of SSIs occurring recently … because the GI surgery, they refer quite a lot and they want 7our opinion quite often, whereas other types of surgery … never refer. - Tissue viability nurse