Our findings (see Table 2) address our research questions and are structured within the Context-Mechanism-Outcome framework.
RQ1: How did the context shape the ways in which the SRF was implemented?
Passion, will, and infrastructure coalesced around the SRF: ‘Genomics has come of age’
The context enabled the implementation of the SRF through the alignment of two key factors. Firstly, a pre-existing appetite to explore how sequencing could be used to manage healthcare-associated infections (HCAIs), and secondly, the availability of considerable infrastructure arising from the commencement of the COG-UK programme in 2020 to monitor emerging variants of SARS-CoV-2 across both communities and hospitals (24). Although this alignment emerged during COVID-19, data often also spoke directly to the future (‘building a legacy,’ Site 1; ‘a foundation for other viruses,’ Site 4). The extract below shows these elements and signals the considerable struggle of early implementation:
In a time of need, it might be the right time to really push down these barriers [to using sequencing for IPC] because actually, you probably lose the will to live if it wasn’t an emergency, I think at least we’re sort of pushing them down for the future, if not for now. (Site 1)
Passion and will to get the SRF to work was also reflected in several participants being willing to go above and beyond what would normally be expected of them professionally in order to get the SRF up and running.
It made me feel I was useful [in the pandemic response]. And that I could… I wasn’t just not, I wasn't just sitting around, I was able to provide something. (Site 3)
I’m spending time which I don’t have on it and at weekends and things like that…… I think my partner hasn’t seen a lot of me (Site 1)
There is a strong resonance between this theme and NPT’s contextual domain of “Reframing organisational logics” wherein ‘existing social structural and social cognitive resources shape the implementation environment’. It also chimes with NPT’s contextual domain of “Strategic intentions”. Here, both data and theory draw attention to these facilitative aspects of the wider context of the COVID-19 pandemic; it enabled the implementation of the SRF at structural, organisational and intrapersonal levels.
The impact of the Alpha variant: ‘Surrounded and deluged’
This theme shows how the temporal and epidemiological context was fundamentally challenging to the implementation of the SRF. Elements of this context included an unpredictable and increasingly complex work environment (working ‘90 miles an hour’ Site 3); high levels of staff illness; staff burnout (there was ‘a lot of trauma’ Site 3); the sheer volume of patients with COVID-19 (‘we shot off didn’t we, we got stratospheric’ Site 4). Participants talked of this context as a ‘vicious circle’ (Site 1) and that they were in ‘dire straits’ (Site 3): -
Well, we’re in a bad situation with Covid-19 in [city]. We’ve had many hospital onset infections across the whole of [NHS Trust], and that has affected both the patients in wards all-round the hospital... and it’s also obviously affected our staff as well, many of whom have been infected and also had to take time off for family members being infected as well. In terms of the sort of volume of… I mean… it’s everywhere and very difficult to control. And actually we’ve been swamped with it […..] just the sheer volume and the numbers.(Site 1, 628)
There is little immediate resonance between this theme and the theoretical content of NPT. However, it is possible to consider it as representing the unravelling of “Organisational logics” and the diffusion of “Strategic intentions”. Typical hospital function was severely challenged and capacity to implement the SRF was therefore deeply compromised.
Breaching capacity to act: ‘Everything grinds to a halt’
This critically important theme relates to a sense of the imposition of a COVID-related cap on hospital function: there were limits to being capable of responding to the changing COVID-19 situation, and relatedly, limits to the possibility of responding to SRF-delivered insights.
The infection control team, because the fact that there’s been so much, so many cases, obviously they’ve been completely overworked, and so have probably been less able to make reactive decisions based on sequencing results, as they’ve just not got the capacity to deal with all the outbreak areas that we’ve had (Site 2)
This theme resonates with two contextual domains within NPT: “Adaptive execution” and “Negotiating capacity”. “Adaptive execution” has particular resonance with the theme of breaching capacity to act. This NPT construct focuses on how context shapes actors’ ability to adapt the immediate environment to execute an intervention as intended. Participants talked at length of their diminished capacity to act: resources were stretched thin, staff were overburdened, ‘decimated with Covid related stuff unfortunately’ (Site 3), and wriggle room to initiate or reinforce the use of the SRF was either labile or limited.
The stressors on the organisation are such that I don’t think it’s a, I don’t think that the knowledge that transmission has occurred is leading to any intervention that would prevent further transmissions occurring, I think partly because pretty much everything that we’ve got the resource to do is being done….I don’t think the rapid turnaround is proving critical at the moment because of the weight of numbers, for the reasons that I just said, I don’t think we’ve got the resource to respond to it, and I think we’re doing pretty much all we can anyway. (Site 2, 694)
RQ2. Which implementation mechanisms were important for understanding how the SRF effected outcomes?
Effective communication catalyses a chain of action: ‘We’ve all come together to discuss those things and to look at the reports’
Communications, and the subsequent chain of actions flowing from them, constitute an important theme. On a fundamental level, the SRF was only a report - yet it had to, and did at times, catalyse people and a series of processes to enable changes to IPC. In this way, for the SRF to work, there had to be an alignment of diverse people (e.g., the bioinformatician, the microbiologist, the IPC team) and a constellation of congruent actions:
When we were in a flow of, ‘okay, we’ve got this patient come through’, this is the report, and speaking to [HOCI site PI], and then the nurses reacting to that, and making decisions based off of what we found in the reports, it was really interesting just to see the link between all of it, and just, how it can help (Site 5)
Some sites effectively capitalised on the coterminous turn to remote working and found ways of using digital platforms, such as Teams, as a focal point – or hub – ‘focusing in on what the actual team need to do their job’ (Site 1) to ensure a collective response to the SRF. Across the five sites and across time, the degree to which SRF-related communication catalysed IPC action differed. Not all sites managed to establish the ‘flow’ detailed above. Equally, over time, certain communication routes sedimented in response to the changing parameters of what was actually possible to do given the situation on the ground: -
When we first started the rapid phase I was then sending every single report to all the infection control nurses with interpretation, because we had so many, they asked me to stop because … I was basically clogging up their inboxes, […..] so I’ve bowed to their request, I’ve stopped sending those requests to them, I only send them where I think it’s actually going to make a tangible difference. – (Site 2, 694)
This theme clearly relates to the NPT constructs of “Collective action” – stressing the work that teams must do to make an intervention work in the way it is intended. However, there was a sense that this mechanism was particularly fragile and dependent on what local circumstances could permit through the progression of the Alpha variant wave.
New connections catalyse a chain of action
This theme highlights that success in the early implementation of the SRF initially relied on forging, and then sustaining, connections across teams within the hospital. New professional relationships and novel ways of working emerged – for example, between bioinformaticians, microbiologists and IPC nurses. The extract below captures this sense of connections being made ‘I think it’s enabled the development of collaborations that didn’t previously exist, so yeah, I mean it certainly has positives there that are long-term’ (Site 2, 694). New connections were not simply established and then remained static; they were dynamic and processual, as diverse staff understood the SRF and what it did, there was increased buy-in across different teams:
They [IPC nurses] definitely became interested and especially as it became clearer and clearer that data we were generating was useful and timely, yeah, they definitely became very keen and involved, it became more of a two-way process (Site 3)
In some sites, these new connections began to routinise and a new way of working crystallised around the SRF:
I can see it becoming embedded, it’s just a habit. So you say, “I’ve sent this off”, and then you need somebody to, so what we will do, we’ve now got somebody in the system who will go, email everybody, “This has been sent”, forty eight hours later. “Oh, it’s not back”, or, “Oh, it’s back, here it is”, and then I will go, “Oh, let’s discuss it”, and then she will say, “Oh, that’s interesting”. You know, so it’s a sys… it’s a habit as opposed to…. because it’s not normal [laughs]. (Site 1)
Once more, there is a clear dialogue with the NPT mechanism of “Collective action”. In some sites a new assemblage of people and processes came together to enable the SRF’s insights into transmission to be translated into IPC action.
Meetings matter and establish a chain of action
Echoing the theme above, this theme focuses on the ways that, in some sites, communications and connections coalesced and became routinised through regular and timely meetings. The two extracts below show contrasting aspects of this theme. Firstly, an example from a site in which the meetings seemed to work to support the SRF translating to changes to IPC; and a second where key players were not present within these meetings: -
You’d say, “This is what we’ve got”, and report back to the entire group, and it becomes part of the agenda, like under typing whole genome sequencing, “This is what our reports have said”, and then the team decides what that means. I think that’s the only way that it’s really going to work, otherwise it’s just an interesting thing for those of us who’ve got a niche interest. (Site 1, 928)
And so that’s probably an important thing to note here, is that, yes, you’ve got an infection control nurse and you’ve got a virologist and a surveillance officer in this MDT (multi-disciplinary team), but where are our clinicians and the managers from the area who are actually the ones in, on the ground, you know, on the shop floor, who are dealing with these outbreaks and who are best placed to probably take this information and take these actions forward? (Site 4, 490, p. 17)
This theme once more relates strongly to NPT’s “Collective action”. In the sites in which teams worked to formalise communication and connections, these meetings functioned as a means by which the wide variety of people collectively responsible for implementing the SRF could operate as a cohesive unit.
Time criticality and the acknowledged value of the SRF
This minor and somewhat complex theme, relates to the way in which over time – as the SRF was fully understood – staff realised that that there was only a brief window in which its output was probably useful to reduce new nosocomial infections: -
I mean, we have discussed it at some of our local meetings, but it's again it's back to the usefulness of it. It's very interesting to sit and look at it and, but if it's not current to what you're doing there's little point in sharing it with anybody else, is there? (Site 4, 299, p. 7-8)
This theme relates clearly to NPT domains “Coherence” and “Cognitive participation”. “Coherence” relates to practitioners understanding of how and why the intervention is being implemented. For the SRF to succeed, there was a reliance on staff understanding both the form itself and the need for a rapid response to it. Thoroughly understanding the SRF, however, also precipitates an acknowledgement of how important turnaround time was for it to be useful. This sense of understanding the SRF and its time-dependent diminishing returns relates to NPT’s “Cognitive participation”. The theme also resonates with NPT’s “Reflexive monitoring”; it ascribed the extent to which the network of people surrounding the SRF were effectively working together to ensure its success.
Understanding the importance of SRF attribution
This minor and complex theme captures the way that, for some staff, the effects of the SRF were intangible yet for others they were rendered visible. The SRF didn’t particularly change what some IPC staff did as it only changed the location and intensity of what they were doing. In other words, the repertoire of IPC behaviours remained the same. The two contrasting quotes below from the same site show this heterogeneity of experience: -
But my view throughout this is that actually we’re not doing anything differently for an infection prevention and control, we’re looking at standard infection control precautions and transmission-based infection control precautions, they have been there for a very, very long time, it’s just the application of them has probably come to the fore. (Site 5)
I think it was an eye-opening study, because we got to clearly see what the strains were, we got the information really quickly, but with other reports, or other methods, or other testing, it just wouldn’t have had the same effect for us as a team and our knowledge of what’s actually going on with our patients (Site 5)
Accordingly, for some, differentiation between their usual duties, and duties guided by the SRF, was difficult to grasp. This relates to the NPT construct of “Coherence”. Lack of attribution of the SRF to changing IPC behaviours could be considered the result of the ‘layers’ of people involved in the process by which the SRF led to meaningful action (i.e., the chain of actions) rendering the SRF invisible to some.
RQ3. How did people using the SRF imagine its effect on trial outcomes?
Partial success: the imagined outcomes of implementing the SRF
The final theme within our analysis relates to the ways participants talked about the assumed rather than measured outcomes from the implementation of the SRF during the trial. Perhaps unsurprisingly, given both the facilitative aspects of the context and the reported gravity of implementation challenges, there was a sense of partial success at the time of data collection. Although ‘Several bars’ (Site 3) were thought to have been met, ‘it’s all worked fairly well once we’ve ironed out the little initial creases’ (Site 2) there was also an acknowledgment of its likely limitations: -
I think it's got a lot of potential for the future. I think that, you know, as I say this is the first type of study that we've been involved in like this and I think there are lots of lessons to be taken away and learnt from this, and you've got to start somewhere, you know, because nothing's perfect right from the very beginning. So I think it's of value and I think it's worth, I'm glad we've been in it from the beginning. I think it's a valuable experience for our Trust and for our team, but its impact on patient care is not there yet. It needs refining (Site 4, 299, p.8)
Given the context of a short term non-randomised trial, rather than long-term normalisation of the SRF within usual practice, many key aspects of NPT’s outcome constructs were not directly relevant (i.e., ‘Intervention Performance’, ‘Relational Restructuring’, ‘Normative Restructuring’, and ‘Sustainment’). However, there is a sense in which the earlier analysis of mechanisms does capture some emergent prototypical implementation outcomes. In those sites in which chains of action formalised through effective communication, new connections and meetings, there is a sense in which relational restructuring was beginning and in which normative restructuring was occurring.