(2023) 23:109
Tropea et al. BMC Geriatrics
https://doi.org/10.1186/s12877-023-03766-9
BMC Geriatrics
Open Access
STUDY PROTOCOL
IMpleMenting Effective infection prevention
and control in ReSidential aged carE (IMMERSE):
protocol for a multi-level mixed methods
implementation study
Joanne Tropea1,2* , Sanne Peters3,4, Jill J. Francis3,5,6,7, Noleen Bennett8,9,10, Deirdre Fetherstonhaugh11,
Kirsty Buising12,13, Lyn-li Lim8, Caroline Marshall13,14, Madelaine Flynn15,16, Michael Murray11,17,18, Paul Yates17,18,
Craig Aboltins19,20, Douglas Johnson2,21, Jason Kwong18,22,23, Karrie Long24, Judy McCahon25 and Wen K. Lim1,2
Abstract
Background Older people living in residential aged care facilities are at high risk of acquiring infections such as
influenza, gastroenteritis, and more recently COVID-19. These infections are a major cause of morbidity and mortality
among this cohort. Quality infection prevention and control practice in residential aged care is therefore imperative.
Although appointment of a dedicated infection prevention and control (IPC) lead in every Australian residential aged
care facility is now mandated, all people working in this setting have a role to play in IPC. The COVID-19 pandemic
revealed inadequacies in IPC in this sector and highlighted the need for interventions to improve implementation of
best practice.
Methods Using mixed methods, this four-phase implementation study will use theory-informed approaches to: (1)
assess residential aged care facilities’ readiness for IPC practice change, (2) explore current practice using scenariobased assessments, (3) investigate barriers to best practice IPC, and (4) determine and evaluate feasible and locally
tailored solutions to overcome the identified barriers. IPC leads will be upskilled and supported to operationalise the
selected solutions. Staff working in residential aged care facilities, residents and their families will be recruited for
participation in surveys and semi-structured interviews. Data will be analysed and triangulated at each phase, with
findings informing the subsequent phases. Stakeholder groups at each facility and the IMMERSE project’s Reference
Group will contribute to the interpretation of findings at each phase of the project.
Discussion This multi-site study will comprehensively explore infection prevention and control practices in residential aged care. It will inform and support locally appropriate evidence-based strategies for enhancing infection
prevention and control practice.
Keywords Infection prevention and control, Nursing homes, Residential aged care, Best practice, Implementation
science, Organisational readiness, Behaviour change, Mixed methods
*Correspondence:
Joanne Tropea
Joanne.Tropea@mh.org.au
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Tropea et al. BMC Geriatrics
(2023) 23:109
Contributions to the literature
• This multi-level mixed-methods study will use a
range of implementation science frameworks to
investigate and inform infection prevention and control practice change in residential aged care.
• Findings will enhance our understanding of current
practice, including organisational readiness, and barriers to implementation of best practice infection
prevention and control in residential aged care.
• The research team will work in collaboration with
infection prevention and control leads and other key
stakeholders to determine and facilitate contextually
tailored implementation strategies to overcome barriers to best practice infection prevention and control. This approach aims to optimise acceptability and
sustainability of practice change.
Background
Residential aged care facilities (RACFs) or nursing homes
frequently experience outbreaks of common communicable infections such as viral respiratory tract infections
and gastroenteritis which have significant consequences
for residents. These outbreaks occur for several reasons.
Residents live in close proximity to one another, share
living areas and bathrooms, and are exposed to frequent
close interactions with many different staff and visitors
who might themselves carry infection [1]. Some residents exhibit behaviours that favour spread (wandering
behaviours), and some do not have the capacity to following infection control interventions such as staying in
their rooms, disinfecting hands, or practising respiratory
etiquette. Residents are also generally old and frail, with
multiple comorbidities, making them more vulnerable
to significant morbidity and mortality from these infections. A 2018 national survey of Australian RACFs found
45% had experienced an influenza outbreak and 31% a
gastroenteritis outbreak in the preceding 12 months; and
12% of these outbreaks were associated with deaths of
residents [2]. The COVID-19 pandemic has further highlighted the vulnerability of this population; in Australia,
the pandemic has disproportionately affected residents.
As of 22 April 2022, a total of 3873 COVID-19 outbreaks
had occurred in more than 2000 RACFs; over 31,000 residents contracted the virus and 2096 residents died with
COVID-19 [3]. Deaths among residents made up 30% of
all deaths associated with COVID-19 in Australia [4]; this
figure was even higher prior to the rollout of COVID-19
vaccinations and the Omicron variant.
Staff caring for people in RACFs must therefore ensure
effective infection prevention and control (IPC) practices
are in place both to prevent and respond to infections.
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These practices include early recognition of infection and
action to contain the source using appropriate cohorting or isolation strategies, personal protective equipment (PPE), and hand hygiene [5]. Effective IPC not only
requires a workforce with IPC knowledge and skills, but
needs systems, administrative and environmental controls which enable appropriate behaviours [6].
Investigations into COVID-19 outbreaks in Australian RACFs highlighted IPC challenges at multiple levels [7, 8]. Organisational and system level challenges
that contributed to outbreaks were identified, including
poor leadership and management skills, problems with
human resources most notably severe staff shortages,
difficulties with procurement of PPE and other supplies;
problems with the physical layout of buildings, lack of
space and inability to separate residents or staff workflows. Issues at the team and individual staff level were
also reported, including suboptimal staff communication
strategies, inadequate training of staff, and lack of access
to clear information in a timely way. To provide further
context, Table 1 below describes the Australian residential aged care sector and some of the workforce and
resource challenges faced by the sector. It also describes
the introduction of IPC leads that the Australian government mandated in response to the COVID-19 outbreaks
in aged care.
The IPC challenges described above are not unique
to COVID-19 but apply to other infectious diseases. A
rapid Cochrane review, undertaken at the beginning of
the COVID-19 pandemic to inform COVID-19 management, explored organisational, environmental, and
individual barriers and facilitators to healthcare workers’ adherence to IPC guidelines for respiratory infections [19]. They found organisational factors such as
high workload, limited training, limited PPE; and environmental factors such as insufficient space to isolate
patients, anterooms and bathroom facilities influenced
their ability to adhere to IPC guidelines. Individual-level
factors were described in terms of healthcare workers’
attitudes, knowledge, and beliefs. Perceived enablers
included feeling supported by managers; seeing value
in the guideline; being motivated by fear of infecting
themselves, their family, and others; feeling responsible
for their patients; and feeling their safety was valued by
management. Most studies included in the review were
conducted in hospitals; and the authors acknowledged
the lack of research in RACFs [19].
To date, improvement in evidence-based practice in
Australian RACFs has been largely driven at the system
level by mandated requirements. These include government directives mandating staff influenza vaccinations [20]. Although many initiatives to improve IPC
have been introduced, IPC implementation studies in
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Table 1 Residential Aged Care Sector: context of the current study
Australia’s residential aged care sector is complex, with over 800 residential aged care providers from the private (for-profit), not-for-profit, and government sectors operating over 2700 RACFs [9]. Workforce turnover in the sector is high: the 2020 Australian Workforce Census reported 29% annual direct
care staff turnover and 37% turnover of registered nurses in residential aged care compared to the national average of 7.5%. [10, 11]
Compared to hospitals, RACFs have fewer IPC resources such as on-site clinical staff with IPC expertise, and many have less direct access to diagnostic
and support services. Staff responsible for IPC usually have multiple other responsibilities and are not trained to the same level as IPC practitioners in
hospitals [12, 13]. There is also wide variation in staffing levels and skills mix in general, as highlighted by the Royal Commission into Aged Care Quality
and Safety (2021) which found over half the residents were living in facilities with unacceptable levels of staffing [14]. Studies have also shown lower
levels of staffing in RACFs, in particular, low proportions of registered nurses, were associated with greater risk of COVID-19 outbreaks [15, 16]
Aged Care IPC leads: As part of the Australian Government’s response to COVID-19 outbreaks in residential aged care, as of 1 December 2020 every
RACF is required to appoint an on-site nurse as the IPC lead. The IPC lead role is to ensure the RACF is optimally prepared to prevent and respond to
infectious diseases [17]. IPC leads must complete a specialist training course, be employed by the facility, and report directly to the provider. They are
required to observe, assess, and report on IPC practices, help develop procedures, and provide advice to improve IPC within the service [17]
Several challenges related to the Aged Care IPC lead program have been reported, including a lack of a clear role description, new processes that
added burden to an already overburdened job, issues related to the IPC lead training such as having to complete the training in a short period of time
(6-month course condensed into 3-months) [18]. Many IPC leads have been appointed from existing members of the nursing staff and they tend to
have a much broader role in the facility
aged care are lacking; and implementation strategies to
improve IPC practice from other settings such as hospitals are often not transferrable to RACFs because of
differences in the skill mix of the staff, complexity of
the residents’ conditions, and the limited availability of
IPC expertise and resources [21]. In addition, there is a
poor understanding of how change processes can take
place and how contextual factors might influence the
effectiveness of implementation strategies [22]. What is
needed is a clear evidence base to guide how IPC practices can most effectively be implemented in RACFs
that take into account variation at both organisational
and individual staff levels. Calls for action to improve
IPC in RACFs have clearly been made, but such interventions need to be guided by evidence to optimise the
likelihood of success.
The IMMERSE study aims to address these gaps in the
evidence base. It is a mixed-methods, theory-informed,
multi-level implementation project that will use an iterative approach and work in collaboration with IPC leads.
In acknowledgement of the key role of contextual factors in supporting change, organisational readiness for
IPC practice change will be investigated [23, 24]. A full
range of behaviours required from various staff that contribute to effective IPC will be explored using a structured approach (the Actor, Action, Context, Target, Time
framework [25]). Localised barriers to performing these
behaviours will be investigated using the Theoretical
Domains Framework (TDF) to identify priority domains
which can be addressed by specific behaviour change
techniques (BCTs) [26, 27].
Local customisation is key for IPC practices, and it is
expected that a ‘one size fits all’, ‘top-down’ approach is
unlikely to be successful. The IMMERSE research team
will therefore work in close collaboration with the IPC
leads and other key RACF staff to operationalise the
selected BCTs in ways that are feasible and appropriate
at each RACF. The project will also explore the acceptability of a community of practice for IPC leads to share
learnings and resources, to support communication
and networking, and provide up-to-date information
[28, 29]. Similar community of practice models have
been shown to improve healthcare provider knowledge,
improve role certainty, provide social support that fosters change in provider behaviour and hence improve
patient outcomes [30].
Methods
Study aims
The study aims are to: (i) assess organisational readiness for IPC practice change in participating RACFs;
(ii) specify and prioritise component behaviours of good
IPC practice including actions performed by a full range
of RACF staff; (iii) identify barriers experienced and
anticipated by a full range of RACF staff in performing
the identified component behaviours of good IPC practice; (iv) determine feasible, locally relevant, and acceptable solutions to address the identified barriers; and (v)
upskill the IPC leads to facilitate practice changes to
improve and sustain IPC, including the potential for a
community of practice to support IPC leads.
Study design
This is a multilevel, mixed-methods implementation study,
with four phases (Fig. 1). Stakeholder groups at each facility and the IMMERSE project’s Reference Group (carer
advocacy, industry, and government representatives) will
contribute to the interpretation of findings at each phase
of the project. This study was approved by the Melbourne
Health Human Research Ethics Committee (HREC/81901/
MH-2022) for conduct of the study across all sites.
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(2023) 23:109
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Fig. 1 Study phases
Setting and inclusion criteria
RACFs in metropolitan Melbourne and regional Victoria are eligible to participate. Ten RACFs will be
recruited, with representation of metropolitan and
regional locations, small, medium, and large sized,
private, public, and not-for-profit providers, and
culturally and linguistically diverse RACFs. Purposive sampling will be used to ensure representation
from a diverse range of RACFs. RACFs suggested by
the IMMERSE investigators (who have extensive networks and depth knowledge of RACFs in the region)
will be invited to participate. Information leaflets will
be sent with an email invitation to RACF managers
of potential RACFs, and online meetings will be held
with members of the project team and the RACF manager and IPC lead to introduce the research team and
present background information, benefits, and risks
of being involved in the project and what would be
involved. The IPC leads are crucial participants in the
project, and only RACFs with IPC leads who agree to
consent to participate will be included. Collaborative
research agreements between the RACF providers and
the IMMERSE lead investigator will be documented
and signed.
Participants
Staff
A full range of staff employed at the RACFs will be
invited to participate in the study, including facility and
clinical managers, IPC leads, nurses, personal carers,
food services and cleaning staff, and other direct care and
ancillary staff.
Residents and family visitors
Residents and family visitors who can understand English, and residents with the capacity to give informed
consent will be invited to participate in the study. Family
participants must be at least 18 years old
Data collection and analysis
Phase 1 will explore organisational readiness for change
and existing IPC program components at the level of
individual sites. There will be three data collection activities: (i) staff survey of organisational readiness for change;
(ii) IPC lead and/or facility manager survey of local IPC
program components; and (iii) follow-up interviews with
staff, residents, and family visitors about their experiences of IPC program components.
Survey of organisational readiness for change
The staff survey of organisational readiness for change
consists of the Organizational Readiness for Implementing Change (ORIC) [31], and items from the
Organizational Readiness to Change Assessment
(ORCA) Context Assessment scale [32]. The ORIC is
a validated tool for measuring organisational readiness. It assesses change commitment (5 statements)
and change efficacy (7 items). Each of the 12 items is
scored using a 5-point Likert scale ranging from “Disagree” to “Agree”. The ORCA instrument consists of
77 items measured on a 5-point Likert scale to assess
three primary scales—evidence, context, and facilitation. Items relevant to the project were selected from
each subscale of the context scale, and the Likert scale
was modified to be consistent with the ORIC scale.
All staff will be invited to complete the organisational
readiness for change survey. Participation in the survey
will be voluntary and consent implied. This approach,
as opposed to seeking prior consent, will facilitate
greater uptake of the survey and increase likelihood of
sufficient responses at each facility to be able to infer a
valid organisational-level response.
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Survey of IPC program components
Recruitment of residents and families for interviews
IPC leads and facility managers will be asked to complete
the survey of IPC program components. The survey has
been developed for the purposes of this research; item
development was informed by a review of the literature
on core components of IPC programs in RACFs, international and national IPC guidelines, and input from
the IMMERSE Research Team and Advisory Group. It
includes items on IPC personnel, IPC policies and procedures, staff IPC training, resident and family engagement, staff and resident health and safety, surveillance,
IPC program reporting and governance, and antimicrobial stewardship.
The surveys will be pilot tested at non-participating
facilities using think-aloud interviews to assess whether
items are clear and elicit expected responses [33]. They
will be tested among staff from culturally and linguistically diverse backgrounds, and where required, changes
will be made in response to their needs.
Surveys will be sent electronically via email or short
message service (SMS) using Research Electronic Data
Capture (REDCap) [34]. Hard copy versions will be sent
upon request or at RACFs with low uptake. Research
staff will enter hard copy survey responses manually into
REDCap.
Residents and family carers from the RACFs will be
invited to participate in face-to-face or phone interviews.
IPC leads and other senior nursing staff will be asked to
nominate residents who have capacity to consent to participate, and to provide the contact details of family carers who may be interested in participating. Input from
family members of residents who do not have capacity
will be sought, for example family members of residents
with advanced dementia.
While on site visits, research staff will approach residents and family visitors in person to inform them about
the project and invite them to participate. In the event
of difficulty recruiting family carers for interviews, letters of invitation with the plain language statement will
be sent by post or email to family carers and follow up
phone calls made by the researchers. Interviews will
then be scheduled with family members interested in
participating.
Participation in interviews is voluntary. Those who
agree to participate will be provided with plain language
statement and written consent will be obtained. Verbal
consent will be sought from family members who agree
to participate in interviews by phone or web-conference.
As a token of appreciation, the IPC leads and other staff
who participate outside their work hours, and participating residents and family members will be offered a gift
voucher as acknowledgement of the time taken to be
interviewed.
Follow‑up interviews
Follow-up site visits will be conducted to verify the IPC
program survey responses and collect further details on
the IPC program and organisational readiness via semistructured interviews with staff, residents, and family
visitors. Individual or small group interviews will be conducted at each site with a purposive sample of eight multidisciplinary staff, one or two residents, and one family
member. The researchers will use a “walk-and-talk”
approach to verify locations of IPC-related procedures,
staff training logs, equipment, and resources. The “walkand-talk” approach will take place within the RACF, and
it functions as a situated interview in which contextual
triggers might enhance the participants’ descriptions and
make the responses to the interview questions more concrete and locally relevant. The researchers will take notes
during and after the interviews, and a summary of the
interviews will be sent back to participants for verification. Interviews with family members and residents will
collect information about their involvement and engagement in IPC at the RACF. Interviews with residents and
family members will be audio-recorded and transcribed
verbatim for analysis, and the researchers will take notes
(for example, how and where the interview took place,
interruptions, non-verbal cues). The researchers will also
collect data on turnover of senior staff and management
for the duration of the project.
Data analysis
Survey data will be exported from REDCap into statistical software for analysis, and descriptive statistics will be
used to summarise survey item responses. Initial exploration of ORIC and ORCA survey scores will include
inspecting overall RACF-level responses. If warranted,
further exploration of differences between RACF group
responses and healthcare worker groups will be examined using one-way analysis of variance (ANOVA) for
parametric distributed or Kruskal–Wallis for non-parametric distributed data, with level of significance set at p
level = 0.05.
Interview notes and transcripts will be coded and analysed by two researchers (JT, SP) using thematic analysis [35, 36]. The coding process will take an inductive
approach, with themes and codes identified and derived
from the data rather than working with pre-identified
themes and codes. Initially, both researchers will code the
interviews from the first RACF together to formulate a
codebook. They will then code the second interview independently and will review the coding together and reach
consensus through discussion, amending the codebook
if required for further clarity. Coding of the remaining
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interviews will be completed by one researcher, with a
small sample independently double coded to assess interrater reliability (Kappa; κ).
Analysis will proceed separately for each RACF. The
QSR NVivo software program [37] will be used to assist
with storage, coding and searching of data. Survey and
interview data will be triangulated using structured
methods, as described in Hopf and colleagues (2016)
[38], to assess the extent to which the RACF is ready for
innovation and has the appropriate IPC infrastructure in
place.
Data reporting
A summary of the findings will be presented to participating facilities. Where areas for improvement are identified, evidence-based solutions will be utilised. Where
there little or no evidence base, the researchers in collaboration with RACF staff will determine solutions and
make recommendations to address them. These recommendations will leverage simple, less costly, and existing solutions (resources, networks and supports) and
where more costly and time-consuming solutions are
required, we will advocate for the development of specific
resources and supports. RACFs will then be invited to
participate in Phase 2 of the project.
Phase 2 will investigate staff behaviours relating to
current IPC practice and compare this to guideline recommendations to identify gaps in practice. This will be
followed by identification of barriers to translating IPC
guideline recommendations and principles into practice.
This phase consists of three key activities: (i) scenariobased assessment of IPC practice; (ii) document analysis
of key IPC procedures; and (ii) exploration of barriers
using the TDF.
Scenario‑based assessment
Staff will be guided through hypothetical sequential
descriptions of two common IPC scenarios; one focussing on reactive and one on proactive IPC practice. These
scenarios will be developed by the IMMERSE Research
Team; and the preferred sequence of actions for each scenario will be mapped out using the Action, Actor, Context, Target, Time (AACTT) framework for specifying
behaviour, including team-based behaviours [25].
For each scenario, staff will be asked to describe individual and team level behaviours, including how they
make decisions and what actions they would do, in
response to sequential scenario descriptions. Application of the AACTT framework during this step will be
used to help identify which individuals (Actors) at which
levels of an organisational hierarchy need to do something differently to perform the specified evidence-based
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IPC practice (action) for certain residents (target) at an
appropriate time and in a specific setting (context). The
interview topic guide will be based on the AACTT-specified behaviours. Interviews will be audio-recorded and
transcribed verbatim.
Responses to the scenario-based assessment will be
summarised according to the domains of the AACTT
framework. The matrix generated by participants will
be compared to the ideal sequence matrix developed by
the IMMERSE research team (based on guideline documents; described below). The findings will highlight areas
of good IPC practice and areas of suboptimal IPC practice and will identify behaviours that could be improved.
Document analysis
Document analyses of key IPC policies and procedures
from participating RACFs will be conducted. The IPC
procedures will be coded into the domains of the AACTT
framework, will be rated for specificity and summarised
in matrix form. The matrix generated from the document
analysis will then be compared to the national guideline
matrix developed by the IMMERSE research team.
The findings from the scenario-based assessment and
document analyses will be presented to staff at each of
the participating RACFs; and priority areas for improvement will be agreed in collaboration with IPC leads and
other key stakeholders, using a consensus approach [39].
Exploration of barriers
The findings from the above activities will then be used
to guide the follow-up staff interviews. This allows
more focused investigations into the barriers and drivers of Actions for each Actor group and will inform our
approach to measuring the success of the implementation strategies in terms of behavioural outcomes (i.e., do
the specified Actors engage in the specified Actions at the
appropriate Times and Places?). We will likely focus on
three or four behaviours or actions that need to change
from the scenario-based assessment to explore the barriers in translating best practice IPC recommendations
into practice. The ‘Actors’ identified in the previous activity—those staff who need to do something differently, will
be invited to participate in semi-structured interviews
(one-on-one or small groups). The interview topic guide
will be developed based on the TDF domains using published methods [40]. Interviews will be audio-recorded
and transcribed verbatim. Transcripts will be imported
into QSR NVivo for analysis.
Interview transcripts will be coded and analysed by
two researchers (JT, SP). Initially, both researchers will
code the first interview together to formulate the coding strategy, using the TDF domains as a guide. They will
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then code the second interview independently and will
review the coding together and reach consensus through
discussion. Coding of the remaining interviews will be
completed independently, with a small sample double
coded to assess interrater reliability (Kappa; κ). Data will
initially be coded deductively into theoretical domains,
then inductively to identify specific barriers and enablers
within each domain according to TDF guidance [40].
Analysis will proceed separately for each site (to identify site-specific barriers) and for each professional
group. The ‘COnsolidated criteria for REporting Qualitative research’ (COREQ) checklist will be used to enhance
the reporting of our research [41]. Findings will be summarised and used to inform Phase 3 activities.
Phase 3 will map BCTs to address the identified barriers to best practice IPC and determine feasible and
acceptable solutions.
Systematic mapping methods will be used to map BCTs
that address the individual- and team-level barriers to the
priority behaviours identified in Phase 2. The matrix developed by Michie et al. will be used, which links a taxonomy
of BCTs to TDF domains and indicates which BCTs are
likely to be effective in changing that particular domain
with a view to supporting behaviour change [26, 42].
The findings will then be presented to the IMMERSE team
and other key stakeholders to establish potential modes of
delivery in terms of feasibility and appropriateness. At each
RACF, we will work in collaboration with IPC leads and
other key staff to select the most appropriate BCTs (solutions) and work with them to operationalise the techniques
in a way that has good fit within the context. The aim of
these sessions will be to select feasible and fit-for-purpose
intervention strategies and intervention components. Criteria for success will be agreed by stakeholders and are likely
to include the measures of staff satisfaction, staff turnover,
IPC lead self-efficacy, organisational readiness.
Phase 4 will apply evidence-based techniques with a
view to upskilling the IPC leads to facilitate IPC practice
change and explore the potential of an IPC lead community of practice.
The research team will work directly with IPC leads
to assess acceptability of selected BCTs or solutions. We
will use evidence-based techniques to upskill IPC leads
to enable them to deliver the selected BCTs to their colleagues, for example goal setting in relation to IPC practices together with monitoring and feedback, building
self-efficacy, building a safety culture to improve collective practice, and embedding reminders that fit clinical workflow. Training sessions for upskilling will be
conducted and may involve simulation-based training,
peer-to-peer mentoring, and feedback in the context of
positive social interactions. Sharing of local experiences
and resources will be facilitated by a member of the
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research team with behaviour change expertise so IPC
leads can learn from one another, including exploration
of a community of practice for IPC leads.
Discussion
This study will address a much-needed area of research.
Prior to COVID-19, few published studies had investigated IPC practice in RACFs. Barriers to implementation
of evidence-based IPC in RACFs have been explored in
relation to hand hygiene, influenza management and antimicrobial stewardship [43–45]. However, theory- and evidence-informed implementation studies to overcome these
barriers are lacking. Training, upskilling, and educating
RACF staff have been the focus of most provider and government strategies to improve IPC practice. These strategies are important and can address gaps in knowledge and
skills, however they do not address other factors that can
impact on IPC practice, such as environmental context and
resources, reinforcement, motivation, and social influences.
The IMMERSE study seeks to address these gaps in
research by comprehensively exploring IPC practice in
RACFs and using multiple frameworks to inform and
support IPC practice change. The study is novel in design,
being, to our knowledge, the first to assess organisational
readiness to change and how it impacts on supporting
IPC practice change; the first to apply the AACTT framework to explore staff behaviours in response to common
IPC scenarios; and the first to investigate barriers to best
IPC practice using the TDF, and to then map and deliver
feasible BCTs to overcome these barriers. The IMMERSE
researchers will work directly with IPC leads to operationalise the BCTs. Working in collaboration with IPC
leads and other key stakeholders will optimise acceptability and sustainability of solutions.
This is an opportunity to transform the care provided to older people living in RACFs by improving IPC
through identifying and addressing organisation-, team-,
and individual-level barriers to effective IPC practice, and
supporting IPC leads to facilitate IPC practice change.
Abbreviations
AACTT
Action, Actor, Context, Target, Time
ANOVA
Analysis of variance
BCT
Behaviour change techniques
COREQ
Consolidated criteria for reporting qualitative research
IMMERSE IMpleMenting Effective infection prevention and control in ReSidential aged carE
IPC
Infection prevention and control
MRFF
Medical Research Future Fund
ORCA
Organizational Readiness to Change Assessment
ORIC
Organizational Readiness for Implementing Change
PPE
Personal protective equipment
RACFs
Residential aged care facilities
REDCap
Research Electronic Data Capture
SMS
Short message service
TDF
Theoretical Domains Framework
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Acknowledgements
The authors would like to thank members of the IMMERSE Reference Group.
Authors’ contributions
All authors, JT, SP, JFF, NB, DF, KB, LL, CM, MF, MM, PY, CA, DJ, JK, KL, JM and WKL
contributed to the original concept and study design. JT, SP and JFF led the
writing of this paper. All authors reviewed, provided critical comments and
suggestions for revision, and approved the final version of the manuscript.
Funding
This study is funded by the Medical Research Future Fund (MRFF) Dementia,
Ageing and Aged Care Mission—2020 Dementia, Ageing and Aged Care
Grant Opportunity.
Availability of data and materials
The datasets used and/or analysed during the current study will be available
from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study was approved by the Melbourne Health Human Research Ethics
Committee (HREC/81901/MH-2022) and covered conduct of the study at all
participating facilities. Site specific research governance was granted at the
Royal Melbourne Hospital and Kilmore District Health Service for participation in the study at an affiliated residential aged care facility from each
organisation.
Consent for publication
Not applicable.
Competing interests
The authors declare they have no competing interests.
Author details
1
Department of Aged Care, Royal Melbourne Hospital, Level 8 CRM, 300
Grattan Street, Parkville, VIC 3050, Australia. 2 Department of Medicine – Royal
Melbourne Hospital, University of Melbourne, Parkville, VIC 3010, Australia.
3
School of Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia. 4 Department of Public Health and Primary Care, University of Leuven,
KU Leuven, Louvain, Belgium. 5 Department of Health Services Research,
Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia. 6 Department of Oncology, Sir Peter MacCallum, University of Melbourne, Parkville, VIC
3010, Australia. 7 Ottawa Hospital Research Institute – General Campus, Centre
for Implementation Research, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada.
8
Victorian Healthcare Associated Infection Surveillance System (VICNISS)
Coordinating Centre and Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne
VIC 3000, Australia. 9 Department of Infectious Diseases, National Centre
for Antimicrobial Stewardship, University of Melbourne, Melbourne, VIC 3000,
Australia. 10 Department of Nursing, School of Health Sciences, University
of Melbourne, Parkville, VIC 3010, Australia. 11 Australian Centre for Evidence
Based Aged Care (ACEBAC), La Trobe University, Bundoora, VIC 3086, Australia.
12
Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC
3050, Australia. 13 Department of Infectious Diseases, University of Melbourne
at the Peter Doherty Institute for Infection and Immunity, Melbourne VIC 3000,
Australia. 14 Infection Prevention and Surveillance Service, Royal Melbourne
Hospital, Parkville, VIC 3050, Australia. 15 Director of Infection Prevention,
Northern Health, Epping, VIC 3076, Australia. 16 Victorian Aged Care Response
Centre, Australian Department of Health, Melbourne VIC 3000, Australia.
17
Department of Geriatric Medicine, Austin Health, Heidelberg, VIC 3084,
Australia. 18 Department of Medicine – Austin Health, University of Melbourne, Heidelberg, VIC 3084, Australia. 19 Department of Infectious Diseases,
Northern Health, Epping, Vic 3076, Australia. 20 Department of Medicine,
Northern Clinical School, University of Melbourne, Epping VIC 3076, Australia.
21
Departments of General Medicine and Infectious Diseases, Royal Melbourne
Hospital, Parkville VIC 3050, Australia. 22 Department of Infectious Diseases,
Austin Health, Heidelberg VIC 3084, Australia. 23 Department of Microbiology &
Immunology, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne VIC 3000, Australia. 24 Director Nursing Research
Page 8 of 9
Hub, Royal Melbourne Hospital, Parkville VIC 3050, Australia. 25 Consumer Representative of the IMMERSE Research Team, and Melbourne Academic Centre
for Health, Parkville VIC 3050, Australia.
Received: 18 July 2022 Accepted: 19 January 2023
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