The toolkit team was comprised of eight members– four physicians, two nurses, one administrator, and one engineer/facilities management staff member. At least five of the team members participated in the evaluation interviews and cross-sectional surveys across each time point of data collection.

Feasibility

Data collected using the monitoring checklist indicated completion of every step and activity outlined. The document review of the checklists resulted in all steps of the toolkit implementation being completed by the team with the tools provided.

Appropriateness

Two key themes of appropriateness of the toolkit, time commitment and resources required, were identified through key informant interviews.

Time commitment required for the toolkit by team members

When discussing the perceived fit and compatibility of the toolkit, team members expressed that dedicated time was not given to them to perform their assigned activities for the project in addition to their regular duties. Team members described that they were often asked to perform the toolkit activities alongside their regular facility duties making it difficult to commit time to the toolkit.

“…the way we work, I think our system, we do not allocate special time for different activities. So, you are a microbiologist, you are in infection control, you are in antibiotic stewardship, you teach, you train. You just do everything the way that you [should] when it comes up. So, there’s no dedicated time to say you need to do two hours of antimicrobial stewardship in a week or do six hours of this in the day. So, everything is all lumped together. You need to find a balance with all these activities” - Physician 1.

Survey results relating to time commitment varied throughout at the different time points of data collection. While most participants stated that the toolkit did not demand too much time away from their work duties, others disagreed, specifically after Step (A) Prepare for Action and Step (B) Conduct baseline assessment (Fig. 1). However, despite facing challenges in the lack of dedicated time provided to team members, time spent on the toolkit was seen as time well spent and worthwhile for the team.

“…but the meetings doesn’t [sic] take so much time and some of them are a mixture of virtual meetings and then physical meeting so it didn’t take, really if we consider it, is not too much and it has been a fruitful time for all of us.”– Physician 2.

Fig. 1

Electronic survey data analysis comparing participant answers to the perceived time commitment (Burden) for the toolkit after Steps A, B & D of the toolkit implementation at LUTH in Lagos, Nigeria, 2021. (n = number of participants)

Resources required to sustain toolkit activities

Team members expressed concerns that resources may not be available within the facility to support lasting changes identified by the toolkit. Team members described that a lack of funding for environmental cleaning may limit the sustainability of improvements in the future at the facility and that leadership allocation of funds would be necessary for continued improvement after implementation.

“We need financial assistance. We need funds. You know, to get the materials, to get equipment, we need funds. We need management to inject funds. Because when you put everything together, if there is no backup fund then at the end of the day, we have not done anything that can last. So, we need management to inject funds for the project.”– Engineer.

Team members also cited concerns with a lack of appropriate materials (e.g., disinfectants) and equipment (e.g., mops) to support the implementation of cleaning procedures according to the best practices which were taught during the training, rolled out to frontline cleaning staff during the project, and included in new standard operating procedures developed by the project team.

Acceptability

Five key themes were identified in key informant interviews relating to constructs of acceptability: one of which described perceived challenges and overlapped with themes identified as relating to appropriateness and four distinct themes which generally described perceived effectiveness and successes associated with the toolkit.

Perceptions of time commitment and resource requirements to sustain toolkit activities

While the issues of time commitment and resources were described within the context of the facility operations and structure, these themes also influenced acceptability as the toolkit members perceived them as challenges within their experience of the toolkit. Lack of dedicated time given for toolkit activities was described as a function of the facility; however, time management was also perceived as a general challenge throughout the toolkit process. Perceptions about time management were discussed mostly during interviews after Step A. Prepare for action). Team meetings were described as a challenge among team members due to conflicting work schedules. However, this was compensated for by arranging short retreats on the weekend and a mix of in-person and virtual meetings for toolkit related activities.

“Getting together unified [sic] to activate the group for this purpose can be difficult, because everyone has his own schedule, so that [is] the only challenge I would say that I’m experiencing presently.”– Engineer.

Team members also perceived challenges in the availability of materials to sustain improvements made. Most comments related to these challenges were brought up during interviews conducted after Step D. Implement program improvements.

“…another area of challenges is the materials itself, because in as much as there are [sic] dedicated staff or a person that is willing to do work, if you’re not provided with everything necessary that you need to carry out the work, then it brings the difficulty to the table.”– Nurse 1.

Perceptions of toolkit structure and usability of toolkit materials

The design of the toolkit and its accompanying implementation tools were perceived to be effective at identifying gaps and enabling improvements to be made on environmental cleaning best practices. The toolkit was described as simple and easy to use by team members. The simplicity of the toolkit, its design, and materials made it flexible for facility needs, allowing for ease of adaptability.

“…you cannot take away the role of having a systemic process in place. So, with this toolkit there is already a structure in place. So, it made it easy–we probably would have stumbled our way and spend [sic] more time planning, so the toolkit saves time and pointed us in the right direction at the right time, so there’s a lot of time saved. And, also, the process—we’ve learned how to go approach such problems now with a process, a stepwise process, so it took it was very helpful.”– Physician 3.

Most team members expressed that some adaptation of the toolkit tools (e.g., baseline assessment questions) were required. Once adapted to the context of the facility or ward, the tools were perceived as useful.

“It [toolkit implementation tool] was not perfect for my environment, but I used it in line with what’s available to our procurement departments. So, I was able to visit the procurements section, and then see what was available. So based on the suggestion or sample of what I have in the toolkit, I used it to form and develop what I could present and that was brought up in a meeting and then to defend it, to explain it, and then the modifications was [sic] done before the final submission.” - Nurse 1.

Perceptions and knowledge about environmental cleaning and environmental cleaning staff

Toolkit team members expressed that the toolkit was successful in increasing their knowledge and awareness for environmental cleaning practices in their healthcare facility. The toolkit provided a new and organized way to learn about environmental cleaning, which changed team members’ perceptions and increased their appreciation for the importance of environmental cleaning and environmental cleaning staff for IPC.

“My experience with working on the team has been an eye opener for me, even as the maintenance officer… We need to make the environment more conducive for the cleaners and the patients. The way they were disposing water before was inappropriate. We need a separate way to remove sluice water than the multiuse sinks.” - Engineer.

Particularly among the physicians, they reported positive perceptions related to their increased knowledge, citing understanding how to prepare disinfectants, how frequently cleaning should take place on the units, and the cleaning procedures themselves. They also expressed an appreciation for the fact that environmental cleaning staff are part of the IPC team.

“This has emphasized the role of teamwork in whatever we want to do. If we want to prevent infection in the neonatal unit, we cannot overlook some people. Everybody has to work hand in hand and the cleaners are part of that team. And we start with them, because if they don’t understand what it is that they are doing and why they are doing, they will be on their own. Everybody has to be carried along and the cleaners and team have to understand why it’s important that we prevent infections in our newborn, so I think this has really opened my eyes and also taught me that I shouldn’t be neglecting some segments that are part of it. They have to be involved.”– Physician 4.

Within the survey results, team members indicated that the toolkit was influential in their abilities to identify areas of improvement in environmental cleaning in some capacity across all time points. The perceived increased ability to identify areas of improvement was found to be most influential after Step D. Implement program improvements, after they’d both identified and implemented improvement activities (Fig. 2).

Fig. 2

Electronic survey data analysis comparing participant answers to the perceived ability to identify areas of improvement (Affective Attitude) after Steps A, B & D of the toolkit implementation at LUTH in Lagos, Nigeria, 2021 (n = number of participants)

Perceptions about training for cleaning staff undertaken as part of the toolkit implementation

The creation and implementation of a training for facility cleaning staff designed by the LUTH toolkit team was perceived as beneficial and successful. The training, which included cleaning staff, clinical staff from the neonatal units, and facility leadership, was described as helpful in bringing to light the importance of training and engaging cleaners in the environmental cleaning process at the facility.

“[The training] was effective in that people have acquired basic knowledge. A lot of times we tend to think that all we’ve been doing cleaning, we know [sic]. But in identifying these gaps we now know better, how to clean, where to target, how to clean from where to where, even the storage of all the cleaning materials and all that. So it was effective, a lot of knowledge was impacted.”– Physician 3.

Toolkit team members also expressed seeing the impact of the training in terms of the practices of cleaning staff as well as their motivation on the wards.

“…cleaners’ attitudes are now changed, cleaners’ motivation and, yes, and that is [sic], served as a source of change. We now have more cleaners coming in to say, I want to be part of it and get it right so, we achieved that. And if these things as efficient [sic] as it is expected, I think we have it better.”– Nurse 1.

Perceptions about the multidisciplinary team approach with the inclusion of facility leadership and the involvement of a project coordinator

Members of the toolkit team recounted the benefits of working in a multidisciplinary team as a part of toolkit implementation. The opportunity to work with staff across departments at the facility was perceived as contributing to the success of the toolkit implementation. Involvement of facility leadership (e.g., Chairman Medical Advisory Committee (CMAC)) in the toolkit process was perceived to improve impact and the sustainability of improvements.

“I’m also glad that this project is coming up with involvement with the top managerial, like the CMAC is there, so it’s easier when you want to inculcate things like this into the system…because if he is not there to follow to all the activities, it might just be you pouring water on stone by the time you’re done. It’s just there. So, I also like the fact that the top people who are responsible, they are there.” - Nurse 2.

The importance of the project coordinator also attributed to the perceived success of the implementation of the toolkit. Support from the project coordinator alleviated challenges with implementation by providing support and structure to the team throughout the implementation process. The perceived importance of the project coordinator to the success of the toolkit implementation was mentioned largely by the nurses in the toolkit team during Time Point 2, at a critical time when decisions on improvement activities to prioritize had to take place.

If he [project coordinator] wasn’t there, it will [sic] have been difficult to use.”– Nurse 2.

The team members also cited the project coordinator’s role in preparing documents and agendas in advance of team meetings and facilitating meetings to keep team members focused.