Table 3 Results of interview analysis

Knowledge

I know/do not know what the Sepsis Six involves

[The Sepsis Six is] a package of care which has been shown to improve mortality in patients with sepsis. (Consultant 1)

My colleagues do/do not know what the Sepsis Six involves

the more senior sort of colleagues weren’t familiar with systemic inflammatory response syndrome, recognise all the sort of markers. (Nurse 4)

I am aware/not aware of the evidence behind the Sepsis Six

There have been obviously clinical trials which I can’t remember the names of. (Junior doctor 2)

My colleagues are aware/not aware of the evidence behind the Sepsis Six

If I’m honest then no. [My colleagues and I are not aware of the evidence behind the Sepsis Six] (Nurse 3)

People would give better Sepsis Six performance if they were more aware of the later complications of poorly managed sepsis

I think if they had perhaps more awareness about how, like, poor sepsis management could affect a patient long term, they might be, they might have more urgency in carrying it all, sort of out. About what would happen in the long term. (Nurse 4)

Having knowledge and understanding of the Sepsis Six does/does not influence the likelihood of it being performed

And it’s always, [giving antibiotics] tends to get done I think, because I think everyone understands the urgency. (Junior doctor 1)

Skills

I do/do not have the skills to perform the Sepsis Six

I mean I haven’t given antibiotics myself. (Junior doctor 1)

My colleagues do/do not have the skills to perform the Sepsis Six

maybe if [nurses are] newly qualified, not being able to give the IV antibiotics because they would then have, because they haven’t done their IV pack (Nurse 1)

There is/is insufficient provision of training and assessment in the skills required to perform the Sepsis Six

I think we’ve recognised that, and we’ve trained our nurses to deliver antibiotics, fluids, take blood cultures and lactates, put in urinary catheters, so we know our nurses can do all of this, we train them to do all of this. (Consultant 1)

Memory, Attention and Decisions

It’s easy/difficult to remember the 6 steps in clinical practice

Give 3, take 3 away. And that we have it written down on our proformas. (Consultant 1)

The decision to start the Sepsis Six is not made because sepsis is not recognised

So I think I’ve got a reasonable understanding of recognising sepsis. (Junior doctor 3)

Regular use of the Sepsis Six makes it easier to remember the steps

I mean when doing on a daily basis pretty easy to remember. But I guess if you’re not doing it on a daily basis you might forget (Junior doctor 2)

Behavioral Regulation

Sepsis Six performance is (not) monitored or audited regularly in my department

[Sepsis 6 is audited on a] weekly basis and the results are published weekly. (Junior doctor 3)

I/we get insufficient feedback on our Sepsis Six performance

Yes it would be helpful to have more monitoring systems in place. And individual feedback to clinicians. (Consultant 2)

There are sufficient tools in place to help guide and track Sepsis Six performance in individual patients

Yes, we’ve got [a Sepsis 6 tool], it’s at the back of the pro forma and the BUFALO stickers. So there’s a lot of guidance. (Consultant 3)

Improving sepsis care and Sepsis Six performance is (not) discussed in regular meetings in my department

What we’re doing in surgery is auditing this sort of thing on a monthly basis, and that’s going to be presented at governance meetings. (Consultant 2)

Sepsis Six performance improves if we are involved in the quality improvement process

Yeah, I think so, because I think people would own things more if they felt it was, they were included in it (Nurse 2)

There are (no) action plans to improve Sepsis Six performance

there are other things that we’re doing such as implementing junior doctor training, nurse training on sepsis, through educational sessions, through induction. (Consultant 1)

Social Influences

My colleagues opinions do/do not affect my performance of the Sepsis Six

I don’t think the opinions of my colleagues does affect whether I do the Sepsis Six actually. (Junior doctor 3)

My Colleagues do/do not believe that the Sepsis Six is beneficial to patient care

Yeah I think it’s generally believed that these steps benefit patient outcomes, so I think everyone’s kind of in favour of them. (Junior doctor 2)

Departmental culture facilitates/hinders performance of the Sepsis Six

I think that’s because there isn’t a culture of doing fluid charts on every patient that comes through us (Consultant 1)

There is insufficient leadership to improve Sepsis Six performance

But if there was a clear strategy, a clearer kind of team role, leadership role for the patients, the benefits of it, can’t see why it wouldn’t be used and why it couldn’t improve. (Consultant 3)

Healthcare workers do/do not feel able to escalate up the hierarchy

if you have it on a care pathway, that gives them allowance, permission almost to phone the consultant and escalate it, so they’re allowed to do that, rather than feeling I shouldn’t do this. (Consultant 2)

Having a Sepsis “Champion” would/would not improve performance of the Sepsis Six

it might be beneficial if, other wards as well to have a designated sepsis champion or link nurse as such, so that we can perhaps hold regular meetings every couple of months, to see how we can make changes to sepsis care. (Nurse 4)

Social and Professional Role

Performing the steps in the Sepsis Six is (not) my role

I think they’re all part of it. (Consultant 2)

Performing all steps in the Sepsis Six is (not) my colleagues’ role

I think it should be everyone’s responsibility and role to do it. (Consultant 3)

It is my/my colleagues’ role (doctor/nurse/HCA) to identify septic patients

our nurses are very good at identifying sick patients. (Junior doctor 3)

It is my role to decide when to perform the Sepsis Six

we usually don’t give oxygen to somebody unless their sats are low, but in this instance, occasionally I’ve been told by a surgeon, I want them to have 2 l of oxygen. (Nurse 2)

There is high turnover of medical/nursing staff in areas looking after septic patients

Our medical staff, so half of them are transient, half of them are permanent. (Consultant 1)

My role is to improve Sepsis Six performance through non-clinical factors (leadership, support, supervision)

My role is that even if the patient is stable to ensure all the steps had been followed, and to reinforce and educate. (Consultant 3)

There are some steps in the Sepsis Six which I/my colleagues do not/are not allowed to perform

I don’t know, as a trust I don’t think the nurses usually take blood cultures, it seems to be a doctor role. (Nurse 2)

Non-clinical staff (eg bed management) put pressure on clinical staff to prioritise tasks other than Sepsis Six

And there’s such a drive for discharging them, and getting patients out, and often the bed manager puts so much pressure on the nursing staff on the wards. (Consultant 2)

Staff should be empowered to improve their role in Sepsis Six performance

So I think being involved in the audit kind of made us kind of aware of what needs to be done. (Junior doctor 3)

Environment, Context and Resources

I do (not) have sufficient resources (staff; time; equipment; medicines; bed) to perform the Sepsis Six in one hour.

Not enough beds (Consultant 2)

The equipment I have does/doesn’t work

our gas machine is down a lot of the time (Junior doctor 3)

The layout of the hospital hinders/helps my performance of the Sepsis six in one hour (patient location, equipment, medicine).

trying to get a patient seen and then treated within that time, and then if they’re coming up to 4 h of being in the department are they moved to another ward before their treatment sort of is delivered, (Nurse 4)

Belief in Consequences

Performing the steps in the Sepsis Six improves patient outcomes

Yeah, I believe it’s vital. There’s evidence out there which supports, supports it, so, yeah (Consultant 2)

The benefits of performing the Sepsis Six outweigh the risks

I think generally the advantages should outweigh the risks. (Junior doctor 2)

The benefits vs risks of performing the Sepsis Six (or some parts of it) are (not) different in certain patient groups

I think any patient with known heart problems, I’d be a little bit more careful. (Nurse 3)

The quicker the steps can be delivered, the more impact they have

Well, I believe if it’s carried out promptly within the 1 h then it can definitely improve the patient’s outcome. (Nurse 3)

Early and regular reassessment of patients requiring the Sepsis Six gives the best outcomes

I think if you keep doing them without reassessment then that would lead to problems, but in the first hour I don’t think it’s an issue. (Consultant 2)

Belief in Capabilties

I am (not) confident performing the steps in the Sepsis Six

I think, you know, I’ve got the skill to perform these 6 steps, there’s no doubt about it. The training has been there, I have the skill to do it (Consultant 1)

My colleagues are (not) confident performing the steps in the Sepsis Six

I mean I would hope most people were... but yeah, I think most people are confident that I’ve seen (Junior doctor 2)

Some of the Sepsis Six steps are more difficult than others to achieve (urine output, cultures, antibiotics)

it’s just the urine output measurement which causes ongoing difficulties, (Consultant 1)

There is good/poor communication and teamwork between members of the team looking after septic patients

It’s definitely a team priority to be able to carry it all out, so if we can sort of work together, I believe that it can be done a lot quicker, rather than doing it single-handedly. (Nurse 4)

We provide good sepsis care at this hospital

I think for the most part our septic patients is reasonably well recognised via the acute care bundle, because they come in, they have the acute care pathway, filled out for every patient (Consultant 2)

I am confident looking after sick septic patients

I’m very good at dealing with a crisis and just getting on with it (Nurse 2)

Intentions

I (don’t) prioritise performing the Sepsis Six on a septic patient over other tasks

I think unless somebody was having a cardiac arrest I would prioritise this probably above most other things. (Nurse 2)

I intend to improve my knowledge of the Sepsis Six

I think I do need to know a bit more about it, so I might try and educate myself before I go back to work (Nurse 2)

I intend to continue to perform the Sepsis Six on septic patients

I guess, well I’ll carry on carrying it out until it’s, unless there’s anything else new that comes up that improves sepsis care (Nurse 4)

I am more likely to complete all steps of the Sepsis Six if I think the patient is sick/less likely if they are well

if we are concerned someone really is poorly, then they often will become catheterised (Nurse 2)

Sometimes I choose (not) to complete the full Sepsis Six because the risks and benefits are different for that patient/situation.

your octogenarian who’s got sepsis, you might not go chucking in 2 l immediately. (Consultant 2)

My colleagues (don’t) prioritise performing the Sepsis Six on a septic patients over other tasks

but it’s usually the other pressures that we have on, like prioritising other patients for example, and how big our caseload is at that time (Nurse 4)

Some steps in the Sepsis Six are more/less important than others

I like having the fluids here quickly. That’s one of the better ones, I think (Nurse 3)

I (don’t) perform the Sepsis Six despite not having a confirmed diagnosis because I (don’t) believe the risks of undertreating sepsis outweigh the risks of performing the Sepsis Six

they’re not septic, but they just got a big SIRS response and they looked septic when they came in, so having antibiotics in that situation is not the wrong thing to do, as a one off, but a patient’s presenting with peritonitis or what’s not, they need to have early sepsis source control. (Consultant 2)

Goals

I work towards a goal that the Sepsis Six should be completed and documented within an hour on all septic patients.

We should do it on all, it should be done within an hour. (Consultant 3)

The hospital has/does not have a goal of improving Sepsis Six compliance

I know that the Trust is starting a BUFALO[sic] to help people remember how to deliver the Sepsis Six (Nurse 4)

Optimism

Sepsis Six compliance at this hospital will (not) improve

Knowing how well in general all the care bundles are used, unless there’s a clear strategy on how to improve it, my worry would be that it might not improve significantly (Consultant 3)

Increasing Sepsis Six compliance will improve patient care

I’m very optimistic that if we can push this forward that it will hugely improve patient care, and their outcome. (Nurse 2)

Reinforcement

Individuals are not formally rewarded or punished for (failing to) complete the Sepsis Six

Not punished, obviously it’s audited, and the departments are fed back (Junior doctor 2)

The department or hospital is (not) formally rewarded or punished for (failing to) complete the Sepsis Six

No, I’m not aware of any ways in which we as, do you mean as a trust are punished? (Nurse 4)

Emotions

I get emotionally affected negatively/positively by managing septic patients

I mean obviously you do [get affected emotionally by looking after septic patients], if they’re unwell (Junior doctor 2)

If we are affected emotionally (eg stressed, excited, fatigued) it leads to better/worse clinical performance when looking after septic patients

Well if anything it makes me go, try and make, do it faster because I recognise that they’re quite sick. (Junior doctor 1)

I feel good if I deliver the Sepsis Six/bad if I don’t deliver the Sepsis Six to a septic patient

I try to carry it out within the 1 h, and when it hasn’t happened I kind of feel, like frustrated (Nurse 4)