Managing periprosthetic joint infection—a qualitative analysis of nursing staffs’ experiences

Endoprosthetic joint replacement is a life-enhancing procedure for millions of people around the world, which provides pain relief, restores function and preserves independence, especially in elderly patients. In Germany, primary total knee or hip arthroplasty is among the most common procedures, with an increase in the number of surgeries of up to 45% predicted for the year 2040 [1]. However, periprosthetic joint infection (PJI) is a dreaded complication in orthopaedics and trauma surgery with an incidence of 24/100,000 inhabitants in Germany [2]. For patients, PJI represents a high burden and severe limitations are often unavoidable despite modern and interdisciplinary treatment concepts. The treatment is complex depending on diverse factors such as duration of infection, underlying pathogens, and condition of the implanted prosthesis and soft tissues. Options include surgical debridement with implant retention and antibiotic therapy (DAIR), one-stage revision, or two-stage prosthesis replacement in which a new revision endoprosthesis is placed after an implant-free interval. In a significant number of patients, reimplantation is not considered feasible, leaving only arthrodesis, a Girdlestone situation, or amputation as treatment alternatives. Consequences are long hospital stays with multiple surgeries, including removal of the implant, immobility, administration of local and systemic antibiotics, often associated with side effects, and further socioeconomic issues. In addition, PJI is potentially life-threatening, with increased mortality rates compared with patients who do not develop an infection after joint replacement [3, 4]. Hence, PJI has profound effects on the patients’ quality of life leading to high levels of psychological distress [5‐7]. In recent years, beside the use of patient-reported outcome measures, quantitative analyses capturing patients’ experiences following one- and two stage revision for PJI were brought into the focus of orthopaedic and trauma surgery research [8, 9]. Also, the negative emotional impact of PJI on orthopaedic surgeons and the challenge of making treatment decisions was elicited by conducting in-depth qualitative research interviews [10‐12]. However, for an ideal management approach, it is important to understand the experiences of all persons involved in the treatment and the impact of managing PJI on nursing staff has not been investigated yet.

As such analysis would be beneficial in terms of identifying improvable factors, this study aims at answering the following research questions utilizing a qualitative approach: (1) Is there an emotional impact of caring for PJI patients perceived by nurses? (2) What are perceived main challenges in the management of PJI?

The study took place in a German university orthopedic trauma center level I.The study population was identified using a purposive sampling strategy to ensure that participating nurses had experience in the management of PJI of at least one year [13, 14]. Participants were approached face-to-face and asked for their study participation after explaining the background and the purpose of the interviews. In total, n = 22 nurses were approached, wereof n = 2 (9.1%) declined to participate. Purpose sampling was done until the data reached theoretical saturation based on data replication or recurrence in the interview transcripts, meaning that no new themes could be identified [15]. Informed consent was obtained from all participants prior to the interviews. The study was approved by the institutional ethics committee of the University Hospital Regensburg according to the Helsinki Convention (file number 21–2464-101).

A semi-structured interview guide was conceptualized by the authors developed iteratively through multiple rounds of discussion and pilot tested. In-depth qualitative research interviews were conducted in person between March 2021 and June 2021 by a female researcher with a background in psychosomatic medicine and experience in qualitative research in an undisturbed office room. The interviewer was occupied at the same hospital, however no relationship with the participant was established prior to the study commencement. Interviews lasted between 20 and 38 min. No repeat interviews were carried out and no field notes were made during the interview. The following areas were covered in the interviews: professional experience, facilitating factors, challenges and strength in the PJI management, emotional impact and support needs. No participant dropped out. In total, 20 nurses were willing to participate. Purpose sampling was done until the data reached theoretical saturation based on data replication or recurrence in the content, meaning that no new themes could be identified [15]. All interviews were audio recorded, anonymized, transcribed and translated from German to English. Transcripts were returned to all included participants for comments. Here, no further corrections were made. To ensure trustworthiness of this research [16], credibility (internal validy) was enhanced by iterative questioning and rapport building. All participants were aware, that given statements will not be assigned to them personally and will have no effect regarding their professional position. Further, confirmability (objectivity) and reflexivity was given as the interviewer had no prior relationship with the participant and no personal or professional association with the inpatient ward. To enhance the confirmability, two researchers independently analyzed the data, which was then discussed by the whole research team (n = 7).

Data were analyzed with a content analysis. During the process, first, “meaning units” were extracted from the transcripts. This were then condensed by shorting the text while preserving the essential part. Next, an abstraction took place meaning that the condensed meaning units were labelled by a code by two researchers. Then, a descriptive grouping of related content into categories took place as described previously [10]. Finally, themes were assigned to the categories, i.e., an interpretative meaning of related data (Table 1). [17]. Codes were checked for consistency by the whole research team continously returning to the interviews and meaning units and themes were discussed until consensus was reached.

In total 20 participants with at least one year of experience working with PJI patients were interviewed (Table 2). The content analysis resulted in the identification of three main themes covering challenges in the managemant of PJI (Table 1, Fig. 1).

In this study, personal experiences, strength, challenges and factors facilitating the management of PJI were identified using a qualitative approach. Previously, similar studies were carried out revealing the negative impact of PJI on the patients as well as the surgeons [8‐12]. However, the nursing staffs’ perspectives on strengths and challenges in the care of PJI patients has not been evaluated yet.