Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using normalisation process theory

Abstract

Background: Antimicrobial stewardship (AMS) describes activities concerned with safeguarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uniprofessional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives. Methods: This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n = 72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions 'which group of actors have which problems, in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice'. Results: Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners.

Understanding how and why audits work in improving the quality of hospital care: A systematic realist review

“…Of the included papers, 61 focussed on clinical audits, 17 on accreditation/certification and 7 on peer reviews. In terms of the evidence levels established by EPOC review group [30], one randomised trial was found [35], two controlled studies [36,37], 66 case studies , and 16 descriptive studies [104][105][106][107][108][109][110][111][112][113][114][115][116][117][118][119]. Using the QI-MQCS, the completeness of reporting scores ranged from 4 to 16 (16 being the highest possible score) (S1 Table ).…”

“…Several studies have described local audits that were started by intrinsically motivated healthcare professionals on issues they felt to impact on patient care [ 48 , 53 , 61 , 63 , 69 , 82 , 88 , 97 , 99 , 103 ]. In contrast, if healthcare professionals perceive an audit as a ‘side-line’ or ‘mandatory exercise’, rather than a process to contribute to improved quality of care, they will not feel engaged and not put significant effort into the change [ 77 , 118 ]. This is especially true when audits are externally initiated and have a strong organisational focus, sometimes without links to clinical care [ 102 , 104 , 106 – 108 , 117 ].…”

What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course

“…Even though theoretical advances from academia or policy describe nurses’ roles, these are yet to be translated to clinical settings. 28 , 29 Published evidence also suggest that the extent to which these professionals are involved remains a barrier; 30 , 31 however, we recognize not all pharmacists and nurses may be suitably trained for AMS activities, and, where possible, should involve those with specialist knowledge/skills. Patient education on rational antibiotic use was an area that the learners acknowledged pharmacist and nurses to have an important role.…”

Assessing the impact of the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) on hospital antimicrobial stewardship programmes: results of a worldwide survey

“…As demonstrated in earlier studies[ 10 , 43 – 47 ], organisational factors such as a lack of financial and human resources remain important barriers to the implementation of AMS. This could explain why only one-third of hospitals had conducted a follow-up PPS at the time of the survey, as incorporating the PPS throughout the hospital’s AMS activities requires a dedicated and sustainable investment of time and resources.…”

“…The importance of social and contextual factors determining antimicrobial prescribing behaviour is increasingly being acknowledged. In recent years, qualitative studies have explored some of the drivers behind hospital prescribing practices, such as medical hierarchies and social norms[ 31 , 47 , 50 , 51 ], the dynamic between immediate, individual patient care and long-term impact on AMR[ 31 , 52 ] and clinical uncertainty[ 51 , 53 ]. Since many of these barriers and driving factors are context-dependent, identifying barriers and strategies to overcome them on a local level should allow hospitals to tailor AMS interventions more precisely and thereby maximise the sustainability of these interventions [ 54 ].…”