Using formative evaluation to improve uptake of a web-based tool to support antimicrobial stewardship

Zaidi, Syed Tabish Razi; Thursky, Karin

doi:10.1111/jcpt.12093

Cited by 13 publications

(38 citation statements)

References 37 publications

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“…In such a context of learning through implicit or explicit role-modelling within hierarchical relationships, junior doctors follow the example of seniors, not just in their prescribing decisions, but also in what they count as legitimate sources of support for making prescribing decisions ( CMOCs 6–8 in Part S5). 27 , 49 , 53–56 , 60 , 61 , 66 , 70 , 74 , 76 , 80–94 Data from included studies indicates that doctors-in-training will be more inclined to follow guidelines when this is clearly signalled as appropriate behaviour by the senior clinical staff they are accountable to. The primary influence behind guideline use seems to be whether these are adopted and perceived as credible by senior colleagues ( CMOC 9 in Part S5 for factors influencing guideline credibility and use).…”

Section: Resultsmentioning

confidence: 99%

“…By creating a legitimate role for other health professionals in the antimicrobial prescribing process, senior doctors signal to their trainees what is appropriate behaviour to follow, whose opinion counts, in what cases and to what extent ( CMOCs 11–12 in Part S5). 28 , 53 , 71 , 76 , 97 , 98 Some contexts are described in the literature where inter-professional (where relative status differences are more ambiguous) supervision and contribution may play an important role. For example, newly qualified doctors may turn to the pharmacist as a source of support external to the medical hierarchy, as they will feel less fear of appearing ignorant or experiencing negative repercussions ( CMOC 13 in Part S5).…”

Section: Resultsmentioning

confidence: 99%

“…Their ability to ask questions and confidently argue alternative positions changes over time, as with increasing seniority they are expected to assume more autonomy and responsibility ( CMOCs 27–28 in Part S5). 55 , 57 , 72 , 76 , 77 , 100 , 111 , 115 , 116 , 129 …”

Section: Resultsmentioning

confidence: 99%

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Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

Papoutsi

Mattick

Pearson

et al. 2017

Journal of Antimicrobial Chemotherapy

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BackgroundAntimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers.MethodsThe review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners.ResultsBy synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one’s reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians’ prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions.ConclusionsThis review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

Papoutsi

Mattick

Pearson

et al. 2017

Journal of Antimicrobial Chemotherapy

View full text Add to dashboard Cite

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“…43,98,194 Involving junior doctors in the development of competencies, workplace feedback programmes or other antimicrobial prescribing interventions could contribute to more targeted design and better-informed implementation efforts. Principles of participatory design 195 would enable inclusivity, alignment of goals and continuous learning for all professional groups and training levels on the issue of AMR -when sensitively designed to address the issues of power and hierarchy.…”

Section: Participatory Designmentioning

confidence: 99%

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Papoutsi

Mattick

Pearson

et al. 2018

Health Serv Deliv Res

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BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Several formative evaluations [17,18] were performed to test for failure points of the PI-CDSS over a period of three months. The first formative evaluation was system integration testing (SIT), a system validation check that verified the sense, accuracy, and appropriateness of the clinical content of the 'inputs' (clinical questions) and 'outputs' (clinical advice) on the GUI and RMA [16] using 20 clinical cases.…”

Section: Knowledge Evaluationmentioning

confidence: 99%

Modeling the Construct of an Expert Evidence-Adaptive Knowledge Base for a Pressure Injury Clinical Decision Support System

2017

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Abstract:The selection of appropriate wound products for the treatment of pressure injuries is paramount in promoting wound healing. However, nurses find it difficult to decide on the most optimal wound product(s) due to limited live experiences in managing pressure injuries resulting from successfully implemented pressure injury prevention programs. The challenges of effective decision-making in wound treatments by nurses at the point of care are compounded by the yearly release of wide arrays of newly researched wound products into the consumer market. A clinical decision support system for pressure injury (PI-CDSS) was built to facilitate effective decision-making and selection of optimal wound treatments. This paper describes the development of PI-CDSS with an expert knowledge base using an interactive development environment, Blaze Advisor. A conceptual framework using decision-making and decision theory, knowledge representation, and process modelling guided the construct of the PI-CDSS. This expert system has incorporated the practical and relevant decision knowledge of wound experts in assessment and wound treatments in its algorithm. The construct of the PI-CDSS is adaptive, with scalable capabilities for expansion to include other CDSSs and interoperability to interface with other existing clinical and administrative systems. The algorithm was formatively evaluated and tested for usability. The treatment modalities generated after using patient-specific assessment data were found to be consistent with the treatment plan(s) proposed by the wound experts. The overall agreement exceeded 90% between the wound experts and the generated treatment modalities for the choice of wound products, instructions, and alerts. The PI-CDSS serves as a just-in-time wound treatment protocol with suggested clinical actions for nurses, based on the best evidence available.

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Using formative evaluation to improve uptake of a web-based tool to support antimicrobial stewardship

Cited by 13 publications

References 37 publications

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Modeling the Construct of an Expert Evidence-Adaptive Knowledge Base for a Pressure Injury Clinical Decision Support System

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