BackgroundAntibiotic stewardship, the proper management of antibiotics to ensure optimal patient outcomes, is based on quality improvement. Evidence-based guidelines and protocols have been developed to improve this process of care. Safe and timely patient care also requires optimal coordination of staff, resources, equipment, schedules and tasks. However, healthcare workers encounter barriers when implementing these standards and engage in workarounds to overcome these barriers. Workarounds bypass or temporarily ‘fix’ perceived workflow hindrances to achieve a goal more readily. This study examines workaround behaviours that nurses and doctors employ to address the challenges encountered during their antibiotic stewardship efforts and their impact, at a tertiary hospital in Malawi.MethodsThis was a qualitative descriptive case study design and is part of a large mixed methods study aimed at understanding nurses’ role in antibiotic stewardship and identifying barriers that informed the development of nurse-focused interventions. For this study, we conducted interviews with staff and observations of nurses antibiotic stewardship practices on two adult medical wards. We convened three focus group discussions with doctors, pharmacists and laboratory technologists (n = 20), focusing on their attitudes and experiences with nurses’ roles in antibiotic stewardship. We also observed nurses’ antibiotic stewardship practices and interactions duringfour events: shift change handovers (n = 10); antibiotic preparation (n = 13); antibiotic administration (n = 49 cases); and ward rounds (n = 7). After that, the researcher conducted follow up interviews with purposively selected observed nurses (n = 13).ResultsUsing inductive and deductive approaches to thematic analysis, we found that nurses established their ways of overcoming challenges to achieve the intended task goals with workarounds. We also found that nurses’ practices influenced doctors’ workarounds. We identified six themes related to workarounds and grouped them into two categories: “Taking shortcuts by altering a procedure” and “Using unauthorized processes”. These behaviors may have both positive and negative impacts on patient care and the health care system.ConclusionThe study provided insight into how nurses and doctors work around workflow blocks encountered during patient antibiotic management at a tertiary hospital in Malawi. We identified two categories of workaround namely taking shortcuts by altering a procedure and using unauthorized processes. Addressing the blocks in the system by providing adequate resources, training, improving multidisciplinary teamwork and supportive supervision can minimize workarounds.Electronic supplementary materialThe online version of this article (10.1186/s12913-019-3900-0) contains supplementary material, which is available to authorized users.

BackgroundTimely initiation of antibiotics within one hour of prescription is one of the recommended antibiotic stewardship interventions when managing patients with pneumonia in the emergency department. Effective implementation of this intervention depends on effective communication, a well-established coordination process and availability of resources. Understanding what may influence this aspect of care by using process mapping is an important component when planning for improvement interventions. The aim of the study was to identify factors that influence antibiotic initiation following prescription in the Adult Emergency and Trauma Centre of the largest referral hospital in Malawi.MethodsWe conducted a prospective observational case study using process mapping of two purposively selected adult pneumonia patients. One of the investigators CM observed the patient from the time of arrival at the triage area to the time he/she received initial dose of antibiotics. With purposively selected members of the clinical team; we used simple questions to analyze the map and identified facilitators, barriers and potential areas for improvement.ResultsBoth patients did not receive the first dose of antibiotic within one hour of prescription. Despite the situation being less than ideal, potential facilitators to timely antibiotic initiation were: prompt assessment and triaging; availability of different expertise, timely first review by the clinician; and blood culture collected prior to antibiotic initiation. Barriers were: long waits, lack of communication/coordinated care and competency gap. Improvements are needed in communication, multidisciplinary teamwork, education and leadership/supervision.ConclusionProcess mapping can have a significant impact in unveiling the system-related factors that influence timely initiation of antibiotics. The mapping exercise brought together stakeholders to evaluate and identify the facilitators and barriers. Recommendations here focused on improving communication, multidisciplinary team culture such as teamwork, good leadership and continuing professional development.Electronic supplementary materialThe online version of this article (10.1186/s12879-018-3620-9) contains supplementary material, which is available to authorized users.

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