An exploration of workarounds and their perceived impact on antibiotic stewardship in the adult medical wards of a referral hospital in Malawi: a qualitative study

Abstract

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.

Sustained Reduction in Third-generation Cephalosporin Usage in Adult Inpatients Following Introduction of an Antimicrobial Stewardship Program in a Large, Urban Hospital in Malawi

“…Clinical decision-making is not only influenced by guidelines and operational constraints; the social determinants of prescribing must be understood in order to effect a change in practice [ 28 ]. Hierarchy and peer pressures shaped antibiotic prescribing decisions in our study, as in other settings [ 26 ], but these influences have not previously been explored in Africa, where qualitative studies of stewardship have focused on nursing behaviors [ 24 , 25 ] and general perceptions of AMR [ 29 ]. More in-depth social research should be undertaken to provide a deeper understanding of the mechanisms for changing behavior, if large-scale programs are to be successful.…”

The use of antibiotics in the intensive care unit of a tertiary hospital in Malawi

“…Irrational use of antibiotics has been reported to be a contributing factor to poor outcomes such as prolonged length of stay and death in ICU [21] and increases costs [22]. Indeed, efforts through antibiotic stewardship programs are being put in place to help combat the problem of irrational antibiotic use in healthcare both in Malawi and other countries [13,[23][24][25][26]. During this study period, there was no evidence of such programs in the ICU and we are not aware of programs tackling antibiotic use specifically in ICUs in Malawi.…”

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

“…There has been a dearth of studies showing how persistent coping behaviours may hide systems problems and quantifying the resulting impact. Available coping-related studies mostly focus on determining how much coping or ‘workarounds’ occur after a new policy or technology was introduced to a hospital or clinic 1–3 20–31. In other words, they focus on what healthcare workers may do to avoid adopting a new situation like healthcare personnel reverting to using paper-based methods when electronic health record technology is introduced or what personnel do besides using new patient identification barcodes because the barcodes are unreliable.…”