Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using Normalisation Process Theory

Abstract

BackgroundAntimicrobial stewardship (AMS) describes activities concerned with safe-guarding 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 uni-professional 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' .ResultsResults 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.ConclusionsThis study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust

Factors influencing the stewardship activities of Antimicrobial Management Teams: a national cross-sectional survey

“…Thus, there is apparent inequity in both specialist medical input and overall FTE resource availability per 1000 beds for the larger-to medium-sized Health Boards. This would endorse the qualitative finding we reported previously, that AMT resource availability is problematic, with apparent disparity across Health Boards [9]. Arguably, an ideal AMT composition would include input from both infectious disease and clinical microbiology consultants (or indeed a jointly trained infection specialist), each bringing their own specialist perspectives, as well as a specialist nurse in addition to the AMT pharmacist; however, this was not common.…”

“…This discussion brings together the findings of this survey and our previous qualitative study to address the final research question: 'What are the key factors that influence the scope of AMT activities across Scottish Health Boards?'. A key strength is the use of our earlier qualitative findings [9] to develop a descriptive cross-sectional survey tool, looking in detail at AMT composition, leadership and resource allocation. By looking at these factors in light of Health Board size and associated AMT activities, interesting comparisons can be made.…”

“…Therefore, factors influencing the scope and frequency of AMT activities are complex and can not be simply explained by AMT resource availability alone. Reflection on the findings of our qualitative work [9], the theme 'people matter' is relevant here, where the enthusiasm of individual AMT members and the leadership style of the AMT leads who engage in more 'outreach' type work, using personal relationships to influence prescribers, was reported to impact the implementation of stewardship (Supplementary Material). This suggestion is endorsed in the literature review reported by Steinmann et al, who found that an empowering AMT leadership style may lead to higher engagement of physicians, allowing them to overcome reported barriers of AMS implementation [17].…”

“…Responding to these recommendations, a recent qualitative study involving AMS implementation leads and frontline practitioners (N ¼ 99) used Normalization Process Theory to explore barriers and enablers affecting the implementation of a national AMS programme in Scotland [9]. Findings showed that perceived barriers to implementation included organizational context and AMT resource availability, as well as AMT leadership influence.…”

Developing a Sustainable Antimicrobial Stewardship (AMS) Programme in Ghana: Replicating the Scottish Triad Model of Information, Education and Quality Improvement

“…This will support long-term engagement beyond the project to provide continued advice and guidance as the Ghana AMS programmes mature, as well as potentially supporting the spread of AMS to other hospitals in Ghana. Using a multi-professional approach along with behavior change techniques has also been crucial as stewardship needs to be owned by clinical teams and practiced by all staff to be reliable and sustainable [ 17 ].…”