Mula Chimwemwe Tusekile, Human Nicola, Middleton Lyn
Department of Clinical Nursing, University of Malawi, Kamuzu College of Nursing, Blantyre, Malawi.
School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
BMC Health Serv Res. 2019 Jan 23;19(1):64. doi: 10.1186/s12913-019-3900-0.
Antibiotic 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.
This 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).
Using 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.
The 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.
抗生素管理是指对抗生素进行合理管理以确保患者获得最佳治疗效果，其基于质量改进。已制定了循证指南和方案来改善这一护理过程。安全、及时的患者护理还需要对人员、资源、设备、日程安排和任务进行优化协调。然而，医护人员在执行这些标准时会遇到障碍，并采取变通方法来克服这些障碍。变通方法绕过或暂时“解决”了被认为的工作流程障碍，以便更轻松地实现目标。本研究考察了马拉维一家三级医院的护士和医生为应对抗生素管理工作中遇到的挑战而采取的变通行为及其影响。
这是一项定性描述性案例研究设计，是一项大型混合方法研究的一部分，该研究旨在了解护士在抗生素管理中的作用，并确定为以护士为重点的干预措施的制定提供依据的障碍。在本研究中，我们对工作人员进行了访谈，并观察了两个成人内科病房护士的抗生素管理实践。我们与医生、药剂师和实验室技术人员（共20人）进行了三次焦点小组讨论，重点讨论了他们对护士在抗生素管理中作用的态度和经验。我们还观察了护士在四项活动中的抗生素管理实践和互动：交接班（10次）；抗生素配制（13次）；抗生素给药（49例）；以及查房（7次）。之后，研究人员对有目的地挑选出的参与观察的护士（13人）进行了跟进访谈。
通过归纳和演绎的主题分析方法，我们发现护士通过变通方法确立了克服挑战以实现预期任务目标的方式。我们还发现护士的实践影响了医生的变通方法。我们确定了与变通方法相关的六个主题，并将它们分为两类：“通过改变程序走捷径”和“使用未经授权的流程”。这些行为可能对患者护理和医疗系统产生积极和消极的影响。
该研究深入了解了马拉维一家三级医院的护士和医生如何应对患者抗生素管理过程中遇到的工作流程障碍。我们确定了两类变通方法，即通过改变程序走捷径和使用未经授权的流程。通过提供充足资源、培训、改善多学科团队合作和支持性监督来解决系统中的障碍，可以尽量减少变通方法。
