Glasgow Caledonian University, Glasgow, UK.
Health Protection Scotland, Glasgow, UK.
Antimicrob Resist Infect Control. 2020 Jul 2;9(1):99. doi: 10.1186/s13756-020-00767-w.
Antimicrobial 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.
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'.
Results 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.
This 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 theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts.
抗菌药物管理（AMS）描述了为未来保障抗生素而开展的各项活动，旨在减少抗生素耐药性（AMR）这一主要全球公共卫生威胁的驱动因素，因为抗生素在预防和治疗感染方面的效果降低。合理使用抗生素是 AMS 的核心。虽然之前的研究已经探索了特定 AMS 干预措施的有效性，主要是从单一专业角度，但我们的文献检索无法找到任何现有证据来评估从多专业角度实施综合国家 AMS 计划的过程。
本研究旨在从多专业角度解释影响国家抗菌药物管理计划实施的机制。数据收集包括对来自 14/15 个苏格兰卫生委员会的 27 名实施领导临床医生进行深入的定性电话访谈，以及来自五个卫生委员会的 15 个医生、护士和临床药师焦点小组（n=72），这些焦点小组是根据报告的处方差异有针对性地选择的。首先对数据进行主题分析，然后对障碍和促进因素进行分类，并使用规范化进程理论（NPT）作为解释影响实施过程的机制的解释性视角。分析解决了 NPT 的问题，“哪些群体的行为者在哪些领域存在哪些问题，以及哪些问题会影响 AMS 融入日常医院实践”。
结果表明，主要障碍与组织背景和资源可用性有关。AMS 对实施领导和处方医生具有一致性；对顾问和可能无法接受培训的护士来说则不然。优先事项的冲突使得一些顾问很难获得支持；有限的角色认知意味着很少有护士或临床药师参与 AMS。实施 AMS 的集体个人和团队行动可能会受到缺乏医疗连续性和等级关系的限制。基于审核结果的反思性监测受到 AMS 领导向从业者提供直接反馈的能力的限制。
本研究从多专业、多组织的角度提供了国家 AMS 计划实施的障碍和促进因素的原始证据。使用稳健的理论框架（NPT）为研究结果提供了方法学严谨性。我们的研究结果对寻求在可比背景下加强医院 AMS 计划可持续实施的国际医疗保健政策制定者和从业者具有重要意义。
