Last week we wrote about how to integrate characteristics of high reliability organizations (HROs) in your antimicrobial stewardship efforts. The blog suggested that one approach is to defer to experts – from pharmacy to frontline staff – regardless of where they are in your organization’s hierarchy.
However, the reality is that not all staff are engaged by antimicrobial stewardship (AMS) programs and not all staff are experts. According to the CDC, 50 percent of antibiotics are not prescribed appropriately. So, what can you do to motivate staff who might be experts, but aren’t acting on their expertise? Or frontline staff who are simply not doing their part with AMS?
One solution, according to a recent Dutch study, is to facilitate a structured intervention so frontline staff can better understand how they can improve their efforts. The study followed a group of physicians working at hospitals in the Netherlands. The researchers invited the physicians to perform root cause analyses on inappropriate prescribing patterns. The physicians then built solutions around the causes they identified – for example, creating additional education and supervision to address inappropriate prescribing by inexperienced residents. There was a 13 percent improvement in the appropriateness of prescribing between the start of the intervention and a 12-month follow-up.
There are some limitations to the research, one being the unique nature of Dutch healthcare and the ability to replicate the approach in other systems. However, the studies main conclusions hold true elsewhere. A Cochrane Review published earlier this year examined 221 studies, 96 from North America. The review distinguished between restrictive and enabling techniques. Restrictive techniques usually consist of telling someone what not to do, while enabling techniques provide advice or feedback about how to improve behaviors. The review found the latter to be more effective.
Fundamentally, it makes a lot of sense. Remember being told as a kid to not touch something or to wait to eat or drink because it was too hot? It’s likely that, at least once, you did exactly the opposite. But after a burnt tongue or two, we learned. The same basic logic applies to enabling techniques: they present the opportunity to learn and understand why a behavior needs to be changed, rather than just saying that it needs to be done.
Enabling techniques are also far more engaging than a list of restrictions. In the Dutch study, physicians had the opportunity investigate their prescribing patterns and build out their own solutions. Approaches can be even simpler; earlier this year, a study tested how effective an online course, consisting of six 30-minute sessions, was in empowering nurses to improve antibiotic use in a long-term care setting. Not only did their knowledge scores improve, the nurses reported feeling more connected to the role they could play in AMS.
Changing patterns of behavior is difficult, but it isn’t impossible. Using resources and information to engage staff with AMS programs, could be the added call to action they need.