The importance of culture and team dynamics in antimicrobial stewardship

Hello, my name is Esmita Charani and I am a researcher and a clinical pharmacist at Imperial College in London. Today, I’m going to be talking about why culture and team dynamics matter in antimicrobial stewardship. I’m going to be using examples from our own research here at Imperial, and that of colleagues elsewhere, to illustrate why we need to consider the influence of culture on antibiotic prescribing behaviours. Up until 100 years ago, a patient with an infectious disease would most probably die of their infection or its complications. It was only with the discovery of antibiotics by Fleming, in the Alexander Fleming building where I am right now at Imperial College in London, that we were able to successfully treat infections.

However, very early on in their use, antibiotics, these new wonder drugs, displayed a sting in their tail, antimicrobial resistance. With the continued widespread use of antibiotics despite alarming increases in the development and spread of resistant pathogens, organisations have fixed all efforts on getting the bug/drug patient combination right to ensure the effectiveness of the antibiotics we use. This is because antibiotic therapy remains a specialty that requires knowledge and expertise. Now it is estimated that up to one third of hospital antibiotic prescriptions may be inappropriate. Trying to explain the concept of collateral damage caused by inappropriate antibiotic use to the average health care professional remains a challenge. Therefore, antibiotic interventions are all concerned with behaviour change.

Culture plays a role in this subject, but to date has been largely neglected and left out of the equation. To date, most research in antibiotic stewardship has focused on the easily tangible and measurable. For example, producing policy and guidelines, measuring resistance, and measuring prescribing practise, with a little education and training, mainly aimed at junior doctors. A Cochrane Review, in which I was a co-investigator, highlighted the short-term merit of restrictive interventions and the longer-term merits of persuasive interventions in antibiotic stewardship. However, a major gap remains in research on the social science perspective of antibiotic prescribing in secondary care.

The impact of culture, both as organisational and inter- and intra-disciplinary level, and the impact of peers, team working and involvement of the different professions remains, to a large extent, unknown. Culture can be defined in many ways. I use the definition of culture by Spradley. “Culture,” he defines, is “the acquired knowledge people use to interpret, experience, and generate behaviours.” It refers to how we learn and moderate our behaviours as members of a team. Culture does not have to underpin everything that we do, but we use it as a cognitive map, a GPS if you like, to navigate our behaviours with. But why is culture important in this field?

Well, as mentioned before, if all antibiotic stewardship programmes have behaviour change as an outcome, and in view of the definition of culture by Spradley, then all antibiotic stewardship programmes are concerned with culture. We avoid culture at our peril. It has been said culture eats strategy for breakfast. So I want to use some evidence from literature to see if the saying holds true. In a study in three primary care general practice surgeries over two years, Gabbay and colleagues used ethnography methods to investigate how GPs access evidence-based guidelines. What they found and defined as mindlines was really culture at work. In their two years of observing doctors and nurses, they discovered that health care professionals rarely refer to explicit guidelines.

Rather, they use collectively reinforced, internalised, tacit mindlines that were structured from personal and colleague’s experiences and interactions with opinion leaders. health care professionals, they found, use socially constructed knowledge. Moving forward, a recent Health Foundation report, compiled by Professor Dixon-Woods and colleagues, investigated the implementation of the Matching Michigan guidelines in over 200 intensive care units in the United Kingdom. They were interested in investigating reasons for the decline effect. The decline effect refers to the inability to reproduce successful intervention outcomes in different settings. They used ethnography research to differentiate between the successful and unsuccessful units implementing the same intervention.

They found successful units to have demonstrated an understanding of local working arrangements, and engagement with, and involvement of, local key opinion leader staff. In the field of antibiotic stewardship, evidence also points to the influence of culture as a key determinant of antibiotic prescribing behaviours. In a systematic review conducted in 2011, which included both qualitative and quantitative research, we found very little evidence of using social science research in antibiotic stewardship programmes. This was despite qualitative evidence, albeit limited, indicating antibiotic prescribing to be more complex than a simple case of following guidelines. This systematic review was followed up with a qualitative study, where 39 health care professionals from nursing, medical, and pharmacy professions across three hospitals were interviewed.

The study explored their perceived self-reported determinants on antibiotic prescribing behaviours. What was identified was the existence of tacit rules governing prescribing. Hierarchy and prescribing etiquette overruled policy and guidelines. Senior clinicians wielded significant influence on the prescribing choices and decisions of junior doctors. When we replicated the study in Norway, it was interesting to find differing results, with hierarchy not emerging as a key determinant. This may be due to the fact that Norway, being a more egalitarian society, has made efforts to flatten visible hierarchies. For example, in Norwegian hospitals, all hospital staff wear the same white uniform. And these activities may have inadvertently helped them overcome some of the barriers which we still face in the UK NHS model.

The Cochrane Systematic Review of antibiotic prescribing interventions in hospitals is currently being updated. Despite the emerging evidence indicating the strong influence of culture on team dynamics, it is disappointing to see no new papers emerging which attempt to incorporate better social science into antibiotic stewardship programmes. Culture matters and needs to be better understood and addressed in the context of antibiotic stewardship programmes. If you’re interested to explore this emerging topic further, here is a list of papers and presentations which you can access online.