Discussion between Dr Nick Barber and Dr Michael Borg

Hello, my name is Nick Barber and I’m here with Michael Borg who is going to talk about behavioural change. So, Michael, when we have relatively junior staff wanting to create change, and there are some challenges for them, how can they go about creating some change? Yeah, I mean, junior staff are ideally placed in order to initiate behaviour change because they, not only are closest, very often closest, to the patient, they are also the individuals, especially in the medical and ancillary professions, who are very often up to date in guidelines. They know what the policies are at the hospital, most, and therefore, they can identify whether there are any issues that need to be addressed.

The problem, of course, is what we call power distance and this relates to hierarchy. So medical professions tend to be quite hierarchical in themselves. And then over and above that, societies differ in terms of the of level of power distance. So, for example, there are lots of work done in cultural anthropology by people like Geert Hofstede from The Netherlands, which shows that societies and cultures change significantly from one to the other. So there are some countries, especially the Anglo Saxon countries, the Scandinavian countries, where power distance is very low and these countries tend to be quite horizontal in the way they approach decision making.

So there is, very often, quite extensive consultation across the groups and decisions are taken as a team, rather than as individuals. Other countries, such as Latin countries, for example, tend to have a more rigid power distance set up. They tend to be more, pyramidal. Consultation, team involvement, the decision making tends to be more individualised than as a group. And therefore, when you have these situations, especially in these countries, there may be challenges for more junior staff to actually address more senior staff or those higher up in the pyramid, who in turn may sometimes feel actually offended that some of their juniors are actually raising these issues to them. And this is, unfortunately, a reality.

OK, so that’s really quite powerful. It’s a cultural thing. Are there any other cultural issues which would affect the ability to create change? Yes, another dimension that Hofstede has lately identified. It was called uncertainty avoidance. And whereas power distance relates to hierarchy, uncertainty avoidance relates to ambiguity and the way in which societies approach ambiguity. So if we take the situation of antibiotic prescribing of course there is a lot of ambiguity there. He knows is this infection viral or bacterial? What organism is causing it? And therefore, how am I going to approach this?

So you find, and there is quite a lot of research now available, that countries which are high in uncertainty avoidance tends to be those countries where antibiotics are used more for situations or conditions which are most likely be viral, such as sore throats, for example. And where wider spectrum antibiotics are used, the classical just-in-case situation. So there are these two main cultural dimensions, or cultural characteristics, which definitely impact our antibiotic prescribing. OK, so that’s very helpful and very powerful. And so what can be done about this? What sorts of solutions are there to these deeply ingrained cultural factors? Yeah, I mean, I think for a start, we have to make two things clear.

First of all, there will be some environments which are more challenging in order to achieve more effective antibiotic stewardship. And I think that is a clear starting point. It doesn’t, however, mean that there is nothing you can do. Because knowing your cultural background is very powerful, because it gives you the right tools and the right ideas to approach because the other thing about cultural diversity is that, when it comes to behaviour change, there are no copy-and-paste solutions. So it’s very important to see what others are doing, but it’s essential to adapt it to your own situation. So, for example, when you are in a high power distance environment, and it’s very important, for example, to identify connection power.

Connection power is basically making effective connections with people who have influence, whether it’s because of their position, or it’s because they are well respected peers. So it’s very important in antibiotic stewardship initiatives in power distance countries to actually these individuals on board and they will front the programme. They will be the individuals who are pushing this forward even though it may be more junior staff who will actually be doing the actual groundwork and most of the work over there. In terms of uncertainty avoidance, it’s always a question of trying to identify certainty. Now it’s very difficult to sell certainty in the concept of resistance because resistance tends to be quite an ambiguous topic to actually raise with our colleagues.

So I have to identify ways and means of trying to get more uncertainty. So one way of doing that is actually to utilise any outbreaks that occur and use these very clearly as the certain repercussions of what is happening as a result of the antibiotic use within that hospital. One way we have also tried to address this in antibiotic algorithms, because you’ll find these as providing more certainty than just generic diagrams. Because if you have a yes or no approach, that in itself lends itself to certainty. And finally, and one of the most important ways in which you can provide certainty, is actually to have assistants to clinical colleagues, to have microbiologists and ID physicians available.

Because by having this availability of support, by instilling and trying to encourage joint ward rounds for example, then you are sharing the ambiguity. And therefore, it is much easier to actually convince our colleagues that narrow spectrum antibiotic, in this situation, is sufficient because they are sharing that a uncertainty, and therefore that responsibility, with their microbiology or infectious diseases’ peers.

Michael, that’s fantastic. Thank you very much for your time.