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Barriers and Facilitators – part 2

Welcome to part two of the presentation on behavioural approach to identifying barriers and facilitators to antimicrobial stewardship programmes.
So this is the second part of the presentation on Behavioural Approach To Identifying Barriers and Facilitators to Antimicrobial Stewardship Programmes. In the last slide of Part 1 of the presentation, we asked you to take a few minutes to match each of the six questions, used by Steinmo and et. al., to identify and investigate barriers to the implementation of the Sepsis Six with one of the six COM-B subcomponents. On this slide you will see there are listed six questions classified within the six COM-B subcomponents. Hopefully your answers will look just like ours. So psychological capability. An example of psychological capability would be memory. That is remembering to carry out all the steps of Sepsis Six in practice.
And physical capability concerns other than cognitive skills. For example, claiming proficiency, training, and ability to carry out each of the steps of Sepsis Six.
Reflective motivation. Whether or not implementing the Sepsis Six is a priority, is an important influence on the reflexive motivation. For example, the priority that is giving to Sepsis Six versus any competing priorities. Automatic motivation.
Emotional states, for example, worry about not catching it in time, identifying a septic patient, or anxious about performing the six steps in an hour are important influences on automatic motivation.
Physical opportunity. In addition to having access to necessary resources, for example, blood culture packs, IV lines, staff, physical opportunity would include having the time to perform all six steps.
Social opportunity. In addition to the people around you and the social environment where you work, social opportunity includes cooperation or conflict between team members.
The COM-B is a higher order summary or synthesis. Some find it useful to work at this level of granularity. However, each of the COM-B components could be broken down into further domains. These are outlined in another area developed, Behavioural science framework, namely, the Theoretical Domains Framework, in short, TDF. TDF was developed by an international panel of 32 experts in psychology and implementation, who synthesised 128 constructs from 33 behaviour change theories and simplified them into domains. The version two of the TDF has 14 domains. Each of the COM-B components can be broken down into further domains from the TDF, for example, motivation.
The COM-B component motivation can be broken into TDF domains– emotions, reinforcement, social, or professional goal and identity, beliefs about capabilities, goals, beliefs about consequences, optimism, and intentions. It is perfectly fine to work with either or both frameworks for Behavioural diagnosis, depending on preference and level of granularity required.
On this slide, you can see the four selected examples of barriers and facilitators to the Sepsis Six implementation, categorised into four selected TDF domains, and how they relate to the COM-B components.
Those four TDF domains are knowledge, values about consequences, social influences, environmental context, and resources. For example, the TDF domain beliefs about consequences of implementing or not implementing Sepsis Six related to the COM-B component motivation includes a barrier fear of harming patients, a barrier lack of trust and competence in the evidence of effectiveness of Sepsis Six, and facilitator needing to believe benefits outweigh risks, and the facilitator seeing health improved immediately and following-up specific patients.
Let’s work on an example. Selective reporting of antibiotic susceptibility test results is one possible laboratory-based antibiotic stewardship intervention. Pulcini and colleagues conducted a cross-sectional self-administered internet-based survey with national representatives from 35 European countries and Israel to identify where and how selective reporting of antibiotic susceptibility test results is implemented in Europe in inpatient and outpatient settings.
This is a list of exam three, seven barriers to the implementation of selective reporting of antimicrobial susceptibility tests which were identified in this international study by Pulcini and colleagues.
If Pulcini et. al., decided to use the TDF-based questions in their survey, here you can see types of domain-specific questions from relevant seven TDF domains they would be asking to identify those seven barriers. For example, to identify barriers related to environmental contacts and resources about selective reporting of antimicrobial susceptibility testing, they would be asking participants if they have access to the information they need and if they have enough time to do the six steps.
On this slide you can see how each reported barrier was categorised by assent to one or more of select seven TDF domains. By selecting a random domain-specific question from the previous slide that captures how they considered the barrier hinders implementing selective reporting and then linking it with a related COM-B component. Let’s consider each categorised barrier. A lack of investment for performing an action is one form of lack of reinforcement. Others include the influence of recognition from other professionals and feeling that performing the action is making a difference.
Those include the influence of having a national or local guideline, policy, or clear pathway that recognises the importance of and provide a plan of how to perform an action in a context in time. Other examples of goals include having targets to meet and making personal action plans. Experts having doubts about usefulness or applicability are examples of beliefs about consequences. Another example is fear of having– fear of harming patients.
The preferences of the organisation in which you work, in this case, private laboratories, are a social influence. Others include social support from colleagues and norms, that is believing that others would approve of you performing the action or believing that respected colleagues would also perform the action.
Environmental conflicts and resources include barriers such as not having sufficient time to perform actions, as well as the resources suggest a lack of clinical data. In addition, this domain includes having insufficient financial support from your organisation or health care system. The final statement expresses concerns about laboratory microbiologists having the knowledge or skills required to implement selective reporting. In this context, this is the only one of the seven barriers that is about knowledge and skills.
The main benefit of the use of a behaviour theory framework is the potential to understand the likely process of change before investing effort and resources in conducting exploratory piloting and formal testing. This should lead to the development of a more impactful behaviour change intervention, reduction in research waste, and waste in practice, that is, more efficient use of what are often limited quality improvement resources. Categorising barriers and facilitators using a behaviour theory framework has its challenges. For example, it requires a level of interpretation that has to be explicitly stated and consistently applied. As with any other skill, it improves with practice.
Therefore, we encourage you to complete this final activity to practice Categorising barriers and facilitators to implementation of ASPs in hospitals reported in literature. Hopefully, through this exercise, you will become even more aware that ASP is a competence behaviour influenced by an equally complex set of factors beyond knowledge deficits. This is very important to consider when selecting intervention strategies, as we need to look beyond educational approaches alone.
Thank you very much for your attention. Any questions, queries, feedback, please you get in touch.

Welcome to part two of the presentation on behavioural approach to identifying barriers and facilitators to antimicrobial stewardship programmes.

Please find a downloadable PDF of the PowerPoint slides below.

Implementing the Sepsis Six:

In the last slide in part one of the presentation, we asked you six questions; we hope you managed to match to each question (used by Steinmo et al), with one of the six COM-B sub-components.

In the download section you will find answers to the questions that match with the COM-B sub-components.

Let us know in the comments below if you got the correct answers.

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Utilising Social Science and Behaviour Change in Antimicrobial Stewardship Programmes: Improving Healthcare

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