WHO antibiotic awareness poster in Thiruvananthapuram Government Medical College Hospital, Kerala
(Photo by Esmita Charani ©)
This case study reflects the outcomes of an in-depth ethnographic investigation on the influence of culture across the medical and surgical specialties on antibiotic prescribing behaviours in one hospital in London. Using ethnography and face to face interviews provided fresh perspectives on how culture and team dynamics influence antibiotic decision making across different healthcare settings and specialties. This animation summarises the findings of our study which opened opportunities for us to further investigate antibiotic use across surgical pathways in different settings. This ethnographic investigation coincided with a larger programme of studies investigating the influence of culture and team dynamics on antibiotic prescribing behaviours across different healthcare economies and cultures. This study took place in England, India, Norway, France, and Burkina Faso and investigates the challenges that healthcare professionals face across different resource settings when optimising antibiotic use in hospitals.
Interviews with stakeholders in 49 hospitals across 5 countries showed that optimising antibiotic use in surgery is seen as a challenge across the different professions and countries. This is reflected in the quotes below:
“The problem with the surgical approach is that daily input is required. It gives us opportunity as infection specialists to build rapport with the junior doctors and nurses in the surgical teams but the surgeons don’t care about that. Infections in surgery are usually healthcare acquired, and so the surgical teams are happy for us to manage the infections for them. What I would like to see is the surgeons taking more responsibility for the infections.” Infection specialist – France
“People find it difficult to question the surgeons, and they also find it difficult to argue [with them], so this has come up a lot …that even if the therapy may not be appropriate, and there may not be any evidence of infection but the patient’s improving, how can they argue against that?” Infection specialist – England
“I think there is huge irrational antibiotic use in surgery, because I find most surgeons feel it is my patient which is at stake so I must treat him irrespective of cost or whatever stakes that are there, I really don’t care about tomorrow. It’s just like global warming, isn’t it? Like let me use it now, I don’t know if this is going to come a million years later, we don’t realise that some of those effects are for our children.” Surgeon – India
Aiming to describe and share the findings of the qualitative research with a wider community of people, we developed an animation. Using an animation as a platform to share the study findings was an exercise in highlighting the gaps in the language that we use to discuss antimicrobial resistance. This is critical, as even amongst healthcare professionals the concept of antimicrobial stewardship may not be well recognised. Whilst presenting our research to an audience of surgeons in Jaipur, India, only three out of the 40 individuals in the room had heard of the term antimicrobial stewardship. Therefore, in the animation we refrained from using such terms, trying instead to describe the problem through simpler language.
Throughout our research we have always had much interest in the qualitative approach to study decision-making across surgical and medical teams, and different healthcare professionals in different countries. The doctors, surgeons, pharmacists, and nurses have much to say about their experiences with antibiotic prescribing practices across different specialties, sharing with us the different challenges and resource limitations that they face. Despite the differences in workforce capacity, financial resources, and infrastructure across all the participating countries, a conscious effort is being made to improve antibiotic use in hospitals and to prevent infections. The interventions employed are diverse and include removing shoes before entering intensive care units (India – see picture below), or providing a standard uniform for all staff to wear in clinical areas (Norway), or develop local antibiotic prescribing policies (England). We set out to investigate the influence of different cultures across these countries on clinical practices. We found however, that culture can also be influential across professional and specialty boundaries.
Visitor and staff shoes outside the adult intensive care unit of the Amrita Institute of Medical Sciences, Kochi, Kerala
(Photo by Esmita Charani ©)
Despite the availability of evidence-based guidelines and policy, anecdotally and historically, surgeons are considered the most difficult to reach specialty when it comes to infection management and antibiotic use. While guidelines and recommendations provide a road map to how and what needs to be done, they do not always address the complexity that is inherent in healthcare. Different healthcare professionals and teams are often working to different policies, targets, and end goals. It is important therefore to understand and accept that there are no universal solutions to the challenges encountered in complex healthcare systems. Culture is about the shared norms, values, and assumptions amongst groups of people and a better understanding of culture can help explain healthcare behaviours in the context in which they are observed. Our social science focused research has identified that non-interference with the prescribing decisions of others, acceptance of non-compliance to policy and hierarchy of prescribing whereby junior doctors prescribe are the overriding characteristic of antibiotic prescribing in hospitals. It is the senior members of the team, however, who decide what is to be prescribed for patients. Understanding culture and context is highly relevant when trying to understand how and why interventions and policies fail to be implemented as expected.
Through investigating antibiotic prescribing across surgical teams using intensive direct observations in England and India, we have identified that antibiotic management in surgery is complex. This is not because there is less attention to infection management in surgical teams, but rather because of the different way in which surgical teams prioritise the care of their patients. Antibiotic prescribing in surgery is driven by a need to prevent infections following a surgical intervention. The surgical teams are divided between the very different environments of the operating theatre, outpatient clinics and inpatient wards. This dynamic is universal for surgical teams anywhere in the world. This requirement to be in different places means that often antibiotic prescribing decisions are delegated to other healthcare professionals. Additionally, effective antibiotic management is frustrated by diffusion of responsibility. The surgical teams, also because of the nature of their schedules and divided teamwork, are less likely to have the time to be able to engage with other healthcare professionals. What was compelling was the common theme in the way that surgical teams operate across different countries and settings. The findings allude to a common culture across medical practice that transcends geographical boundaries and is entrenched in the medical training of healthcare professionals and how patient care and well-being is prioritised across different specialties.
PhD MSc MPharm – Lead Research Pharmacist at NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance of the Imperial College London