Optimising Prescribing

Optimising Prescribing projects

Improving surgical antibiotic prescribing practice (2020-2027)

Research shows that surgical teams (surgeons, anaesthetists, junior doctors, pharmacists and nurses) do not always use antibiotics in the best way which can lead to unnecessary patient harm, for example antibiotic resistance and hospital-acquired infections. We must improve surgical antibiotic prescribing but to be effective we must understand what influences practice. This NIHR-funded project aims to improve antibiotic prescribing for surgical patients by working with surgical teams to introduce new ways of working that are informed by a deep understanding of the influences on their antibiotic prescribing practice.

The research has three sequential parts, with each informing the next:

  1. A systematic review and meta-ethnography (qualitative evidence synthesis).
    Analysis of previous studies on surgical antibiotic prescribing has enabled us to see a more ‘whole picture’ and to identify important research gaps for exploration. Through this work, we identified how and why contextual factors act and interact to influence antibiotic prescribing behaviour amongst surgical teams, and have develop new clinically applicable theory to advance understanding.
  2. Ethnography. Surgical teams from two NHS hospitals will be observed in the workplace, and surgical team members and patients will be interviewed, to explore influences on antibiotic prescribing decisions. Notes written during the observations and audio recordings from the interviews will be closely studied and analysed. This will lead to a deep understanding of what influences surgical teams when they make antibiotic prescribing decisions and what might be workable in practice to modify the status quo, to improve practice.
  3. Service improvement (using a Change Laboratory).
    Surgical team members from one NHS hospital will work together, with a researcher, to review current practice (identified in part two). The group will design and introduce new ways of working, to improve antibiotic prescribing practice. Infection rates and antibiotic prescribing will be monitored throughout to assess the impact.

Stakeholder engagement (including surgical team members, microbiologists, pharmacists and patients) has, and will continue to be, integrated throughout the research process to ensure the inclusion of varied interpretive repertoires and that the findings are clinically meaningful.

Optimising prescribing feedback conversations (2020-21)

Our previous research consistently demonstrates substantial reductions in prescribing errors following feedback interventions (e.g. 38% reduction in Parker et al. 2019). Yet such interventions have not been adopted or sustained as part of routine healthcare practice, when faced with funding cuts or staffing shortages. We have shown that prescribing practice is complex and multidirectional, with significant social and professional influences. The diverse sources of uncertainty that conjointly lead to prescribing errors defy unidirectional notions, such as ‘corrective feedback on error’. This project focused on the implementation of prescribing feedback conversations that, when optimised, can improve patient care. The project aimed to identify and better understand the barriers and enablers to implementing prescribing feedback interventions that can empower prescribers to enhance their development and improve patient care; and to identify the process measures that can help to drive adoption, retention and spread of good practice. With support from ESRC Impact Acceleration funding, we brought together diverse academic and external partners who represent medical education, policy-makers, and clinical practice, and engaged with a wide community of key stakeholders, including pharmacists, doctors, nurses, patients, educational programme directors, and policy makers. This led to the production of free-to-reuse resources for clinical practitioners to spread knowledge of best practice, and for policy makers to gain quick access to evidence syntheses.

The IMPACT (IMProving Antimicrobial presCribing of doctors in Training) realist review (2017-19)

Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers.  The IMPACT realist review located and synthesised 131 research articles to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners.  The review highlighted the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. Doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one’s reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians’ prescribing habits; (ii) take into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions.  This review contributed to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.