University of Oulu

Parker H, Frost J, Day J, Bethune R, Kajamaa A, Hand K, et al. (2022) Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings. PLoS ONE 17(7): e0271454.

Tipping the balance : a systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings

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Author: Parker, Hazel1; Frost, Julia2; Day, Jo2;
Organizations: 1Pharmacy Department, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
2College of Medicine and Health, University of Exeter, Exeter, United Kingdom
3Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
4Faculty of Education, University of Oulu, Oulu, Finland
5Medical Directorate, NHS England & NHS Improvement, London, United Kingdom
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 1.3 MB)
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Language: English
Published: Public Library of Science, 2022
Publish Date: 2022-11-25


Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might ‘tip the balance’ towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

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Series: PLoS one
ISSN: 1932-6203
ISSN-E: 1932-6203
ISSN-L: 1932-6203
Volume: 17
Issue: 7
Article number: e0271454
DOI: 10.1371/journal.pone.0271454
Type of Publication: A2 Review article in a scientific journal
Field of Science: 3121 General medicine, internal medicine and other clinical medicine
Funding: This report is independent research supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Program Clinical Doctoral Research Fellowship, Miss Hazel Parker, ICA-CDRF-2018-04-ST2-019) and the National Institute for Health and Care Research Applied Research Collaboration South West Peninsula. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care. The funder, sponsor and authors’ institutions have had no role in developing the protocol.
Copyright information: © 2022 Parker et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.