- Email: [email protected]
Spreading the word, not the infection: Reaching hospitalists about the prevention of antimicrobial resistance
Spreading the word, not the infection: Reaching hospitalists about the prevention of antimicrobial resistance Megan E. Bush-Knapp, MPH,a Kristin J. Brinsley-Rainisch, MPH,a Rachel M. Lawton-Ciccarone, MPH, CHES,a Ronda L. Sinkowitz-Cochran, MPH,a Daniel D. Dressler, MD, MSc,b Tina Budnitz, MPH,c and Mark V. Williams, MDb Atlanta, Georgia
Background: To reach and engage hospitalists in the prevention of antimicrobial resistance, the Society of Hospital Medicine and the Centers for Disease Control and Prevention developed and conducted a quality improvement workshop based on the Centers for Disease Control and Prevention’s Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. Methods: We aimed to examine motivating factors, perceived barriers, and cues to action for hospitalists to learn about and engage in the prevention of antimicrobial resistance and to determine whether a workshop can facilitate the implementation of a quality improvement project. Using the Health Belief Model as a theoretical framework, we interviewed hospitalists who attended (attendees) and did not attend (nonattendees) the workshop. Data were qualitatively coded and analyzed. Results: Nine attendees and 10 nonattendees participated in interviews. Motivating factors for attending the workshop included an interest in the topic of quality improvement and antimicrobial resistance prevention, the promotion of the workshop by institutions and colleagues, the opportunity to network with colleagues, and the qualifications of the presenter. Barriers to involvement in quality improvement efforts and the prevention of antimicrobial resistance for both attendees and nonattendees included perceived lack of time, other institutional priorities, and lack of administrative and institutional support. Attendees and nonattendees also identified perceived effective and preferred methods for receiving information about antimicrobial resistance, such as workshops and presentations, e-mail, institutional involvement, and the Internet. Overall, attendees thought that the workshop could be effective in facilitating the implementation of a quality improvement project. Conclusion: By considering factors that influence behavioral change, interventions, such as the Society of Hospital Medicine workshop, have the ability to reach and engage clinicians such as hospitalists in quality improvement efforts to prevent antimicrobial resistance and improve adherence to infection control strategies. Furthermore, this study demonstrated that the Health Belief Model can provide an applicable framework for examining factors that influence clinician behavior. (Am J Infect Control 2007;35:656-61.)
Antimicrobial resistance has emerged as a significant public health problem, especially within the hospital setting. Despite guidelines and policies for health care providers to follow that prevent antimicrobial resistance, compliance with recommended infection control practices remains low, and rates of antimicrobialresistant infections continue to rise.1-4 The increasing From the Division of Healthcare Quality Promotion,a National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Department of Health and Human Services; the Emory University School of Medicine,b Emory University; and the Society of Hospital Medicine,c Atlanta, GA. Address correspondence to Kristin J. Brinsley-Rainisch, MPH, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, 1600 Clifton Road MS A-31, Atlanta, GA 30333. E-mail: [email protected]. The authors have no relevant financial interest in this article. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. 0196-6553/$32.00 Copyright ª 2007 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2007.03.006
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prevalence of resistant pathogens and the diminishing efficacy of antimicrobials creates the need to examine different strategies for approaching the prevention of health care-associated infections and calls for leaders within the hospital to engage in quality improvement efforts to prevent antimicrobial resistance and improve patient safety. Hospitalists are promising candidates to support this leadership role because they are responsible for managing the care of hospitalized patients.5 The field of hospital medicine was established in 1996 with the belief that the use of hospitalists might lower inpatient costs without compromising quality of care or patient satisfaction.6 In fact, studies have shown that the use of hospitalists in some institutions decreased treatment costs and length of hospital stay by 10% to 25%.7,8 This fast growing field had more than 8000 hospitalists in practice in the United States in 2004, and the numbers are expected to grow to 20,000 by the year 2010.6,9,10 Because of their growing numbers and onsite availability in the hospital setting, hospitalists, like infection control professionals (ICPs) and health care epidemiologists, are uniquely positioned to be leaders in quality improvement efforts including programs to prevent antimicrobial-resistant infections. To
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engage hospitalists in quality improvement efforts, such as antimicrobial resistance prevention, it is important to examine possible behavioral influences. Components of the Health Belief Model (HBM) or similar health behavior theories have been applied in studies regarding infection control and antimicrobial resistance. Applications of behavioral theories can identify influencing factors, such as perceived susceptibility and risk, perceived benefits and barriers, cues to action, and self-efficacy, that predict whether an individual will engage in specific behaviors to prevent antimicrobial resistance.11 For example, lack of perceived threat has been used to assess the likelihood of behavioral change for prevention of antimicrobial resistance; cues to action have been used to address perceived threat and lack of awareness about health care concerns; and perceived barriers have been used to evaluate adherence to hand hygiene and best practice guidelines.2,11-18 Interventions can be targeted to these factors to facilitate behavioral change. As a part of national efforts to address antimicrobial resistance, the Centers for Disease Control and Prevention (CDC) developed the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings (Campaign). The Campaign is targeted at clinicians and comprises 4 main strategies for the prevention of antimicrobial resistance: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Within the 4 strategies, the Campaign offers 12 evidence-based practice recommendations tailored to specific patient populations, such as hospitalized adults and children, that can prevent the emergence and transmission of antimicrobial-resistant pathogens. In 2004, the Society of Hospital Medicine (SHM) and the CDC collaborated to develop a quality improvement tool kit based on the Campaign. The tool kit contained educational materials from the Campaign as well as a slide set about quality improvement, worksheets, and additional materials, such as infection control policies and guidelines, to be presented during a 90-minute workshop. Using the HBM as a framework, we interviewed hospitalists following an SHM workshop to identify facilitators, barriers, and cues to action for hospitalists to learn about and engage in the prevention of antimicrobial resistance and to assess whether the workshop facilitated the implementation of a hospital quality improvement project.
METHODS In December 2004, the Atlanta chapter of the SHM held an educational workshop in Atlanta, Georgia, to present a quality improvement tool kit aimed at reducing health care-associated infections, specifically
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bloodstream infections, and antimicrobial resistance in health care settings. The workshop was advertised to all 55 Atlanta chapter SHM members using e-mail, and attendees were provided a complimentary dinner. Both members who attended (attendees) and did not attend the workshop (nonattendees) were interviewed by phone in the 6- to 8-week period following the workshop. A sample of the workshop attendees was selected for individual follow-up telephone interviews. Attendee interviews consisted of 15 open-ended questions pertaining to demographics, reasons for workshop attendance, likes and dislikes of the workshop, recall of main messages, perceived effectiveness of the workshop and tool kit in raising awareness of antimicrobial resistance, implementation of quality improvement projects, and methods for informing hospitalists about antimicrobial resistance. A convenience sample of Atlanta SHM members who did not attend the workshop was selected from the Atlanta chapter SHM membership list. Nonattendees were contacted by e-mail to participate in a telephone interview regarding educational opportunities about quality improvement and antimicrobial resistance. The open-ended, 8 question interview asked about demographics, reasons for not attending the workshop, implementation of quality improvement projects, methods for informing hospitalists about antimicrobial resistance, and awareness of antimicrobial resistance education materials. Interviews were conducted by a moderator with a standardized script, and data were recorded using a tape recorder and note taker. All participants were informed that the recordings were to be used for data organization and aggregation only and that identities would be kept confidential. Three researchers (M.E.BK., K.J.B-R, R.L.S-C] qualitatively analyzed the responses collected during the interviews through a process of aggregation and categorization by themes.
RESULTS Fifteen Atlanta chapter SHM members attended the workshop. Nineteen hospitalists were interviewed by phone (n 5 9 attendees, n 5 10 nonattendees). Of these 19, 58% (n 5 6 attendees, n 5 5 nonattendees) classified themselves as practicing hospitalists, 21% (n 5 4 nonattendees) as residents, 11% (n 5 1 attendee, n 5 1 nonattendee) as administrators, and 11% (n 5 2 attendees) as other, including an orthopedic surgeon and clinical pharmacist. The average years in practice were 8.5 (range, 1-25 years) for interviewees. There were no significant differences in years in practice between attendees and nonattendees or in responses based on years of practice.
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Among workshop attendees, the most common reasons for attendance were an interest in quality improvement to prevent antimicrobial resistance and improve patient safety (n 5 4, 44%) and promotion of the workshop by their institution or colleagues (n 5 3, 33%). Other motivations for attendance included the opportunity to meet colleagues and network, SHM sponsorship, the speaker, and the workshop location. For nonattendees, the most common barriers to workshop attendance were scheduling conflicts and/or inconvenient timing (n 5 8, 80%). One hospitalist stated, ‘‘I found the topic very interesting and regret that I could not make it. I hope there are future opportunities for events like this.’’ Another barrier cited for nonattendance was lack of awareness about the workshop (n 5 2, 20%). In response to the question ‘‘what did you like about this workshop?’’ most attendees agreed that they liked the opportunity to meet colleagues and exchange ideas (n 5 5, 56%) and the overall presentation (n 5 5, 56%). One hospitalist commented,‘‘[With this workshop], you have the opportunity to meet other hospitalists from the area. You exchange ideas, share problems, and think up solutions to common problems.’’ Some attendees said that they enjoyed the speaker (n 5 3, 33%) and found the information useful (n 5 3, 33%). Other responses included the organization of the workshop, the tool kit, and the workshop time and location. In addition, the attendees cited that they would have liked more time to interact with other colleagues and a larger audience. All attendees perceived that a workshop, like the SHM workshop, is an effective way to address antimicrobial resistance concerns because workshops can raise awareness, present ‘‘practical material in a practical manner,’’ give the opportunity to network, and serve as a reminder. One hospitalist stated, ‘‘I think [a workshop like this] is helpful. It’s something that’s got to be a part of an ongoing program. It’s not just a one time thing.’’ All attendees also agreed that a workshop, like the SHM workshop, motivates physicians to initiate quality improvement projects because of the workshop’s ability to raise awareness. When asked ‘‘have you implemented or suggested implementing the quality improvement tools that you learned in this workshop?’’ 3 (33%) attendees indicated that they were in the process of implementing quality improvement projects and were utilizing the tool kit presented during the workshop. One hospitalist commented that the workshop was helpful in ‘‘laying out the steps and process’’ to design a quality improvement project. However, the majority (n 5 6, 67%) of attendees had not implemented or suggested implementing the tools. The major barriers to using the tools included lack of time, other priorities, and lack of system-wide support. One hospitalist stated, ‘‘I think
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[quality improvement] is more like a system-wide [issue] that needs to be [addressed institutionally] instead of on the individual basis.’’ Another participant responded, ‘‘We cannot implement certain things by ourselves. We have to go through committees and [other processes].’’ Similarly, the 10 nonattendees were asked whether they had implemented or suggested implementing a quality improvement project to prevent health careassociated infections and antimicrobial resistance in their institution: only 3 (30%) had implemented or suggested implementing a quality improvement project in their institution. Nonattendees personally involved in the implementation of a quality improvement project believed that administrative support and evidencebased research facilitated the implementation of projects. One nonattendee replied, ‘‘I think primarily administrative and political will [is facilitating the implementation of quality improvement projects].’’ Of the 7 who had not participated in quality improvement project implementation, most (n 5 6, 86%) had not participated because of the existence of an already established project. To determine cues to action, both attendees and nonattendees were asked to name what they thought were the most effective ways to reach clinicians such as hospitalists about antimicrobial resistance topics. Responses from attendees and nonattendees were similar. The methods mentioned most were workshops and presentations (n 5 5, 56% attendees; n 5 6, 60% nonattendees). E-mail (n 5 2, 22% attendees; n 5 4, 40% nonattendees) and institutional/hospital support (n 5 2, 22% attendees; n 5 3, 30% nonattendees) also were cited. Other methods included the Internet, continuing medical education, professional societies, and CD-ROM. One nonattendee held that there is no one way to reach health care providers: ‘‘[Naming one way] is difficult, because we are inundated with so many different things. . . . We get e-mails that are sent from corporate [or] from local hospitals [or we read journals]. I mean there is so much of this that hits us that I’m not sure [of the best way to reach us all].’’ When asked about their preferred ways to receive information on the topic of antimicrobial resistance, the attendees and nonattendees provided similar responses at different frequencies. The majority (n 5 7, 70%) of nonattendees and 2 (22%) attendees preferred e-mail as a way to receive information. Five (56%) attendees and 3 (30%) nonattendees named workshops and presentations. Other preferred methods included the Internet, journal articles, continuing medical education, flyers in the lounge, CD-ROM, institutional/hospital ‘‘involvement,’’ other colleagues, and lay press. Both attendees and nonattendees were asked whether they had ever heard about or seen any of
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the educational materials from the CDC’s Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. The majority (n 5 8, 80%) of the nonattendees were familiar with the Campaign, whereas the majority (n 5 6, 67%) of the attendees were not familiar with the Campaign (prior to the workshop). Of the hospitalists familiar with the Campaign, 1 attendee and 4 nonattendees knew about the Campaign from their facilities, 1 attendee and 2 nonattendees from workshop or presentations, 3 nonattendees from the Internet, 2 attendees from coworkers, and 1 nonattendee from the Joint Commission on the Accreditation of Healthcare Organizations.
DISCUSSION Using the HBM as a theoretical framework, we examined the behavioral influences of hospitalists, such as motivating factors, barriers, and cues to action, to gain an understanding of how to better reach and engage clinicians such as hospitalists in quality improvement efforts to prevent antimicrobial resistance. According to the HBM, for an intervention, such as the SHM workshop, to impact competence and act as a precursor to behavior change, clinicians must first be motivated to participate. The most common motivating factor for attendance was an interest in the topic of quality improvement to prevent antimicrobial resistance and improve patient safety. Because part of the emerging role of the hospitalist and that of the ICP includes sponsoring or initiating quality improvement efforts, motivation to attend based on this topic indicates that clinicians who attended were interested in learning more for their professional development and care improvement.9,19 Another commonly cited motivating factor for attendance included promotion of the workshop by institutions and colleagues. In addition, unfamiliarity with a topic, namely the Campaign, and a desire to know more about a topic in general may have served as a motivating factor. Interestingly, 80% of nonattendees knew about the Campaign, whereas only 33% of attendees had previous knowledge. In examining motivating factors to attend an educational workshop about preventing antimicrobial resistance, Giblin et al found similar results revealing that 72% of clinicians attended to learn more for their job, 22% attended because of pressure by peers or administration, and 17% attended because they wished to learn more about a topic in general.13 Some attendees also reported that they attended and enjoyed the workshop because of the speaker, a fellow hospitalist and a leader in SHM. This finding is supported by other research indicating that information presented by an opinion leader might be more effective in engaging physicians to follow new practices.13,20 Opinion
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leaders can act as role models in practice and encourage ownership of the issues at an institutional level.21 In designing and promoting future workshops, organizations should ensure that the topics are relevant to the work of the audience and that the institution supports and promotes the workshop. Because all attendees reported that they would encourage a colleague to attend this workshop, promotion through past attendees or others familiar with the topics might provide additional motivation. Of those not attending the workshop, the majority had scheduling conflicts that hindered their attendance. Time-related barriers (ie, lack of time and other priorities) contributed to lack of engagement in quality improvement efforts for attendees as well. Several attendees had not implemented or suggested implementing the quality improvement tools from the workshop because of perceived lack of time and other pressing priorities. Not unique to hospitalists’ participation in quality improvement efforts, lack of time also has posed barriers for physicians and health care providers in other areas, such as hand hygiene adherence.2,14-18,22 If quality improvement efforts for the prevention of antimicrobial resistance are deemed an institutional priority, hospitalists and other clinicians may no longer perceive lack of time and other priorities as barriers. Although literature supports the idea that clinicians such as hospitalists have the ability to take leadership in quality improvement efforts, some of the interviewed hospitalists found it difficult to implement programs and perceived that changes could not be accomplished without better administrative and institutional support.5,8,9,19,23 In hospitals in which administrative and institutional support was present, the support provided motivation and served as a cue to action, and the hospitalists felt enabled to engage in quality improvement efforts. As stated by one nonattendee, ‘‘some of the administration at my facility are recognizing that there’s a need and are empowering us by giving us the authority and the time to do [quality improvement projects].’’ Individual and administrative actions are often interdependent and may require support from one another to create and implement successful projects on a system-wide basis. To determine other cues to action for clinicians, the attendees and nonattendees were asked to provide what they perceived as the most effective and preferred methods for receiving information about antimicrobial resistance. Similar to previous research with other physicians, the participants of this study cited a variety of methods, indicating that a multimodal approach may be necessary to reach hospitalists.13,24,25 Workshops and presentations, e-mail, institutional involvement, and the Internet were cited most often and perceived as both effective and preferred strategies. Interestingly,
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e-mail was the most commonly named preferred method for receiving information, whereas workshops and presentations were perceived as the most effective. Clinicians such as hospitalists may prefer e-mail because of time constraints but realize that workshops and presentations offer a more in-depth opportunity for learning. Also of note, in one previous study, journal articles had been cited as the most preferred way to learn about antimicrobial resistance issues by 88% of the surveyed physicians; however, in this study, very few hospitalists cited journal articles as a cue to action.25 Although part of the discrepancy in results may be related to the data collection methods, the difference may be worth further investigation to understand better how to reach clinicians such as hospitalists and how their effective and preferred methods compare with those of other physicians and health care providers. Additionally, a common theme throughout the interviews was interest in the opportunity to network and exchange ideas. The ability to communicate with colleagues was a factor that attendees liked about the workshop, wanted more time for, and perceived to be an effective way to address antimicrobial concerns. According to Davis et al, interaction among physicians may influence the individuals’ learning and likelihood to change by producing a level of cognitive dissonance between what peers know and do compared with the learner.26 Offering a forum for communicating about subjective norms around antimicrobial resistance can provide motivation and a cue to action.27 Some studies also have found that physicians preferred communication with peers as a means for learning about antimicrobial resistance.25,28 Giving participants the opportunity to network, exchange ideas, and work in groups may be an effective strategy to foster behavioral change in clinicians such as hospitalists. Because of the small sample size and limited geographic region, the results of this study may not be generalizable to all hospitalists or to clinicians of different areas and specialties. Additionally, because the interviews took place 6 weeks after the workshop, attendees may not have had enough time for project initiation and/or implementation of the presented strategies. Although this research provides a qualitative foundation for understanding behavioral influences of clinicians such as hospitalists, expanded research with larger sample sizes and longer follow-up period or secondary interviews may offer a more comprehensive view on how to reach and engage this group of clinicians in quality improvement efforts. In addition, future efforts to encourage behavioral change may require a 2-step process. The first step prepares clinicians for change, and the second step supports them in overcoming specific barriers to implementation of quality improvement efforts.
Furthermore, future research should focus on methods for engaging clinicians such as hospitalists as well as hospital administration in the process of quality improvement efforts. The participants of this study continually cited the importance of institutional support. Future research also could examine how hospitalists like ICPs as leaders can gain the support and buy-in of other health care workers, hospital staff, and most importantly hospital administration. Although not all attendees had implemented or suggested implementing quality improvement projects, all perceived that a workshop, like the SHM workshop, was an effective way to address antimicrobial resistance and initiate preventative projects. This workshop served as a cue to action; provided motivating factors by offering job-related information, role models in the field, and the opportunity to network with colleagues; and outweighed barriers by providing motivating factors and cues to action. The HBM provides an applicable framework to examine factors that influence the behaviors of clinicians, and, by addressing these factors, interventions, such as the SHM workshop, have the ability to reach and engage hospitalists and ICPs alike in quality improvement efforts to prevent antimicrobial resistance and improve patient safety within health care settings.
References 1. National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470-85. 2. Centers for Disease Control and Prevention. Guidelines for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/ SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51:1-44. 3. Garner JS. Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53-80. 4. Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis WR, Boyce JM, et al. SHEA guideline for prevention nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Entercoccus. Infect Control Hosp Epidemiol 2003;24:362-86. 5. Wachter RM, Goldman L. The emerging role of ‘‘hospitalists’’ in the American health care system. N Engl J Med 1996;335:514-7. 6. Wachter RM. Hospitalists in the United States—mission accomplished or work in progress? N Engl J Med 2004;350:1935-6. 7. Wachter RM. The hospitalist movement: Ten issues to consider. Hosp Pract (serial online) February 1999 (cited December 15, 2004). Available at: http://www.hosppract.com/issues/1999/02/wachter.htm. Accessed December 15, 2004. 8. Baudendistel TE, Wachter RM. The evolution of the hospitalist movement in the USA. Clin Med 2002;2:327-30. 9. Amin AN. The hospitalist model of care: a positive influence on efficiency, quality of care, and outcomes. Crit Path Cardiol 2004;3: S5-7. 10. Amin AN. Identifying strategies to improve outcomes and reduce costs—a role for the hospitalist. Curr Opin Pulm Med 2004;10: S19-22.
Bush-Knapp et al 11. Janz NK, Champion VL, Strecher VJ. The health belief model. In: Glanz K, Rimer BK, Lewis FM, editors. Health behavior and health education: theory, research, and practice. 3rd ed. San Francisco: Jossey-Bass; 2002. p. 45-66. 12. Wester CW, Durairaj L, Evans AT, Schwartz DN, Husain S, Martinez E. Antibiotic resistance: a survey of physician perceptions. Arch Intern Med 2002;162:2210-6. 13. Giblin TB, Sinkowitz-Cochran RL, Harris PL, Jacobs S, Liberatore K, Palfreyman MA, et al. Clinicians’ perceptions of the problem of antimicrobial resistance in health care facilities. Arch Intern Med 2004;164: 1662-8. 14. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001;7:234-40. 15. Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162:1037-43. 16. O’Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001;29:353-60. 17. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1-8. 18. Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. J Hosp Infect 1995;30:88-106. 19. Goldman L. The impact of hospitalists on medical education and the academic health systems. Ann Intern Med 1999;130:364-7. 20. Pittet D. The Lowbury lecture: behaviour in infection control. J Hosp Infect 2004;58:1-15.
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21. Cooper T. Educational theory into practice: development of an infection control link nurse programme. Nurs Ed Pract 2001;1:35-41. 22. Osborne S. Influence on compliance with standard precautions among operating room nurses. Am J Infect Control 2003;31:415-23. 23. Plauth WH, Pantilat S, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med 2001;111:247-54. 24. Brinsley KJ, Sinkowitz-Cochran RL, Cardo DM, and the CDC Campaign to Prevent Antimicrobial Resistance Team. Assessing motivation for physicians to prevent antimicrobial resistance in hospitalized children using the Health Belief Model as a framework. Am J Infect Control 2004;33:175-81. 25. Brown TT, Proctor SE, Sinkowitz-Cochran RL, Smith TL, Jarvis WR, and the Society for Healthcare Epidemiology of America. Physician preferences for continuing medical education with a focus on the topic of antimicrobial resistance: Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2001;22:656-60. 26. Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, TaylorVaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282:867-74. 27. Pittet D. Hand hygiene: improved standards and practice for hospital care. Curr Opin Infect Dis 2003;6:327-35. 28. Srinivasan A, Song X, Richards A, Sinkowitz-Cochran R, Cardo D, Rand C. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 2004;164:1451-6.
Background: To reach and engage hospitalists in the prevention of antimicrobial resistance, the Society of Hospital Medicine and the Centers for Disease Control and Prevention developed and conducted a quality improvement workshop based on the Centers for Disease Control and Prevention’s Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. Methods: We aimed to examine motivating factors, perceived barriers, and cues to action for hospitalists to learn about and engage in the prevention of antimicrobial resistance and to determine whether a workshop can facilitate the implementation of a quality improvement project. Using the Health Belief Model as a theoretical framework, we interviewed hospitalists who attended (attendees) and did not attend (nonattendees) the workshop. Data were qualitatively coded and analyzed. Results: Nine attendees and 10 nonattendees participated in interviews. Motivating factors for attending the workshop included an interest in the topic of quality improvement and antimicrobial resistance prevention, the promotion of the workshop by institutions and colleagues, the opportunity to network with colleagues, and the qualifications of the presenter. Barriers to involvement in quality improvement efforts and the prevention of antimicrobial resistance for both attendees and nonattendees included perceived lack of time, other institutional priorities, and lack of administrative and institutional support. Attendees and nonattendees also identified perceived effective and preferred methods for receiving information about antimicrobial resistance, such as workshops and presentations, e-mail, institutional involvement, and the Internet. Overall, attendees thought that the workshop could be effective in facilitating the implementation of a quality improvement project. Conclusion: By considering factors that influence behavioral change, interventions, such as the Society of Hospital Medicine workshop, have the ability to reach and engage clinicians such as hospitalists in quality improvement efforts to prevent antimicrobial resistance and improve adherence to infection control strategies. Furthermore, this study demonstrated that the Health Belief Model can provide an applicable framework for examining factors that influence clinician behavior. (Am J Infect Control 2007;35:656-61.)
Antimicrobial resistance has emerged as a significant public health problem, especially within the hospital setting. Despite guidelines and policies for health care providers to follow that prevent antimicrobial resistance, compliance with recommended infection control practices remains low, and rates of antimicrobialresistant infections continue to rise.1-4 The increasing From the Division of Healthcare Quality Promotion,a National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Department of Health and Human Services; the Emory University School of Medicine,b Emory University; and the Society of Hospital Medicine,c Atlanta, GA. Address correspondence to Kristin J. Brinsley-Rainisch, MPH, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, 1600 Clifton Road MS A-31, Atlanta, GA 30333. E-mail: [email protected]. The authors have no relevant financial interest in this article. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. 0196-6553/$32.00 Copyright ª 2007 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2007.03.006
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prevalence of resistant pathogens and the diminishing efficacy of antimicrobials creates the need to examine different strategies for approaching the prevention of health care-associated infections and calls for leaders within the hospital to engage in quality improvement efforts to prevent antimicrobial resistance and improve patient safety. Hospitalists are promising candidates to support this leadership role because they are responsible for managing the care of hospitalized patients.5 The field of hospital medicine was established in 1996 with the belief that the use of hospitalists might lower inpatient costs without compromising quality of care or patient satisfaction.6 In fact, studies have shown that the use of hospitalists in some institutions decreased treatment costs and length of hospital stay by 10% to 25%.7,8 This fast growing field had more than 8000 hospitalists in practice in the United States in 2004, and the numbers are expected to grow to 20,000 by the year 2010.6,9,10 Because of their growing numbers and onsite availability in the hospital setting, hospitalists, like infection control professionals (ICPs) and health care epidemiologists, are uniquely positioned to be leaders in quality improvement efforts including programs to prevent antimicrobial-resistant infections. To
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engage hospitalists in quality improvement efforts, such as antimicrobial resistance prevention, it is important to examine possible behavioral influences. Components of the Health Belief Model (HBM) or similar health behavior theories have been applied in studies regarding infection control and antimicrobial resistance. Applications of behavioral theories can identify influencing factors, such as perceived susceptibility and risk, perceived benefits and barriers, cues to action, and self-efficacy, that predict whether an individual will engage in specific behaviors to prevent antimicrobial resistance.11 For example, lack of perceived threat has been used to assess the likelihood of behavioral change for prevention of antimicrobial resistance; cues to action have been used to address perceived threat and lack of awareness about health care concerns; and perceived barriers have been used to evaluate adherence to hand hygiene and best practice guidelines.2,11-18 Interventions can be targeted to these factors to facilitate behavioral change. As a part of national efforts to address antimicrobial resistance, the Centers for Disease Control and Prevention (CDC) developed the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings (Campaign). The Campaign is targeted at clinicians and comprises 4 main strategies for the prevention of antimicrobial resistance: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Within the 4 strategies, the Campaign offers 12 evidence-based practice recommendations tailored to specific patient populations, such as hospitalized adults and children, that can prevent the emergence and transmission of antimicrobial-resistant pathogens. In 2004, the Society of Hospital Medicine (SHM) and the CDC collaborated to develop a quality improvement tool kit based on the Campaign. The tool kit contained educational materials from the Campaign as well as a slide set about quality improvement, worksheets, and additional materials, such as infection control policies and guidelines, to be presented during a 90-minute workshop. Using the HBM as a framework, we interviewed hospitalists following an SHM workshop to identify facilitators, barriers, and cues to action for hospitalists to learn about and engage in the prevention of antimicrobial resistance and to assess whether the workshop facilitated the implementation of a hospital quality improvement project.
METHODS In December 2004, the Atlanta chapter of the SHM held an educational workshop in Atlanta, Georgia, to present a quality improvement tool kit aimed at reducing health care-associated infections, specifically
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bloodstream infections, and antimicrobial resistance in health care settings. The workshop was advertised to all 55 Atlanta chapter SHM members using e-mail, and attendees were provided a complimentary dinner. Both members who attended (attendees) and did not attend the workshop (nonattendees) were interviewed by phone in the 6- to 8-week period following the workshop. A sample of the workshop attendees was selected for individual follow-up telephone interviews. Attendee interviews consisted of 15 open-ended questions pertaining to demographics, reasons for workshop attendance, likes and dislikes of the workshop, recall of main messages, perceived effectiveness of the workshop and tool kit in raising awareness of antimicrobial resistance, implementation of quality improvement projects, and methods for informing hospitalists about antimicrobial resistance. A convenience sample of Atlanta SHM members who did not attend the workshop was selected from the Atlanta chapter SHM membership list. Nonattendees were contacted by e-mail to participate in a telephone interview regarding educational opportunities about quality improvement and antimicrobial resistance. The open-ended, 8 question interview asked about demographics, reasons for not attending the workshop, implementation of quality improvement projects, methods for informing hospitalists about antimicrobial resistance, and awareness of antimicrobial resistance education materials. Interviews were conducted by a moderator with a standardized script, and data were recorded using a tape recorder and note taker. All participants were informed that the recordings were to be used for data organization and aggregation only and that identities would be kept confidential. Three researchers (M.E.BK., K.J.B-R, R.L.S-C] qualitatively analyzed the responses collected during the interviews through a process of aggregation and categorization by themes.
RESULTS Fifteen Atlanta chapter SHM members attended the workshop. Nineteen hospitalists were interviewed by phone (n 5 9 attendees, n 5 10 nonattendees). Of these 19, 58% (n 5 6 attendees, n 5 5 nonattendees) classified themselves as practicing hospitalists, 21% (n 5 4 nonattendees) as residents, 11% (n 5 1 attendee, n 5 1 nonattendee) as administrators, and 11% (n 5 2 attendees) as other, including an orthopedic surgeon and clinical pharmacist. The average years in practice were 8.5 (range, 1-25 years) for interviewees. There were no significant differences in years in practice between attendees and nonattendees or in responses based on years of practice.
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Among workshop attendees, the most common reasons for attendance were an interest in quality improvement to prevent antimicrobial resistance and improve patient safety (n 5 4, 44%) and promotion of the workshop by their institution or colleagues (n 5 3, 33%). Other motivations for attendance included the opportunity to meet colleagues and network, SHM sponsorship, the speaker, and the workshop location. For nonattendees, the most common barriers to workshop attendance were scheduling conflicts and/or inconvenient timing (n 5 8, 80%). One hospitalist stated, ‘‘I found the topic very interesting and regret that I could not make it. I hope there are future opportunities for events like this.’’ Another barrier cited for nonattendance was lack of awareness about the workshop (n 5 2, 20%). In response to the question ‘‘what did you like about this workshop?’’ most attendees agreed that they liked the opportunity to meet colleagues and exchange ideas (n 5 5, 56%) and the overall presentation (n 5 5, 56%). One hospitalist commented,‘‘[With this workshop], you have the opportunity to meet other hospitalists from the area. You exchange ideas, share problems, and think up solutions to common problems.’’ Some attendees said that they enjoyed the speaker (n 5 3, 33%) and found the information useful (n 5 3, 33%). Other responses included the organization of the workshop, the tool kit, and the workshop time and location. In addition, the attendees cited that they would have liked more time to interact with other colleagues and a larger audience. All attendees perceived that a workshop, like the SHM workshop, is an effective way to address antimicrobial resistance concerns because workshops can raise awareness, present ‘‘practical material in a practical manner,’’ give the opportunity to network, and serve as a reminder. One hospitalist stated, ‘‘I think [a workshop like this] is helpful. It’s something that’s got to be a part of an ongoing program. It’s not just a one time thing.’’ All attendees also agreed that a workshop, like the SHM workshop, motivates physicians to initiate quality improvement projects because of the workshop’s ability to raise awareness. When asked ‘‘have you implemented or suggested implementing the quality improvement tools that you learned in this workshop?’’ 3 (33%) attendees indicated that they were in the process of implementing quality improvement projects and were utilizing the tool kit presented during the workshop. One hospitalist commented that the workshop was helpful in ‘‘laying out the steps and process’’ to design a quality improvement project. However, the majority (n 5 6, 67%) of attendees had not implemented or suggested implementing the tools. The major barriers to using the tools included lack of time, other priorities, and lack of system-wide support. One hospitalist stated, ‘‘I think
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[quality improvement] is more like a system-wide [issue] that needs to be [addressed institutionally] instead of on the individual basis.’’ Another participant responded, ‘‘We cannot implement certain things by ourselves. We have to go through committees and [other processes].’’ Similarly, the 10 nonattendees were asked whether they had implemented or suggested implementing a quality improvement project to prevent health careassociated infections and antimicrobial resistance in their institution: only 3 (30%) had implemented or suggested implementing a quality improvement project in their institution. Nonattendees personally involved in the implementation of a quality improvement project believed that administrative support and evidencebased research facilitated the implementation of projects. One nonattendee replied, ‘‘I think primarily administrative and political will [is facilitating the implementation of quality improvement projects].’’ Of the 7 who had not participated in quality improvement project implementation, most (n 5 6, 86%) had not participated because of the existence of an already established project. To determine cues to action, both attendees and nonattendees were asked to name what they thought were the most effective ways to reach clinicians such as hospitalists about antimicrobial resistance topics. Responses from attendees and nonattendees were similar. The methods mentioned most were workshops and presentations (n 5 5, 56% attendees; n 5 6, 60% nonattendees). E-mail (n 5 2, 22% attendees; n 5 4, 40% nonattendees) and institutional/hospital support (n 5 2, 22% attendees; n 5 3, 30% nonattendees) also were cited. Other methods included the Internet, continuing medical education, professional societies, and CD-ROM. One nonattendee held that there is no one way to reach health care providers: ‘‘[Naming one way] is difficult, because we are inundated with so many different things. . . . We get e-mails that are sent from corporate [or] from local hospitals [or we read journals]. I mean there is so much of this that hits us that I’m not sure [of the best way to reach us all].’’ When asked about their preferred ways to receive information on the topic of antimicrobial resistance, the attendees and nonattendees provided similar responses at different frequencies. The majority (n 5 7, 70%) of nonattendees and 2 (22%) attendees preferred e-mail as a way to receive information. Five (56%) attendees and 3 (30%) nonattendees named workshops and presentations. Other preferred methods included the Internet, journal articles, continuing medical education, flyers in the lounge, CD-ROM, institutional/hospital ‘‘involvement,’’ other colleagues, and lay press. Both attendees and nonattendees were asked whether they had ever heard about or seen any of
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the educational materials from the CDC’s Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. The majority (n 5 8, 80%) of the nonattendees were familiar with the Campaign, whereas the majority (n 5 6, 67%) of the attendees were not familiar with the Campaign (prior to the workshop). Of the hospitalists familiar with the Campaign, 1 attendee and 4 nonattendees knew about the Campaign from their facilities, 1 attendee and 2 nonattendees from workshop or presentations, 3 nonattendees from the Internet, 2 attendees from coworkers, and 1 nonattendee from the Joint Commission on the Accreditation of Healthcare Organizations.
DISCUSSION Using the HBM as a theoretical framework, we examined the behavioral influences of hospitalists, such as motivating factors, barriers, and cues to action, to gain an understanding of how to better reach and engage clinicians such as hospitalists in quality improvement efforts to prevent antimicrobial resistance. According to the HBM, for an intervention, such as the SHM workshop, to impact competence and act as a precursor to behavior change, clinicians must first be motivated to participate. The most common motivating factor for attendance was an interest in the topic of quality improvement to prevent antimicrobial resistance and improve patient safety. Because part of the emerging role of the hospitalist and that of the ICP includes sponsoring or initiating quality improvement efforts, motivation to attend based on this topic indicates that clinicians who attended were interested in learning more for their professional development and care improvement.9,19 Another commonly cited motivating factor for attendance included promotion of the workshop by institutions and colleagues. In addition, unfamiliarity with a topic, namely the Campaign, and a desire to know more about a topic in general may have served as a motivating factor. Interestingly, 80% of nonattendees knew about the Campaign, whereas only 33% of attendees had previous knowledge. In examining motivating factors to attend an educational workshop about preventing antimicrobial resistance, Giblin et al found similar results revealing that 72% of clinicians attended to learn more for their job, 22% attended because of pressure by peers or administration, and 17% attended because they wished to learn more about a topic in general.13 Some attendees also reported that they attended and enjoyed the workshop because of the speaker, a fellow hospitalist and a leader in SHM. This finding is supported by other research indicating that information presented by an opinion leader might be more effective in engaging physicians to follow new practices.13,20 Opinion
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leaders can act as role models in practice and encourage ownership of the issues at an institutional level.21 In designing and promoting future workshops, organizations should ensure that the topics are relevant to the work of the audience and that the institution supports and promotes the workshop. Because all attendees reported that they would encourage a colleague to attend this workshop, promotion through past attendees or others familiar with the topics might provide additional motivation. Of those not attending the workshop, the majority had scheduling conflicts that hindered their attendance. Time-related barriers (ie, lack of time and other priorities) contributed to lack of engagement in quality improvement efforts for attendees as well. Several attendees had not implemented or suggested implementing the quality improvement tools from the workshop because of perceived lack of time and other pressing priorities. Not unique to hospitalists’ participation in quality improvement efforts, lack of time also has posed barriers for physicians and health care providers in other areas, such as hand hygiene adherence.2,14-18,22 If quality improvement efforts for the prevention of antimicrobial resistance are deemed an institutional priority, hospitalists and other clinicians may no longer perceive lack of time and other priorities as barriers. Although literature supports the idea that clinicians such as hospitalists have the ability to take leadership in quality improvement efforts, some of the interviewed hospitalists found it difficult to implement programs and perceived that changes could not be accomplished without better administrative and institutional support.5,8,9,19,23 In hospitals in which administrative and institutional support was present, the support provided motivation and served as a cue to action, and the hospitalists felt enabled to engage in quality improvement efforts. As stated by one nonattendee, ‘‘some of the administration at my facility are recognizing that there’s a need and are empowering us by giving us the authority and the time to do [quality improvement projects].’’ Individual and administrative actions are often interdependent and may require support from one another to create and implement successful projects on a system-wide basis. To determine other cues to action for clinicians, the attendees and nonattendees were asked to provide what they perceived as the most effective and preferred methods for receiving information about antimicrobial resistance. Similar to previous research with other physicians, the participants of this study cited a variety of methods, indicating that a multimodal approach may be necessary to reach hospitalists.13,24,25 Workshops and presentations, e-mail, institutional involvement, and the Internet were cited most often and perceived as both effective and preferred strategies. Interestingly,
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e-mail was the most commonly named preferred method for receiving information, whereas workshops and presentations were perceived as the most effective. Clinicians such as hospitalists may prefer e-mail because of time constraints but realize that workshops and presentations offer a more in-depth opportunity for learning. Also of note, in one previous study, journal articles had been cited as the most preferred way to learn about antimicrobial resistance issues by 88% of the surveyed physicians; however, in this study, very few hospitalists cited journal articles as a cue to action.25 Although part of the discrepancy in results may be related to the data collection methods, the difference may be worth further investigation to understand better how to reach clinicians such as hospitalists and how their effective and preferred methods compare with those of other physicians and health care providers. Additionally, a common theme throughout the interviews was interest in the opportunity to network and exchange ideas. The ability to communicate with colleagues was a factor that attendees liked about the workshop, wanted more time for, and perceived to be an effective way to address antimicrobial concerns. According to Davis et al, interaction among physicians may influence the individuals’ learning and likelihood to change by producing a level of cognitive dissonance between what peers know and do compared with the learner.26 Offering a forum for communicating about subjective norms around antimicrobial resistance can provide motivation and a cue to action.27 Some studies also have found that physicians preferred communication with peers as a means for learning about antimicrobial resistance.25,28 Giving participants the opportunity to network, exchange ideas, and work in groups may be an effective strategy to foster behavioral change in clinicians such as hospitalists. Because of the small sample size and limited geographic region, the results of this study may not be generalizable to all hospitalists or to clinicians of different areas and specialties. Additionally, because the interviews took place 6 weeks after the workshop, attendees may not have had enough time for project initiation and/or implementation of the presented strategies. Although this research provides a qualitative foundation for understanding behavioral influences of clinicians such as hospitalists, expanded research with larger sample sizes and longer follow-up period or secondary interviews may offer a more comprehensive view on how to reach and engage this group of clinicians in quality improvement efforts. In addition, future efforts to encourage behavioral change may require a 2-step process. The first step prepares clinicians for change, and the second step supports them in overcoming specific barriers to implementation of quality improvement efforts.
Furthermore, future research should focus on methods for engaging clinicians such as hospitalists as well as hospital administration in the process of quality improvement efforts. The participants of this study continually cited the importance of institutional support. Future research also could examine how hospitalists like ICPs as leaders can gain the support and buy-in of other health care workers, hospital staff, and most importantly hospital administration. Although not all attendees had implemented or suggested implementing quality improvement projects, all perceived that a workshop, like the SHM workshop, was an effective way to address antimicrobial resistance and initiate preventative projects. This workshop served as a cue to action; provided motivating factors by offering job-related information, role models in the field, and the opportunity to network with colleagues; and outweighed barriers by providing motivating factors and cues to action. The HBM provides an applicable framework to examine factors that influence the behaviors of clinicians, and, by addressing these factors, interventions, such as the SHM workshop, have the ability to reach and engage hospitalists and ICPs alike in quality improvement efforts to prevent antimicrobial resistance and improve patient safety within health care settings.
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