Protectors vs Police: How Antimicrobial Stewardship Interventions Come Across and How to Change the Narrative

“The antimicrobial stewardship and sepsis teams are like competing voices on my shoulders!” proclaimed a hospitalist during handshake stewardship rounds. Though said in jest, this reaction underscores the common reality that antimicrobial stewardship teams are often perceived as an antibiotic police force with the sole mission of enforcing rules and withholding antibiotics instead of a group that contributes in more balanced ways. This preconceived notion sets the stage for potential tension that may not only undermine the success of future interactions but also decrease the likelihood that our colleagues become empowered allies in stewarding antibiotics. To transform the narrative from one of policing to one of collaboration, it is critical to create a psychologically safe environment in which the steward can gently explore the other person’s understanding and share an alternative perspective. To cultivate space for a productive conversation and positive learning experience, 3 factors are important: (1) The delivery must be nonconfrontational to avoid triggering feelings of defensiveness and judgment; (2) the discussion should be concise in order to be seen as high yield, valuable, and worthwhile in the setting of a fast-paced clinical environment; and finally, (3) the steward must accurately identify and focus educational efforts on knowledge gaps to avoid being perceived as condescending or patronizing.¹ Successfully leading such conversations can be daunting, but several frameworks exist to help initiate these discussions in a structured way. Our aim is to illustrate how these techniques pave the way for an exploratory and educational intervention, helping reframe the role of the steward as a partner, not just an enforcer.

Stewarding Colleagues

Stewardship conversations with colleagues can be made more challenging by differences in training and expertise, discordant clinical incentives and priorities, and entrenched dogmatic beliefs.¹ In addition, sociologists have identified that antibiotic prescribing is a deeply social act, and clinicians therefore often adhere to a culture of noninterference in colleagues’ decision-making, limiting willingness and comfort in intervening.^2,3 One framework to help overcome these barriers and set the stage for a productive conversation is the advocacy-inquiry-listen-teach framework¹:

1. Advocacy: Highlight a discrepancy between a clinical scenario and perceived inconsistent response with nonjudgmental, factual observations.

2. Inquiry: Explore this discrepancy through an open-ended question to identify what motivated the clinician’s decision.

The paired advocacy and inquiry statements enable stewards to engage colleagues in a concise, focused, and uncritical way; in so doing, they help cultivate a psychologically safe environment in which the steward can demonstrate humility in seeking to understand more fully while also giving the clinician the space to have their decision-making heard.

3. Listen: While listening to the colleague’s response, seek to understand the underlying reason guiding their actions.

4. Teach: Provide targeted teaching to address the specific error identified in the listen step; offer to provide helpful references or resources, and suggest a path forward for the patient that incorporates this teaching.

When stewards correctly identify an underlying framework error in the listen step, it is possible to offer concise, high-yield teaching focused on this particular knowledge gap or concern in a nonconfrontational manner. In addition, this approach allows for collaborative decision-making among teams and an opportunity to demonstrate a shared investment in patient outcomes.

Engagement of Frontline Prescribers as Stewards

Patients and their family members frequently have preconceived notions about their underlying diagnosis and the need for antibiotic treatment⁴; in addition, clinicians may feel pressure to prescribe, being fearful of low patient satisfaction and concerned about whether they have sufficient time within an encounter to effectively explain why an antibiotic is not indicated. Engaging frontline prescribers as stewards is critical to decrease unnecessary antibiotics, especially in the outpatient setting. Similarly, creating practical, evidence-based approaches that providers can use in the examination room to decrease conflict and promote psychological safety is key. Rita Mangione-Smith, MD, MPH, and colleagues developed a communication training program for pediatricians to help guide dialogue around respiratory illness treatment (DART)⁵ to do just this.

This research identified that successful clinicians employed a methodical 4-step approach to initiation of successful stewarding conversations with parents when antibiotics were not indicated:

1. Review physical examination findings: Highlight what examination features are reassuring against bacterial infection or suggest a viral etiology.

2. Deliver a clear diagnosis: Address the patient’s preconceived notions of the illness, if needed.

3. Use a 2-part negative/positive treatment recommendation: Note first that an antibiotic is not indicated, followed by positive actions that can be taken to achieve symptom relief.⁶

4. Provide a contingency plan: Give concrete examples of when the treatment plan may need to be revised and how to seek follow-up care if this occurs.⁷

Mangione-Smith and her colleagues’ research identified that this approach was not only associated with low unwarranted prescribing rates but also with improved patient/parent satisfaction and shorter visit lengths—making it a data-driven approach suitable for use in daily clinical interactions beyond respiratory tract infections.⁵

These frameworks offer an organized approach for stewards to explore a colleague’s or patient’s understanding and offer an alternative perspective. In so doing, accountability becomes a shared responsibility and the role of the antimicrobial steward expands from an antibiotic enforcer to a clinical ally protecting a nonrenewable, shared resource and providing valuable input in the shared care of patients. Though rewriting the narrative of antimicrobial stewardship will take time, these steps will help show how stewards can become a welcome, benevolent “voice on the shoulder.”

References

1. Castillo AY, Chan JD, Lynch JB, Bryson-Cahn C. How to disagree better: utilizing advocacy-inquiry techniques to improve communication and spur behavior change. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e201. doi:10.1017/ash.2023.457

2. Szymczak J, Newland JG. The social determinants of antibiotic prescribing. In: Barlam TF, Neuhauser MM, Tamma PD, Trivedi KK, eds. Practical Implementation of an Antibiotic Stewardship Program. Cambridge University Press; 2018:45-62.

3. Charani E, Castro-Sanchez E, Sevdalis N, et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”. Clin Infect Dis. 2013;57(2):188-196. doi:10.1093/cid/cit212

4. Stivers T, Mangione-Smith R, Elliott MN, McDonald L, Heritage J. Why do physicians think parents expect antibiotics? what parents report vs what physicians believe. J Fam Pract. 2003;52(2):140-148.

5. Mangione-Smith R, Zhou C, Robinson JD, Taylor JA, Elliott MN, Heritage J. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med. 2015;13(3):221-227. doi:10.1370/afm.1785

6. Mangione-Smith R, McGlynn EA, Elliott MN, McDonald L, Franz CE, Kravitz RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155(7):800-806. doi:10.1001/archpedi.155.7.800

7. Stivers T. Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance. Soc Sci Med. 2005;60(5):949-964. doi:10.1016/j.socscimed.2004.06.040