Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education
Introduction
Multidrug-resistant infections are one of the greatest threats to human health [1]. Direct consequences of infection with resistant micro-organisms include longer illnesses, increased mortality, prolonged stays in hospital, loss of protection for patients undergoing operations and other medical procedures, and increased costs [1]. Antimicrobial resistance is estimated to be responsible for 25,000 deaths and €1.5 billion in extra healthcare costs every year in the EU alone [2].
Antimicrobial resistance is a multi-faceted problem requiring multi-factorial interventions to prevent its emergence and further spread [3]. Antimicrobial stewardship (AMS) requires an interprofessional approach that involves collaboration between different healthcare providers, to ensure the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance [3], [4], [5].
The education of undergraduate healthcare professional students on AMS has been identified as a key activity for the containment of antimicrobial resistance [6]. However, a cross-sectional survey of undergraduate programmes in human and veterinary medicine, dentistry, pharmacy, and nursing in the UK identified that students receive disparate stewardship education [7]. Only 36.3% of programmes surveyed were reported to include all the recommended AMS principles. These researchers concluded that in order to strengthen the concept of AMS in undergraduate healthcare professional education, there is a need to adopt a comprehensive approach with standardized content. Such an approach has been adopted by infectious disease training programmes in the USA, with the development of a national stewardship curriculum, specifically to address gaps concerning comprehensive and structured educational resources for AMS training [8].
Over recent years there has been increasing emphasis upon competency-based education (CBE). CBE focuses upon the capacity of the learner to successfully carry out tasks in the real world, rather than the learner's ability to absorb and recite content [9]. CBE recognizes that quality of care is not improved simply by accumulating and disseminating the best available evidence; rather, with the increasing emphasis on person-centred care, it is necessary for clinicians to respond to patients' needs in a compassionate, knowledgeable, and co-ordinated fashion [10], [11]. This shift toward assessment of quality and outcomes of care has meant that both professional and interprofessional curricular content is now associated with competencies [12].
Antimicrobial prescribing and stewardship post-registration competencies have been developed for UK prescribers, designed to complement the Royal Pharmaceutical Society (RPS) generic competency framework for all prescribers, and improve the quality of antimicrobial treatment and stewardship and so reduce the risks of inadequate, inappropriate and ill-effects of treatment [13], [14]. This includes doctors and dentists (who can prescribe upon initial registration) and other registered healthcare professionals including pharmacists, nurses, midwives, and allied health professionals (including physiotherapists, podiatrists, radiographers), who can prescribe after completing an additional regulated post-registration prescribing programme [15]. However, not all healthcare professionals go on to prescribe, but may well be involved in various patient- and medicine-related stewardship activities, and therefore an understanding and engagement with local AMS programmes is important. These activities may include medicines management tasks, administration of antibiotics, and monitoring of patients for effectiveness of treatment and adverse effects. Undergraduate education provides an important opportunity to prepare healthcare professionals for these activities. Standardized AMS principles, and AMS competencies for registered practitioners working at an advanced level, exist, and professional standards for undergraduate healthcare professional students reflect some of the knowledge, skills and behaviours relevant to AMS [16], [17], [18], [19], [20], [21]. However, specific competencies designed to address the spectrum of AMS activities have not been established within this context. Additionally, the gradual implementation of new roles in the UK, such as nursing associates and physician associates, to support the delivery of healthcare, are responsible for delivering direct person or patient care [22], [23]. This is likely to include tasks related to medication management and broader AMS approaches such as the prevention of infection; therefore training will be mainly practical and ‘hands on’, and subsequently requires consistent approaches to AMS activities.
It is increasingly recognized that collaboration and teamwork between healthcare professionals are necessary to improve the quality and safety of healthcare [24]. Interprofessional education is important if a workforce is to practice collaboratively, and this resonates with the learning needs associated with AMS [3], [4], [7], [25]. Within an interprofessional team delivering person-centred care, each profession will carry out roles that require both common knowledge and specific educational content to support achieving AMS competencies in a manner consistent with each profession's scope, emphasis, and role in healthcare. Therefore, to help bridge the gap between AMS and the skills, knowledge, and values of the interprofessional healthcare team, this research was undertaken to provide UK national consensus on a common set of AMS competencies appropriate for undergraduate healthcare professional education, designed to address the various patient- and medicine-related stewardship activities in which healthcare professionals are involved. Such competencies will help to standardize curricula and so boost the impact of AMS education and improve clinical practice.
Section snippets
Ethical consideration
Ethical approval for the study was provided by the School of Healthcare Sciences Research Governance and Ethics Committee, Cardiff University (Reference number 427).
Design
The study adopted a Delphi technique. This technique, a widely used formal consensus method in health and social care research, uses a series of data collection rounds (typically two or three) to gather the opinions and judgements of a panel of experts on the topic of interest [26]. Benefits of this technique are the ability to
Results
Of the 21 participants who agreed to take part, 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2 (see Table I for expert panel details).
Discussion
Through an interprofessional consensus process, core competencies in AMS were developed for UK healthcare professional undergraduate education. By starting with pre-defined competency statements and their associated descriptors, the traditional round 1 of a Delphi survey was unnecessary. The Delphi technique enabled panellists to reach consensus with consistently high levels of agreement, on six overarching competency statements representing the knowledge, skills, attitudes, and values that
Acknowledgements
We are grateful to K. Yates, A. Borthwick, I. Reilly, C. Innes, and V. Ness who participated in this work as Expert Panel members. We are also grateful to the Nursing and Midwifery Council for their contribution to this work (H. Bain, an Expert Panel member, being on secondment to the Nursing and Midwifery Council during the time this study was undertaken). We would also like to acknowledge Discover Research and Design Ltd who assisted with the data collection and analysis.
References (42)
Antimicrobial stewardship
Am J Infect Control
(2006)- et al.
Antimicrobial stewardship
Mayo Clin Proc
(2011) The search for good antimicrobial stewardship
Jt Comm J Qual Improv
(2001)- et al.
Delphi methodology in health research: how to do it?
Eur J Integr Med
(2015) Antimicrobial resistance. Fact Sheet No. 194
(2017)Fact sheet. New EU action plan on antimicrobial resistance – questions and answers
(2017)Global action plan on antimicrobial resistance
(2016)- et al.
Mapping antimicrobial stewardship in undergraduate medical, dental, pharmacy, nursing and veterinary education in the United Kingdom
PLoS One
(2016) - et al.
Antimicrobial stewardship training for infectious diseases fellows: program directors identify a curriculum need
Clin Infect Dis
(2018 Apr 16) - et al.
The promise of competency-based education in the health professions for improving global health
Hum Resources Health
(2012)