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Table 1 Summary of key findings and their implications for subsequent efforts to optimize and implement the intervention

From: Implementing an intervention to reduce use of antibiotics for suspected urinary tract infection in nursing homes – a qualitative study of barriers and enablers based on Normalization Process Theory

NPT construct

Key findings

Implications for subsequent attempts to develop and implement the intervention

Coherence

The informants were generally positive about the goals and principles of the intervention. However, they also reported that some staff had been concerned about undertreatment (as a consequence of a more restricted approach), and there were difficulties understanding the clinical terminology of the reflection tool

The educational element of the intervention should be developed further to increase acceptance and understanding of the reflection tool. This may be done through an increased focus on a) explaining key concepts, b) reserving more time for discussing potential concerns of staff, and c) reserving more time for hands-on training

Increased time for these activities during the educational session may be found by removing the communication tool from the intervention (cf. below)

Cognitive participation

Staff engagement in the intervention had varied and challenges with engagement included:

 - Feeling that the reflection tool was a bit overwhelming due to issues of understanding

 - Remembering and prioritizing the tool during a workday with many other tasks

 - Reaching all staff in the organization

Nurses (and/or local team leaders) used routine triage meetings to increase engagement among staff

It is important to ensure that change champions (e.g., nurses or qualified nurse assistants) understand the intervention and regularly have opportunities for explaining the intervention to staff and encourage its use

Collective action

Using the reflection tool correctly could be a challenge for staff due to difficulties with understanding all aspects of the tool. The involvement of a nurse (often at routine meetings) seemed to foster more reflections and a better capacity among staff for using the tool in practice

Routine meetings could be used to ensure that staff regularly discuss (with each other and with nurses or other change champions) how to apply the reflection tool correctly in specific cases

Resistance from relatives to the intervention’s more restrictive approach to antibiotics had been infrequent and could usually be managed through information and dialogue

Health professionals from collaborating organizations were often perceived to have a more test-focused approach than that promoted by the intervention, but they generally accepted the intervention approach when nursing home staff explained the rationale

(Designated) staff should be prepared to manage relations with relatives and health professionals outside the organization when introducing a more restrictive approach to the use of antibiotics

The approaches of GPs to dealing with suspected UTI was a mediating factor which could either support or dampen the implementation of the intervention principles at the nursing homes

Local physicians responsible for prescribing medication should be informed about the intervention (and involved actively if possible) to increase the likelihood that their attitudes and actions align with the principles of the intervention

Reflexive monitoring

Informants found that the intervention had increased the tendency to reflect on situations where UTI was suspected and that this had positive consequences in terms of:

 - reduced use of dipstick testing,

 - employing a wait-and-see approach with increased use of preventive measures focused on residents’ hygiene and fluid intake, and/or

 - reduced number of calls to the GP for prescriptions of antibiotics

In spite of some implementation challenges, the results suggest that it is possible to create more evidence-based practices concerning antibiotics use in nursing homes by employing a combination of educational activities and supportive tools

While the educational session and the reflection tool had influenced knowledge and practice at the nursing homes, the communication tool had rarely been used since staff did not perceive a real need for the tool when communicating with general practice (and since the intervention had sometimes reduced the perceived need for contacting general practice)

It should be considered to remove the communication tool from the intervention so that the time spent on introducing it could instead be used on introducing the reflection tool (since this was a much more important element in the intervention)