“What if the patient has a severe reaction, and it is my fault?” A qualitative study exploring factors for sustainable implementation of penicillin allergy delabelling.

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Marie Bjørbak Alnæs, Brita Skodvin, Jan Anker Jahnsen, Grete Kalleklev Velure, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4592154/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Sep, 2024 Read the published version in Antimicrobial Resistance & Infection Control → Version 1 posted 4 You are reading this latest preprint version Abstract Background Penicillin allergy delabelling (PAD) is a key target in antibiotic stewardship, but uptake of the procedure outside clinical studies is limited. We aimed to explore factors that need to be addressed to sustainably implement a clinical pathway for PAD. Methods We conducted a qualitative study based on semi-structured interviews with focus groups consisting of a purposive sample of twenty-five nurses and physicians working on three different hospitals in Western Norway. Systematic text condensation was applied for analysis. Results Psychological safety was reported as crucial for clinicians to perform PAD. A narrative of uncertainty and anticipated negative outcomes were negatively associated with PAD performance. Education, guidelines, and colleague- and leadership support could create psychological safety and empower health personnel to perform PAD. Key factors for sustainable implementation of PAD were to facilitate the informant’s profound motivation for providing optimal health care and for reducing antimicrobial resistance. Informants were motivated by the prospect of a simplified PAD procedure. We identified three main needs for implementation of PAD: 1) creating psychological safety; 2) utilising clinicians’ inherent motivation and 3) optimal organisational structures. Conclusion A planned implementation of PAD must acknowledge clinicians’ need for psychological safety and aid reassurance through training, leadership, and guidelines. To implement PAD as an everyday practice it must be minimally disruptive and provide a contextually adaptive logistic chain. Also, the clinician’s motivation for providing the best possible healthcare should be utilised to aid implementation. The results of this study will aid sustainable implementation of PAD in Norway. Penicillin allergy delabelling nurse doctor facilitators barriers focus group interview qualitative research implementation. Figures Figure 1 Background Penicillin allergy delabelling (PAD) is one of the cornerstones in antibiotic stewardship and is recognised as an important measure for preventing antibiotic resistance ( 1 , 2 ). Nine out of ten patients claiming to be penicillin allergic were found to tolerate penicillin when subjected to allergologic testing, suggesting an unmet need for systematic evaluation of patients with alleged antimicrobial allergies ( 3 ). PAD guidelines have been developed in many countries, but sustainable dissemination and implementation of these outside allergy units are rare ( 4 – 6 ). Previous analyses of PAD programs have revealed the need for multifaceted efforts to succeed ( 7 ). Moreover, the importance of qualitative research concerning PAD has been demonstrated, and the clinician’s perspective appears to be crucial for the sustainable development and implementation of PAD programs, for the benefit of patients and health care systems ( 8 ). Nevertheless, knowledge about clinicians need to perform PAD is scarce, and only two interview studies from Great Britain and the United States of America have addressed this issue in-depth ( 9 , 10 ). Here PAD was seen as a complex task and not a priority during acute patient presentation. Also, time restraints, a lack of securely communicating penicillin allergy labels and a fear of inducing an allergic reaction were barriers for performing PAD. As the education of health personnel in PAD-, legislation- and health systems are subject to contextual differences, studies from further health care systems are needed ( 8 ). We wanted to perform an interview study with nurses and physicians working in Western-Norway Health Region (WNHR) hospitals to explore how PAD is perceived and identify needs to be met for the sustainable implementation of a clinical pathway for PAD in Norway. Methods Study aims This study explores how nurses and physicians in the WNHR perceive PAD and what needs must be met to sustainably implement a clinical pathway for PAD in Norway. Study setting We performed a qualitative study consisting of semi-structured focus group interviews with physicians and nurses working in hospitals of all service levels (university-, regional- and local hospitals) in the WNHR. The hospitals have a total catchment area of 1,14 million patients ( 11 ). The interviews were performed between September and December 2023. The Norwegian health system is predominantly state funded and governed. Norway has a national action plan ( 12 ) for fighting antimicrobial resistance and antibiotic stewardship is mandatory. In Norway penicillins are the first choose of antibiotic treatment in most settings ( 13 ). Ethics The study was approved by the Regional Committee for Medical Research Ethics Western Norway (REK-West: 199210) and all participants provided informed, written consent both for participation and for publication of the data. The study results are reported in line with the Standards for Reporting Qualitative Research (SRQR) ( 40 ) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) ( 41 ). Participants The informants were recruited for interviews by the local clinical leader and then invited to participate via email. Their level of experience in PAD differed. The informants had varied professional backgrounds, including dermatology, thoracic medicine, otorhinolaryngology, internal medicine, emergency wards, rheumatology and infectious diseases. Three informants had broad experience in PAD, eight stated no previous experience, whereas the rest declared that they had some experience with PAD but lacked formal training in the procedure. The demographics of the informants are presented in Table 1 . Participation was voluntary, and informed written consent was obtained before commencing the interviews. The informants were selected to represent all levels of experience and types of hospitals in the WNHR. The groups were recruited as purposeful samples, aiming at diversity in experience, gender, professional background, and age. Table 1 Demographics Distribution of informants Female Male Total Total number of informants 15 10 25 Nurses 11 1 12 Nurses with ≤ 5 years of practice 3 0 Nurses with ≥ 5 years of practice 8 1 Physicians 4 9 13 Residents 1 2 Board certified specialist doctors 3 7 Theoretical perspectives “A Checklist for identifying determinants of practice” (CIDP) was chosen as a framework informing the interview guide ( 14 ). According to this framework, tailored implementation interventions are strategies designed to improve health care. Examining the challenges that may occur when implementing such interventions will aid in better and more targeted implementation. This can further increase uptake of interventions. Data collection Three of the authors (MBA, BS and MAS) developed the interview guide ( supplement 1) . MBA is a Norwegian female physician working in the WNHR in an Allergy department, and has a special focus on drug allergies, particularly PAD. MBA has no earlier experience in qualitative studies and the work is part of her PhD project. The co-authors BS and MS, who co-created the interview guides, are also Norwegian female physicians, but have broad experience in qualitative research. We developed a guide for focus group interviews as we deemed it the most suitable way of detecting the necessary knowledge, as PAD is a complex intervention dependent on interdisciplinary cooperation. The interview guide was refined after the second interview to optimise the questions and adjust for the allocated timeframe. MBA performed the interviews using a semi structured interview guide (supplement 1). Eight interviews were conducted. One interview included only nurses, and two included only physicians. The rest of the interviews consisted of a mixed group of nurses and physicians. The first interview was performed with a single clinician due to acute changes in clinic staffing. One of the interviews was performed as an online video interview using “Teams” (Microsoft) due to organisational challenges. The other interviews were performed in person. All interviews were recorded by Samsung Galaxy A 34 audio recorder, version 21.4.05.04, a digital recording software and transcribed a verbatim into text by the first author. Data collection was drawn to a close when the interviews provided adequate information power in the sense that no new thematic findings were identified during the interviews and the preliminary analysis ( 15 , 16 ). Analysis Transcripts were analysed with systematic text condensation (STC), a pragmatic method for cross-case, thematic analysis ( 17 ). STC analysis contains four steps: 1) Obtaining an overall impression by reading the complete material 2) Identifying units of meaning containing the participants’ attitudes and opinions towards performing PAD and coding these units 3) Condensing and further abstracting meaning from the coded groups. 4) Summarising together with creating concepts and descriptions from the condensates. MBA, BS, MAS, GVK, and JAJ participated in the analysis. When there were different views on the coding agreement was reached through discussion. The analysis was performed as a stepwise-, cross-sectional-, inductive- and iterative analysis adhering to recommendations for the application of STC. An audit trail was kept throughout the study. The analysis was documented in Word (Microsoft) files. A secure “Teams” (Microsoft) room was used for the analysis, and the participating researchers had access to the running files and all the decisions made throughout the analysis. Results We identified three main needs for implementing PAD: 1) creating psychological safety; 2) utilising clinicians’ inherent motivation to aid implementation; and 3) providing optimal organisational structures. Below, we elaborate our findings illustrated by quotes from the transcripts. Figure 1 demonstrates that all of theese components are needed for clinicians to perform PAD. 1. Creating psychological safety Clinicians’ anxiety when performing PAD must be addressed and decreased: The informants highlighted psychological safety as crucial for performing PAD. An experience of that PAD is supported throughout both their scientific-, and medical communities, and in the workplace was essential, as several physicians expressed a profound sense of uncertainty and anxiety towards PAD. The physicians associated PAD with an inherent risk. This was most prominent in physicians who had never participated in penicillin delabelling. Fear concerning outcomes for patients, with a perceived high risk of reaction to provocation testing, and fear concerning personal and professional consequences if the patient reacted to the penicillin challenge were central aspects. One of the doctors described it as follows: “I feel that we are unsure, lack experience and need to be empowered. We need support both from guidelines, from leaders and colleagues in addition to more knowledge of the field. I am too unsure of the method we use today, and then I don’t do it. You know, we are trained to respect drug allergy labels. Often, we will discuss penicillin delabelling, and are quite convinced that the patient has no penicillin allergy, but then we decide not to perform penicillin delabelling because you know, there could be a very steep fall when overruling a drug allergy warning. Both for the patient and for the doctor. What if the patient has a severe reaction, and it is my fault...Doctor #5 “ The high level of fright towards adverse reactions when performing PAD contradicts the lived experience from the physicians that had performed PAD from time to time, as none of them had ever experienced any severe adverse events when delabelling patients. “Well, the experience over the 13 years I have done delabelling is that there has never been a severe reaction, no anaphylaxis, and I have been quite liberal in my delabelling. Doctor #7” . The nurses all relied on the doctor’s decision concerning delabelling declared penicillin allergy. They said that they do whatever the doctor decides. The nurses were also less nervous towards adverse reactions to the provocation testing as most of them stated that they had performed PAD earlier with skin testing and administered intravenous antibiotic test doses on rare occasions. However, the nurses also reported that to perform PAD they must feel safe within their team and trust the physician in charge. I want it to be a doctor I trust, one I am sure will appear quickly when paged, and that we as a team decide to perform PAD. I must know that we are prepared if a reaction occurs. Nurse #2 Clinicians need empowerment and support to perform PAD: The informants sought empowerment and communicated a need for more knowledge and experience in PAD. They craved information and partly used the interview setting to educate themselves, asking the interviewer several questions about PAD throughout the sessions. They wanted to be able to do PAD and to do it right; to be educated and participate in performing PAD provided increased psychological safety. They were aware that they need to change today’s practice and suggested both lectures and simulation training to make them feel safe to perform PAD. They emphasised that they learn most from each other, such as apprentices from their masters. The participants said that clear guidelines are crucial. The knowledge that government- and medical society led support is available were mentioned as key factors towards establishing psychological safety enabling them to perform PAD. Concerns voiced towards the current state of guidelines concerning PAD were that they are hard to find, outdated and partly contradict each other. Readily available guidelines that coherently communicate PAD and focus on the practical everyday needs concerning the act of delabelling patients were missed. Both nurses and physicians called for better tools for delabelling. The informants reported that they would need support from their peers to perform PAD regularly. l would like it to be like a cooking recipe, and with a preformed scoring system that made the decision to perform delabelling clear and the procedure to do so easy. The guidelines ought to be as identical as possible, in the hospital, in the national antibiotic guidelines and elsewhere. Doctor #2. 2. Utilising clinicians’ inherent motivation to aid implementation Clinicians want to provide the best possible healthcare: The clinician's main motivation and main facilitator for aiding in the sustainable implementation of PAD was the prospect of optimising patient care and reducing the use of broad-spectrum antibiotics. Providing the best clinical care was the main interest of clinicians and the fact that current practice was not ideal was perceived as shameful. In implementing PAD this motivation should be utilised to aid uptake and motivate clinicians to perform PAD on an everyday basis. ” I want to provide the best patient treatment possible. I also want to reduce antimicrobial resistance. And our current method is outdated and rarely performed, we simply must change. I see it as a win-win situation. I mean concerning antibiotic resistance and the patient. It is easier for us to perform delabelling this way. We heal patients from their declared penicillin allergy and can give them the most efficient treatment. Not being able to receive penicillin is quite severe, a disease on its own come to think about it, and changing that, well that is the reward. Nurse #8”. Clinicians want to reduce antimicrobial resistance and further negative impacts of penicillin allergy labeling: The knowledge of the incremental harm of penicillin allergy labels was high concerning antimicrobial resistance. Knowledge concerning the other negative impacts of penicillin allergy labels such as increased morbidity and mortality of the individual patient, increased cost of treatment and longer hospital stays was low. The increased awareness of these topics throughout the interviews, and the possible benefits of PAD, were immediately mentioned as important motivations for them to change their practices and attitudes towards PAD. This knowledge also motivated them to discourage the common practice of simply choosing another antibiotic when the patient declares penicillin allergy, as an easy way out, as the harm in this practice dawned on them. I have been annoyed by all the patients declaring themselves penicillin allergic for uncertain reasons, and then I must prescribe them a broad-spectrum antibiotic. But I was unaware how bad it is overall it is for the patient to be labelled penicillin allergic for no reason, and that our procedures today are so uncertain and outdated, that feels very unsettling. Doctor #3 Clinicians are motivated by the prospect of a simplified clinical procedure: The nurses were particularly motivated by the prospect of an easier clinical procedure, as they perform the test procedure and have the highest workload in PAD. Many of them reported having performed skin-testing and provocation-tests for penicillin allergy earlier and reported that the new method represented time and resources saved on their behalf. This was reported to be a strong motivation I like that it seems easier for us nurses to perform. I believe it is a lot less stressful to just administer a tablet than to perform today’s skin testing, with dilution series of the medication and sorting syringes, it’s quicker too. Nurse #4 3. Providing optimal organisational structures Clinicians need a seamless workflow adapted to their working context: The informants emphasised that an optimal organisational structure was the main prerequisite implementing a clinical pathway for PAD in everyday hospital practice. They called for a preformed logistic chain and for the method to be readily available to be able to perform PAD. This was due to their experienced lack of time in everyday practice as an obstacle for PAD, together with an undefined responsibility of when and where to perform PAD. Streamlining the process would increase uptake and make PAD feasible. If we are to do this on an everyday basis, then we need a system for it in the patient journal, so that it is easy to remember, and quick to perform. If we have to start searching for a form or something, it won’t happen. And we need to know where and when it is expected for us to do this. Doctor #1 The clinicians wanted the clinical pathway for PAD to be available across all platforms and media used in their everyday practice. As one size does not fit all, PADs should be available in both paper forms, mobile phone apps and electronic versions in patients’ health care charts. Nudging, described as automated electronic reminders in the electronic health records was met ambivalently as they were often perceived to obstruct the workflow especially by the physicians, even though their function as clinical reminders was acknowledged as useful. “I experience that we get more and more patients, more and more tasks to perform, and less and less time for each patient, so it must be readily available when I need it, in the systems we use already. So that we don’t forget to do it, and minimal extra hassle occurs. It needs to become sort of second nature for it to be a sustained method. Doctor #10“ The nurses emphasised their position as gatekeepers and reminders of best practices within the medical team. Physicians often rotate between wards during their time on call, as opposed to nurses, who observe patients throughout the day. Clinicians need appointed clinicians to lead implementation: All the informants highlighted the importance of clinical teams and “lighthouses,” meaning that clinicians were especially appointed for both educating and reminding other colleagues to perform PAD. They believed that if the clinical pathway for PAD was embedded into their everyday routine with minimal disruption it would pave the way for sustainable implementation of PAD. Additionally, there was a call for well-functioning interdisciplinary teams as PAD is a complex intervention necessitating cooperation between physicians and nurses. I believe most of us nurses would ask the doctors about penicillin delabelling. Especially during prerounds preparation. But it is a team effort, and you need to have someone to trailblaze it. We have antibiotics teams that could take charge and pull the other with them. Nurse #9 Discussion To the best of our knowledge this is the first qualitative interview study providing an in-depth understanding of the perceived needs of clinicians when implementing PAD in Scandinavia. The informants described their knowledge and motivation for PAD, but also their anxiety and shortcomings concerning performing PAD today. The development of sustainable programs and guidelines ( 18 ) paves the way for sustainable implementation, but true sustainable development only occurs when new knowledge and guidelines are implemented in everyday practice ( 19 ). Our study provides added information about how to make a clinical pathway for PAD fit to practice and identified several targets for implementation efforts that will help improve the implementation of PAD in Norway. Psychological safety Our main finding was that clinicians need psychological safety to perform PAD. The informants were highly motivated to perform PAD, but at the same time unsure and anxious to do so. Anxiety is multifaceted, and both the anticipated fears concerning the patient, concerning themselves, and the fear of professional consequences must be addressed. Their glimpse of potential danger overshadowed their knowledge of benefits and colleagues' reports of successful delabelling experiences. The level of anxiety was also surprisingly high considering the large body of international research on PAD that deems it safe and provides both guidelines and tools for perform delabelling ( 20 , 21 ). Psychological safety has been mentioned as a barrier for performing PAD in a recent study from the USA ( 10 ) but was reported more profoundly by our informants than in this earlier study. The Norwegian health care system is less hierarchical than most health care systems outside Scandinavia. The level of trust in society and the health system is among the highest in Europe ( 22 ), adding to this there has been increased awareness of clinicians' anxiety and errors in Norway in recent years ( 23 ). These social factors probably influenced our results and made it easier for our informants to openly address their professional anxiety concerning penicillin allergy delabelling. Other studies have mentioned that clinicians report PAD to be a complex issue, and they perceive it challenging to examine and communicate penicillin allergy labels. They reported that time to perform PAD is lacking and that they are unsure about who is meant to actually perform PAD ( 9 , 24 , 25 ). We believe that a lack of psychological safety might be a component of several of the other issues raised, as the main fear clinicians report when asked to perform PAD is that their patient might experience an adverse reaction to penicillin after being delabelled. This concern has also been reported as the reason why general practitioners and hospital clinicians do not amend their patient records or prescribe patients penicillin, even after the patient has undergone negative penicillin provocation tests ( 26 – 29 ). In addition, our informants deemed most of the obstacles reported in earlier studies (such as time restraints, practical logistics in performing PAD and reporting results) manageable if they just felt safe to perform PAD. Our informants confirmed that they needed the trust of their organisation and the trust within the team across professions, to feel safe performing PAD. One could say that they needed this external trust to trust themselves. Trust-endorsed processes have been mentioned as necessary in PAD in earlier work ( 9 ). The level of trust in interprofessional health-care teams has been examined in several health care settings and trust in the whole team is deemed a significant enhancer of performance and necessary for the safe delivery of health care ( 30 , 31 ). Ensuring that clinicians feel that it is psychologically safe to perform PAD will likely ease other barriers in PAD, as psychologically safe clinicians have been shown to be more effective and safer in delivering healthcare, demonstrating improved organisational learning at the same time ( 32 ). All key factors to sustainable implementation of PAD. A need for guidelines and mindlines All informants mentioned that guidelines supporting PAD were crucial if they should perform PAD on an everyday basis, and all reported adhering to the national guidelines concerning PAD. However, none of the clinicians had noticed that the national guideline for PAD had been removed from the internet more than a year before the interviews commenced, as it was deemed outdated by the Norwegian Directorate of Health. This demonstrates that guidelines are not necessarily used on a regular basis; rather the mere knowledge that they exist and support their practice, empowers clinicians. Moreover, the embodied and self-perceived knowledge of a topic determines their clinical choices. The word “mindlines” has been introduced to describe the internalised knowledge, ethics and clinical practice each clinician and team possess and act upon on a day-to-day basis ( 33 ). We found that the “mindline”-led practice of each team was decisive for how motivated clinicians were to perform PAD. Teams with positive experience in PAD, knowledge of the harms of penicillin allergy labels and knowledge that their practices concerning PAD today were inferior, were more inclined to implement PAD. This approach adheres to knowledge from organisational theory and implementation science, beyond the particularities of PAD ( 34 , 35 ). Motivation The informants in the focus groups were aware that penicillin allergy labels increase the risk of multiresistant bacterial infections. This finding is in line with earlier studies ( 10 , 27 , 36 ). Their knowledge gaps regarding the other known negative impacts of penicillin delabelling (such as longer hospital stays, and higher mortality rates) were greater than we could expect from the aforementioned studies. We found that this is a source of motivation for performing PAD that has been under facilitated in the WNHR and can be tapped into to aid PAD implementation. For the nurses the prospect of a simplified PAD procedure was deeply motivational, and this source of motivation has not been reported in earlier studies. This may be related to the fact that several nurses in our study had performed skin testing and administered intravenous antibiotic test doses at some point, and therefore noticed the possible benefits of simplified procedure more immediately. It may also be part of the reason why the nurses were more concerned about optimising the organisational context and preparing for a possible adverse reaction, rather than the physicians’ anxiety about causing an adverse reaction. The motivation created by the prospect of a simplified procedure could further ease PAD implementation. Organisational structures Clinicians make a vast number of decisions regarding patients every day and have been reported to manage this by applying “fast and frugal heuristics” ( 37 , 38 ). Hence, new methods must prove both their evidence base and fit rapid decision patterns to be accepted into practice. The informants readily admitted that this way of thinking and working was also part of the reason why they did not perform PAD. Alternative antibiotics could easily be prescribed, and this was the established way of handling patient declaring penicillin allergy. Raising the bar for prescribing alternative antibiotics has been called for in other studies ( 9 , 36 ), but the practicalities of doing so are still unexplored. Our informants suggested amending the electronic patient journals to nudge them away from prescribing other antibiotics. Additionally, they suggested amending the Norwegian antibiotics guidelines, so when a penicillin is the advised treatment, the guideline should recommend performing PAD, in addition to the suggestion of an alternative antibiotic. The informants stated that preformed logistics, where PAD is readily available in the workflow, including preformatted text in the electronic patients' charts were desirable. Organisational structures are the sum of how procedures are performed, by whom, and how decisions are made to obtain an organisational aim ( 39 ). As the organisational workflows of hospitals and clinicians differ, there was a call for both paper forms, computer forms and mobile phone apps, mirroring the complexity of health care and indicating that one size will not fit all. The informants emphasised that a PAD not embedded in their workflow would seldom be performed, as it would not be prioritised over other tasks at hand. The less disruptive and more bundled into current care the methods are, the more likely one is to achieve sustainable implementation of PAD. This is in line with earlier findings ( 9 , 10 , 27 ). Strengths and limitations Interviewing both nurses and physicians enabled us to obtain a broader view of the topic. Having multidisciplinary teams both creating the study and analyse the results also ensured different perspectives on our research question (nurse, pharmacist, and doctors with experience from occupational medicine, infection medicine and thoracic medicine), in addition to the participation of both male and female researchers. Recruiting informants from multiple kinds of hospitals (local, regional and university hospitals), adds transferability to our findings. Earlier studies from the UK ( 9 )and USA ( 10 ) have been single-centre studies and we believe that information from other types of hospitals gives increases the validity of our study. The informants also worked across several types of departments, their experience in PAD varied from none to experienced, and their professional seniority ranged from newly educated to experienced clinicians. We performed interviews with groups consisting of nurses and physicians in as equal numbers as possible, but also performed interviews with physicians and nurses on their own, to ensure that the power dynamics between professions did not restrict the informants’ answers and ensure internal validity. All authors work at WNHR hospital (six physicians, one nurse and one pharmacist) and have a thorough understanding of the everyday working order of the service. We were aware of the high hierarchical position we occupy as senior clinicians, and that this, together with our employment in the same health region as the informants, might have influenced the answers. However, as the informants spoke openly about their own vulnerability and professional anxiety, we assess the internal validity to be high. This study has several limitations. First, the informants all work in one Norwegian health region, potentially reducing the transferability to other countries and different health care systems. Nevertheless, as the study included all types of public hospitals in Norway, the results are most likely transferable to other Norwegian health regions, and other Western countries with similar healthcare organisations and penicillin prescription practices. Second, none of the informants worked in a surgical department at the time they were interviewed. This might limit the transferability to surgical departments, although the informants’ answers are in line with results from previous studies in other countries ( 9 , 10 ). Also, all informants were nominated by their local leader creating a possible bias, as leaders could be inclined to nominate the most skilled clinicians. Conclusion Clinicians need psychological safety to perform PAD. Many of the other obstacles for PAD reported earlier, such as time constraints and practical organisation, were deemed manageable by our informants if they felt psychological safe. The informants voiced a need for empowerment through education, and through leadership-, collegial- and guideline support to experience psychologically safe performing PAD. The need for psychological safety was reported more profoundly than in earlier studies, probably due to social factors. PAD should be a part of everyday practice in a contextually adapted logistic chain. In addition, the clinician’s high level of motivation towards providing the best health care possible should be utilised to aid sustainable PAD implementation. The gained knowledge from this study will aid sustainable implementation of PAD in Norway. Abbreviations WNHR Western Norway Health Region PAD Penicillin allergy delabelling CIPD A checklist for identifying determinants of practice STC Systematic text condensation MBA Marie Bjørbak Alnæs BS Brita Skodvin MAS Margrethe Aase Schaufel GVK Grete Velure Kalleklev JAJ Jan Anker Jahnsen Declarations Ethics approval, consent to participate and for publication of data The study was approved by the Regional Committee for Medical Research Ethics Western Norway (REK-West: 199210) and all participants provided informed, written consent both for participation and for publication of the data. The study results are reported in line with the Standards for Reporting Qualitative Research (SRQR) (40) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) (41). Availability of data and materials The datasets are available from the corresponding author upon reasonable request. General public availability is not guaranteed for confidentiality reasons. Competing interests The authors declare that they have no competing interests. Funding The study was funded by a PhD grant awarded to the first author by The Western Norway Health Region. No grant number applies. Author contributions Marie Alnæs, Brita Skodvin, Margrethe Schaufel, Oddvar Oppegaard, Bård Kittang and Torgeir Storaas constructed the study and recruited participants. Marie Alnæs, Brita Skodvin and Margrethe Schaufel created the interview guide. Marie Alnæs conducted the interviews and transcribed them. Marie Alnæs, Brita Skodvin, Margrethe Schaufel, Jan Anker Jahnsen and Grete Velure Kalleklev performed the analysis. All the authors participated in writing the article in equal terms, and all contributed to refining the study and the article throughout. Acknowledgements We are deeply grateful for the time and thoughts the interviewed colleagues shared with us and the departments participating in the project. 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Patient and Prescriber Views of Penicillin Allergy Testing and Subsequent Antibiotic Use: A Rapid Review. Antibiotics (Basel). 2018;7(3). Trubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, et al. The 3 Cs of Antibiotic Allergy—Classification, Cross-Reactivity, and Collaboration. The Journal of Allergy and Clinical Immunology: In Practice. 2017;5(6):1532-42. Savic L, Thomas C, Fallaha D, Wilson M, Hopkins PM, Savic S, et al. DALES - a prospective cross-sectional study of incidence of penicillin allergy labels, risk of true allergy and attitudes of patients and anaesthetists to de-labelling strategies 2020. Raun I. Healthcare professionals' attitudes to penicillin allergy labels. Danish medical journal 2023. Al-Ahmad M, Rodriguez-Bouza T. Drug allergy evaluation for betalactam hypersensitivity: Cross-reactivity with cephalosporines, carbapenems and negative predictive value. Asian Pac J Allergy Immunol. 2018;36(1):27-31. Gerace KS, Phillips E. Penicillin allergy label persists despite negative testing. The Journal of Allergy and Clinical Immunology: In Practice. 2015;3(5):815-6. Sifaki-Pistolla D, Melidoniotis E, Dey N, Chatzea V-E. How trust affects performance of interprofessional health-care teams. Journal of Interprofessional Care. 2020;34(2):218-24. Gillespie BM, Gwinner K, Chaboyer W, Fairweather N. Team communications in surgery – creating a culture of safety. Journal of Interprofessional Care. 2013;27(5):387-93. Grailey KE, Murray E, Reader T, Brett SJ. The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773. Wieringa S, Greenhalgh T. 10 years of mindlines: a systematic review and commentary. Implementation Science. 2015;10(1):45. Weiner BJ. A theory of organizational readiness for change. Implementation Science. 2009;4(1):67. Kirchner JE, Smith JL, Powell BJ, Waltz TJ, Proctor EK. Getting a clinical innovation into practice: An introduction to implementation strategies. Psychiatry Res. 2020;283:112467. Wilcock M, Powell N, Sandoe J. A UK hospital survey to explore healthcare professional views and attitudes to patients incorrectly labelled as penicillin allergic: an antibiotic stewardship patient safety project. Eur J Hosp Pharm. 2019;26(6):329-33. Gigerenzer G, Todd PM. Fast and frugal heuristics: The adaptive toolbox. Simple heuristics that make us smart. Evolution and cognition. New York, NY, US: Oxford University Press; 1999. p. 3-34. Islam R, Weir C, Del Fiol G. Heuristics in Managing Complex Clinical Decision Tasks in Experts' Decision Making. IEEE Int Conf Healthc Inform. 2014;2014:186-93. Pugh DS. Organization Theory; Selected Readings.: Penguin; 1990. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Academic Medicine. 2014;89(9):1245-51. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6):349-57. Additional Declarations No competing interests reported. Supplementary Files SemistructuredInterviewguide.pdf Supplement 1 Cite Share Download PDF Status: Published Journal Publication published 02 Sep, 2024 Read the published version in Antimicrobial Resistance & Infection Control → Version 1 posted Editorial decision: Revision requested 24 Jun, 2024 Editor assigned by journal 18 Jun, 2024 Submission checks completed at journal 18 Jun, 2024 First submitted to journal 17 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4592154","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318316200,"identity":"4ab30e0e-04cb-4f22-a4d1-c4acb444287a","order_by":0,"name":"Marie Bjørbak Alnæs","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYJCCAwwMFhDGByDBxk6cFgkQzXhwBkgLM3EWgbUwH+YBUwTU6raffXjgQ41EHn97+4PDNr+2yfMxMzB++JiDW4vZmXSDgzOOSRRLnDljcDi377ZhGzMDs+TMbXi0HEhjOMzDJpHYcCOH4XBuz21GoBY2Zl58Ws4/Yzj8559E4vz7zx8ctuy5bU9Yyw2gLYxtEokbbjAYHGb4cTuRCC3PGA729kkkbjyTY3Cwt+F2chszYzN+v5xPY/7w45tN4rzjxx9/+PHntu389uaDHz7i0YIKGNvAZAOx6kHgDymKR8EoGAWjYKQAAAH1WczXFAQ+AAAAAElFTkSuQmCC","orcid":"","institution":"Haukeland University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Marie","middleName":"Bjørbak","lastName":"Alnæs","suffix":""},{"id":318316201,"identity":"164fab52-7af6-4217-b50c-c505803bacc7","order_by":1,"name":"Brita Skodvin","email":"","orcid":"","institution":"The Norwegian Advisory Unit for Antibiotic use in Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Brita","middleName":"","lastName":"Skodvin","suffix":""},{"id":318316202,"identity":"cff8f5bc-b085-4b9f-b1d3-f3ba6c652a87","order_by":2,"name":"Jan Anker Jahnsen","email":"","orcid":"","institution":"Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"Anker","lastName":"Jahnsen","suffix":""},{"id":318316206,"identity":"a947ef60-d0bb-47f7-bd17-2726121cdb81","order_by":3,"name":"Grete Kalleklev Velure","email":"","orcid":"","institution":"Haukeland University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Grete","middleName":"Kalleklev","lastName":"Velure","suffix":""},{"id":318316208,"identity":"f48cbc65-44be-4dac-a5b6-51145f5533dd","order_by":4,"name":"Oddvar Oppegaard","email":"","orcid":"","institution":"Haukeland University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Oddvar","middleName":"","lastName":"Oppegaard","suffix":""},{"id":318316210,"identity":"6f4e1cf9-33c2-4bd3-a864-d12df01e05b3","order_by":5,"name":"Bård Reiakvam Kittang","email":"","orcid":"","institution":"University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Bård","middleName":"Reiakvam","lastName":"Kittang","suffix":""},{"id":318316212,"identity":"572ff727-b056-4189-bdd8-9e43ec031140","order_by":6,"name":"Torgeir Storaas","email":"","orcid":"","institution":"Haukeland University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Torgeir","middleName":"","lastName":"Storaas","suffix":""},{"id":318316213,"identity":"6dcb5684-801f-4f54-b08f-1f2d8c2edb3d","order_by":7,"name":"Margrethe Aase Schaufel","email":"","orcid":"","institution":"Haukeland University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Margrethe","middleName":"Aase","lastName":"Schaufel","suffix":""}],"badges":[],"createdAt":"2024-06-17 06:33:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4592154/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4592154/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13756-024-01456-8","type":"published","date":"2024-09-02T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60429327,"identity":"d97489e2-37cf-4e47-8e79-2457981bb7be","added_by":"auto","created_at":"2024-07-16 16:02:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":127369,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFactors needed for the sustainable implementation of penicillin allergy delabelling.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figureimplementationpenicillindelabeling.png","url":"https://assets-eu.researchsquare.com/files/rs-4592154/v1/ecc3ecabd6efbcd17da034a3.png"},{"id":64185817,"identity":"814dbd2f-0cdd-4d37-b546-f6d4f8e409db","added_by":"auto","created_at":"2024-09-09 16:22:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":789680,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4592154/v1/5144aa6a-adc4-4943-8c85-8710b9349dbb.pdf"},{"id":60430300,"identity":"4433b8eb-532f-4520-9b3f-847471074b3f","added_by":"auto","created_at":"2024-07-16 16:18:15","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":229829,"visible":true,"origin":"","legend":"\u003cp\u003eSupplement 1\u003c/p\u003e","description":"","filename":"SemistructuredInterviewguide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4592154/v1/91e6e836618b9b0c5319e7d0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“What if the patient has a severe reaction, and it is my fault?” A qualitative study exploring factors for sustainable implementation of penicillin allergy delabelling.","fulltext":[{"header":"Background","content":"\u003cp\u003ePenicillin allergy delabelling (PAD) is one of the cornerstones in antibiotic stewardship and is recognised as an important measure for preventing antibiotic resistance (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Nine out of ten patients claiming to be penicillin allergic were found to tolerate penicillin when subjected to allergologic testing, suggesting an unmet need for systematic evaluation of patients with alleged antimicrobial allergies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). PAD guidelines have been developed in many countries, but sustainable dissemination and implementation of these outside allergy units are rare (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious analyses of PAD programs have revealed the need for multifaceted efforts to succeed (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Moreover, the importance of qualitative research concerning PAD has been demonstrated, and the clinician\u0026rsquo;s perspective appears to be crucial for the sustainable development and implementation of PAD programs, for the benefit of patients and health care systems (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Nevertheless, knowledge about clinicians need to perform PAD is scarce, and only two interview studies from Great Britain and the United States of America have addressed this issue in-depth (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Here PAD was seen as a complex task and not a priority during acute patient presentation. Also, time restraints, a lack of securely communicating penicillin allergy labels and a fear of inducing an allergic reaction were barriers for performing PAD. As the education of health personnel in PAD-, legislation- and health systems are subject to contextual differences, studies from further health care systems are needed (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). We wanted to perform an interview study with nurses and physicians working in Western-Norway Health Region (WNHR) hospitals to explore how PAD is perceived and identify needs to be met for the sustainable implementation of a clinical pathway for PAD in Norway.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy aims\u003c/h2\u003e \u003cp\u003eThis study explores how nurses and physicians in the WNHR perceive PAD and what needs must be met to sustainably implement a clinical pathway for PAD in Norway.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eWe performed a qualitative study consisting of semi-structured focus group interviews with physicians and nurses working in hospitals of all service levels (university-, regional- and local hospitals) in the WNHR. The hospitals have a total catchment area of 1,14\u0026nbsp;million patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The interviews were performed between September and December 2023. The Norwegian health system is predominantly state funded and governed. Norway has a national action plan (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) for fighting antimicrobial resistance and antibiotic stewardship is mandatory. In Norway penicillins are the first choose of antibiotic treatment in most settings (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e The study was approved by the Regional Committee for Medical Research Ethics Western Norway (REK-West: 199210) and all participants provided informed, written consent both for participation and for publication of the data. The study results are reported in line with the Standards for Reporting Qualitative Research (SRQR) (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e The informants were recruited for interviews by the local clinical leader and then invited to participate via email. Their level of experience in PAD differed. The informants had varied professional backgrounds, including dermatology, thoracic medicine, otorhinolaryngology, internal medicine, emergency wards, rheumatology and infectious diseases. Three informants had broad experience in PAD, eight stated no previous experience, whereas the rest declared that they had some experience with PAD but lacked formal training in the procedure. The demographics of the informants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Participation was voluntary, and informed written consent was obtained before commencing the interviews. The informants were selected to represent all levels of experience and types of hospitals in the WNHR. The groups were recruited as purposeful samples, aiming at diversity in experience, gender, professional background, and age.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistribution of informants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of informants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNurses\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurses with \u0026le;\u0026thinsp;5 years of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurses with \u0026ge;\u0026thinsp;5 years of practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysicians\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoard certified specialist doctors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTheoretical perspectives\u003c/h2\u003e \u003cp\u003e\u0026ldquo;A Checklist for identifying determinants of practice\u0026rdquo; (CIDP) was chosen as a framework informing the interview guide (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). According to this framework, tailored implementation interventions are strategies designed to improve health care. Examining the challenges that may occur when implementing such interventions will aid in better and more targeted implementation. This can further increase uptake of interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThree of the authors (MBA, BS and MAS) developed the interview guide (\u003cem\u003esupplement 1)\u003c/em\u003e. MBA is a Norwegian female physician working in the WNHR in an Allergy department, and has a special focus on drug allergies, particularly PAD. MBA has no earlier experience in qualitative studies and the work is part of her PhD project. The co-authors BS and MS, who co-created the interview guides, are also Norwegian female physicians, but have broad experience in qualitative research. We developed a guide for focus group interviews as we deemed it the most suitable way of detecting the necessary knowledge, as PAD is a complex intervention dependent on interdisciplinary cooperation. The interview guide was refined after the second interview to optimise the questions and adjust for the allocated timeframe.\u003c/p\u003e \u003cp\u003eMBA performed the interviews using a semi structured interview guide \u003cem\u003e(supplement 1).\u003c/em\u003e Eight interviews were conducted. One interview included only nurses, and two included only physicians. The rest of the interviews consisted of a mixed group of nurses and physicians. The first interview was performed with a single clinician due to acute changes in clinic staffing. One of the interviews was performed as an online video interview using \u0026ldquo;Teams\u0026rdquo; (Microsoft) due to organisational challenges. The other interviews were performed in person. All interviews were recorded by Samsung Galaxy A 34 audio recorder, version 21.4.05.04, a digital recording software and transcribed a verbatim into text by the first author. Data collection was drawn to a close when the interviews provided adequate information power in the sense that no new thematic findings were identified during the interviews and the preliminary analysis (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eTranscripts were analysed with systematic text condensation (STC), a pragmatic method for cross-case, thematic analysis (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). STC analysis contains four steps: 1) Obtaining an overall impression by reading the complete material 2) Identifying units of meaning containing the participants\u0026rsquo; attitudes and opinions towards performing PAD and coding these units 3) Condensing and further abstracting meaning from the coded groups. 4) Summarising together with creating concepts and descriptions from the condensates.\u003c/p\u003e \u003cp\u003eMBA, BS, MAS, GVK, and JAJ participated in the analysis. When there were different views on the coding agreement was reached through discussion. The analysis was performed as a stepwise-, cross-sectional-, inductive- and iterative analysis adhering to recommendations for the application of STC. An audit trail was kept throughout the study. The analysis was documented in Word (Microsoft) files. A secure \u0026ldquo;Teams\u0026rdquo; (Microsoft) room was used for the analysis, and the participating researchers had access to the running files and all the decisions made throughout the analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified three main needs for implementing PAD: 1) creating psychological safety; 2) utilising clinicians\u0026rsquo; inherent motivation to aid implementation; and 3) providing optimal organisational structures. Below, we elaborate our findings illustrated by quotes from the transcripts. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates that all of theese components are needed for clinicians to perform PAD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e1. Creating psychological safety\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eClinicians\u0026rsquo; anxiety when performing PAD must be addressed and decreased:\u003c/h2\u003e \u003cp\u003eThe informants highlighted psychological safety as crucial for performing PAD. An experience of that PAD is supported throughout both their scientific-, and medical communities, and in the workplace was essential, as several physicians expressed a profound sense of uncertainty and anxiety towards PAD. The physicians associated PAD with an inherent risk. This was most prominent in physicians who had never participated in penicillin delabelling. Fear concerning outcomes for patients, with a perceived high risk of reaction to provocation testing, and fear concerning personal and professional consequences if the patient reacted to the penicillin challenge were central aspects. One of the doctors described it as follows:\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I feel that we are unsure, lack experience and need to be empowered. We need support both from guidelines, from leaders and colleagues in addition to more knowledge of the field. I am too unsure of the method we use today, and then I don\u0026rsquo;t do it. You know, we are trained to respect drug allergy labels. Often, we will discuss penicillin delabelling, and are quite convinced that the patient has no penicillin allergy, but then we decide not to perform penicillin delabelling because you know, there could be a very steep fall when overruling a drug allergy warning. Both for the patient and for the doctor. What if the patient has a severe reaction, and it is my fault...Doctor #5 \u0026ldquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe high level of fright towards adverse reactions when performing PAD contradicts the lived experience from the physicians that had performed PAD from time to time, as none of them had ever experienced any severe adverse events when delabelling patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Well, the experience over the 13 years I have done delabelling is that there has never been a severe reaction, no anaphylaxis, and I have been quite liberal in my delabelling. Doctor #7\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThe nurses all relied on the doctor\u0026rsquo;s decision concerning delabelling declared penicillin allergy. They said that they do whatever the doctor decides. The nurses were also less nervous towards adverse reactions to the provocation testing as most of them stated that they had performed PAD earlier with skin testing and administered intravenous antibiotic test doses on rare occasions. However, the nurses also reported that to perform PAD they must feel safe within their team and trust the physician in charge.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI want it to be a doctor I trust, one I am sure will appear quickly when paged, and that we as a team decide to perform PAD. I must know that we are prepared if a reaction occurs. Nurse #2\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eClinicians need empowerment and support to perform PAD:\u003c/h2\u003e \u003cp\u003eThe informants sought empowerment and communicated a need for more knowledge and experience in PAD. They craved information and partly used the interview setting to educate themselves, asking the interviewer several questions about PAD throughout the sessions. They wanted to be able to do PAD and to do it right; to be educated and participate in performing PAD provided increased psychological safety. They were aware that they need to change today\u0026rsquo;s practice and suggested both lectures and simulation training to make them feel safe to perform PAD. They emphasised that they learn most from each other, such as apprentices from their masters.\u003c/p\u003e \u003cp\u003e The participants said that clear guidelines are crucial. The knowledge that government- and medical society led support is available were mentioned as key factors towards establishing psychological safety enabling them to perform PAD. Concerns voiced towards the current state of guidelines concerning PAD were that they are hard to find, outdated and partly contradict each other. Readily available guidelines that coherently communicate PAD and focus on the practical everyday needs concerning the act of delabelling patients were missed. Both nurses and physicians called for better tools for delabelling. The informants reported that they would need support from their peers to perform PAD regularly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003el would like it to be like a cooking recipe, and with a preformed scoring system that made the decision to perform delabelling clear and the procedure to do so easy. The guidelines ought to be as identical as possible, in the hospital, in the national antibiotic guidelines and elsewhere. Doctor #2.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2. Utilising clinicians\u0026rsquo; inherent motivation to aid implementation\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eClinicians want to provide the best possible healthcare:\u003c/h2\u003e \u003cp\u003eThe clinician's main motivation and main facilitator for aiding in the sustainable implementation of PAD was the prospect of optimising patient care and reducing the use of broad-spectrum antibiotics. Providing the best clinical care was the main interest of clinicians and the fact that current practice was not ideal was perceived as shameful. In implementing PAD this motivation should be utilised to aid uptake and motivate clinicians to perform PAD on an everyday basis.\u003c/p\u003e \u003cp\u003e\u0026rdquo; \u003cem\u003eI want to provide the best patient treatment possible. I also want to reduce antimicrobial resistance. And our current method is outdated and rarely performed, we simply must change. I see it as a win-win situation. I mean concerning antibiotic resistance and the patient. It is easier for us to perform delabelling this way. We heal patients from their declared penicillin allergy and can give them the most efficient treatment. Not being able to receive penicillin is quite severe, a disease on its own come to think about it, and changing that, well that is the reward. Nurse #8\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eClinicians want to reduce antimicrobial resistance and further negative impacts of penicillin allergy labeling:\u003c/h2\u003e \u003cp\u003eThe knowledge of the incremental harm of penicillin allergy labels was high concerning antimicrobial resistance. Knowledge concerning the other negative impacts of penicillin allergy labels such as increased morbidity and mortality of the individual patient, increased cost of treatment and longer hospital stays was low. The increased awareness of these topics throughout the interviews, and the possible benefits of PAD, were immediately mentioned as important motivations for them to change their practices and attitudes towards PAD. This knowledge also motivated them to discourage the common practice of simply choosing another antibiotic when the patient declares penicillin allergy, as an easy way out, as the harm in this practice dawned on them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI have been annoyed by all the patients declaring themselves penicillin allergic for uncertain reasons, and then I must prescribe them a broad-spectrum antibiotic. But I was unaware how bad it is overall it is for the patient to be labelled penicillin allergic for no reason, and that our procedures today are so uncertain and outdated, that feels very unsettling. Doctor #3\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eClinicians are motivated by the prospect of a simplified clinical procedure:\u003c/h2\u003e \u003cp\u003eThe nurses were particularly motivated by the prospect of an easier clinical procedure, as they perform the test procedure and have the highest workload in PAD. Many of them reported having performed skin-testing and provocation-tests for penicillin allergy earlier and reported that the new method represented time and resources saved on their behalf. This was reported to be a strong motivation\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI like that it seems easier for us nurses to perform. I believe it is a lot less stressful to just administer a tablet than to perform today\u0026rsquo;s skin testing, with dilution series of the medication and sorting syringes, it\u0026rsquo;s quicker too. Nurse #4\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3. Providing optimal organisational structures\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eClinicians need a seamless workflow adapted to their working context:\u003c/h2\u003e \u003cp\u003eThe informants emphasised that an optimal organisational structure was the main prerequisite implementing a clinical pathway for PAD in everyday hospital practice. They called for a preformed logistic chain and for the method to be readily available to be able to perform PAD. This was due to their experienced lack of time in everyday practice as an obstacle for PAD, together with an undefined responsibility of when and where to perform PAD. Streamlining the process would increase uptake and make PAD feasible.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf we are to do this on an everyday basis, then we need a system for it in the patient journal, so that it is easy to remember, and quick to perform. If we have to start searching for a form or something, it won\u0026rsquo;t happen. And we need to know where and when it is expected for us to do this. Doctor #1\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe clinicians wanted the clinical pathway for PAD to be available across all platforms and media used in their everyday practice. As one size does not fit all, PADs should be available in both paper forms, mobile phone apps and electronic versions in patients\u0026rsquo; health care charts. Nudging, described as automated electronic reminders in the electronic health records was met ambivalently as they were often perceived to obstruct the workflow especially by the physicians, even though their function as clinical reminders was acknowledged as useful.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I experience that we get more and more patients, more and more tasks to perform, and less and less time for each patient, so it must be readily available when I need it, in the systems we use already. So that we don\u0026rsquo;t forget to do it, and minimal extra hassle occurs. It needs to become sort of second nature for it to be a sustained method. Doctor #10\u0026ldquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe nurses emphasised their position as gatekeepers and reminders of best practices within the medical team. Physicians often rotate between wards during their time on call, as opposed to nurses, who observe patients throughout the day.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eClinicians need appointed clinicians to lead implementation:\u003c/h2\u003e \u003cp\u003eAll the informants highlighted the importance of clinical teams and \u0026ldquo;lighthouses,\u0026rdquo; meaning that clinicians were especially appointed for both educating and reminding other colleagues to perform PAD. They believed that if the clinical pathway for PAD was embedded into their everyday routine with minimal disruption it would pave the way for sustainable implementation of PAD. Additionally, there was a call for well-functioning interdisciplinary teams as PAD is a complex intervention necessitating cooperation between physicians and nurses.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI believe most of us nurses would ask the doctors about penicillin delabelling. Especially during prerounds preparation. But it is a team effort, and you need to have someone to trailblaze it. We have antibiotics teams that could take charge and pull the other with them. Nurse #9\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge this is the first qualitative interview study providing an in-depth understanding of the perceived needs of clinicians when implementing PAD in Scandinavia. The informants described their knowledge and motivation for PAD, but also their anxiety and shortcomings concerning performing PAD today. The development of sustainable programs and guidelines (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) paves the way for sustainable implementation, but true sustainable development only occurs when new knowledge and guidelines are implemented in everyday practice (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Our study provides added information about how to make a clinical pathway for PAD fit to practice and identified several targets for implementation efforts that will help improve the implementation of PAD in Norway.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePsychological safety\u003c/h2\u003e \u003cp\u003eOur main finding was that clinicians need psychological safety to perform PAD. The informants were highly motivated to perform PAD, but at the same time unsure and anxious to do so. Anxiety is multifaceted, and both the anticipated fears concerning the patient, concerning themselves, and the fear of professional consequences must be addressed. Their glimpse of potential danger overshadowed their knowledge of benefits and colleagues' reports of successful delabelling experiences. The level of anxiety was also surprisingly high considering the large body of international research on PAD that deems it safe and provides both guidelines and tools for perform delabelling (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Psychological safety has been mentioned as a barrier for performing PAD in a recent study from the USA (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) but was reported more profoundly by our informants than in this earlier study. The Norwegian health care system is less hierarchical than most health care systems outside Scandinavia. The level of trust in society and the health system is among the highest in Europe (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), adding to this there has been increased awareness of clinicians' anxiety and errors in Norway in recent years (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). These social factors probably influenced our results and made it easier for our informants to openly address their professional anxiety concerning penicillin allergy delabelling.\u003c/p\u003e \u003cp\u003eOther studies have mentioned that clinicians report PAD to be a complex issue, and they perceive it challenging to examine and communicate penicillin allergy labels. They reported that time to perform PAD is lacking and that they are unsure about who is meant to actually perform PAD (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). We believe that a lack of psychological safety might be a component of several of the other issues raised, as the main fear clinicians report when asked to perform PAD is that their patient might experience an adverse reaction to penicillin after being delabelled. This concern has also been reported as the reason why general practitioners and hospital clinicians do not amend their patient records or prescribe patients penicillin, even after the patient has undergone negative penicillin provocation tests (\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In addition, our informants deemed most of the obstacles reported in earlier studies (such as time restraints, practical logistics in performing PAD and reporting results) manageable if they just felt safe to perform PAD. Our informants confirmed that they needed the trust of their organisation and the trust within the team across professions, to feel safe performing PAD. One could say that they needed this external trust to trust themselves. Trust-endorsed processes have been mentioned as necessary in PAD in earlier work (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The level of trust in interprofessional health-care teams has been examined in several health care settings and trust in the whole team is deemed a significant enhancer of performance and necessary for the safe delivery of health care (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Ensuring that clinicians feel that it is psychologically safe to perform PAD will likely ease other barriers in PAD, as psychologically safe clinicians have been shown to be more effective and safer in delivering healthcare, demonstrating improved organisational learning at the same time (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). All key factors to sustainable implementation of PAD.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eA need for guidelines and mindlines\u003c/h2\u003e \u003cp\u003e All informants mentioned that guidelines supporting PAD were crucial if they should perform PAD on an everyday basis, and all reported adhering to the national guidelines concerning PAD. However, none of the clinicians had noticed that the national guideline for PAD had been removed from the internet more than a year before the interviews commenced, as it was deemed outdated by the Norwegian Directorate of Health. This demonstrates that guidelines are not necessarily used on a regular basis; rather the mere knowledge that they exist and support their practice, empowers clinicians. Moreover, the embodied and self-perceived knowledge of a topic determines their clinical choices. The word \u0026ldquo;mindlines\u0026rdquo; has been introduced to describe the internalised knowledge, ethics and clinical practice each clinician and team possess and act upon on a day-to-day basis (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). We found that the \u0026ldquo;mindline\u0026rdquo;-led practice of each team was decisive for how motivated clinicians were to perform PAD. Teams with positive experience in PAD, knowledge of the harms of penicillin allergy labels and knowledge that their practices concerning PAD today were inferior, were more inclined to implement PAD. This approach adheres to knowledge from organisational theory and implementation science, beyond the particularities of PAD (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eMotivation\u003c/h2\u003e \u003cp\u003eThe informants in the focus groups were aware that penicillin allergy labels increase the risk of multiresistant bacterial infections. This finding is in line with earlier studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Their knowledge gaps regarding the other known negative impacts of penicillin delabelling (such as longer hospital stays, and higher mortality rates) were greater than we could expect from the aforementioned studies. We found that this is a source of motivation for performing PAD that has been under facilitated in the WNHR and can be tapped into to aid PAD implementation.\u003c/p\u003e \u003cp\u003eFor the nurses the prospect of a simplified PAD procedure was deeply motivational, and this source of motivation has not been reported in earlier studies. This may be related to the fact that several nurses in our study had performed skin testing and administered intravenous antibiotic test doses at some point, and therefore noticed the possible benefits of simplified procedure more immediately. It may also be part of the reason why the nurses were more concerned about optimising the organisational context and preparing for a possible adverse reaction, rather than the physicians\u0026rsquo; anxiety about causing an adverse reaction. The motivation created by the prospect of a simplified procedure could further ease PAD implementation.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eOrganisational structures\u003c/h2\u003e \u003cp\u003eClinicians make a vast number of decisions regarding patients every day and have been reported to manage this by applying \u0026ldquo;fast and frugal heuristics\u0026rdquo; (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Hence, new methods must prove both their evidence base and fit rapid decision patterns to be accepted into practice. The informants readily admitted that this way of thinking and working was also part of the reason why they did not perform PAD. Alternative antibiotics could easily be prescribed, and this was the established way of handling patient declaring penicillin allergy. Raising the bar for prescribing alternative antibiotics has been called for in other studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), but the practicalities of doing so are still unexplored. Our informants suggested amending the electronic patient journals to nudge them away from prescribing other antibiotics. Additionally, they suggested amending the Norwegian antibiotics guidelines, so when a penicillin is the advised treatment, the guideline should recommend performing PAD, in addition to the suggestion of an alternative antibiotic.\u003c/p\u003e \u003cp\u003eThe informants stated that preformed logistics, where PAD is readily available in the workflow, including preformatted text in the electronic patients' charts were desirable. Organisational structures are the sum of how procedures are performed, by whom, and how decisions are made to obtain an organisational aim (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). As the organisational workflows of hospitals and clinicians differ, there was a call for both paper forms, computer forms and mobile phone apps, mirroring the complexity of health care and indicating that one size will not fit all. The informants emphasised that a PAD not embedded in their workflow would seldom be performed, as it would not be prioritised over other tasks at hand. The less disruptive and more bundled into current care the methods are, the more likely one is to achieve sustainable implementation of PAD. This is in line with earlier findings (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eInterviewing both nurses and physicians enabled us to obtain a broader view of the topic. Having multidisciplinary teams both creating the study and analyse the results also ensured different perspectives on our research question (nurse, pharmacist, and doctors with experience from occupational medicine, infection medicine and thoracic medicine), in addition to the participation of both male and female researchers. Recruiting informants from multiple kinds of hospitals (local, regional and university hospitals), adds transferability to our findings. Earlier studies from the UK (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)and USA (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) have been single-centre studies and we believe that information from other types of hospitals gives increases the validity of our study. The informants also worked across several types of departments, their experience in PAD varied from none to experienced, and their professional seniority ranged from newly educated to experienced clinicians. We performed interviews with groups consisting of nurses and physicians in as equal numbers as possible, but also performed interviews with physicians and nurses on their own, to ensure that the power dynamics between professions did not restrict the informants\u0026rsquo; answers and ensure internal validity.\u003c/p\u003e \u003cp\u003eAll authors work at WNHR hospital (six physicians, one nurse and one pharmacist) and have a thorough understanding of the everyday working order of the service. We were aware of the high hierarchical position we occupy as senior clinicians, and that this, together with our employment in the same health region as the informants, might have influenced the answers. However, as the informants spoke openly about their own vulnerability and professional anxiety, we assess the internal validity to be high.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the informants all work in one Norwegian health region, potentially reducing the transferability to other countries and different health care systems. Nevertheless, as the study included all types of public hospitals in Norway, the results are most likely transferable to other Norwegian health regions, and other Western countries with similar healthcare organisations and penicillin prescription practices. Second, none of the informants worked in a surgical department at the time they were interviewed. This might limit the transferability to surgical departments, although the informants\u0026rsquo; answers are in line with results from previous studies in other countries (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Also, all informants were nominated by their local leader creating a possible bias, as leaders could be inclined to nominate the most skilled clinicians.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eClinicians need psychological safety to perform PAD. Many of the other obstacles for PAD reported earlier, such as time constraints and practical organisation, were deemed manageable by our informants if they felt psychological safe. The informants voiced a need for empowerment through education, and through leadership-, collegial- and guideline support to experience psychologically safe performing PAD. The need for psychological safety was reported more profoundly than in earlier studies, probably due to social factors.\u003c/p\u003e \u003cp\u003ePAD should be a part of everyday practice in a contextually adapted logistic chain. In addition, the clinician\u0026rsquo;s high level of motivation towards providing the best health care possible should be utilised to aid sustainable PAD implementation. The gained knowledge from this study will aid sustainable implementation of PAD in Norway.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWNHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWestern Norway Health Region\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePenicillin allergy delabelling\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCIPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eA checklist for identifying determinants of practice\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSystematic text condensation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMarie Bj\u0026oslash;rbak Aln\u0026aelig;s\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrita Skodvin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMargrethe Aase Schaufel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGVK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGrete Velure Kalleklev\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJAJ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJan Anker Jahnsen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval, consent to participate and for publication of data\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study was approved by the Regional Committee for Medical Research Ethics Western Norway (REK-West: 199210) and all participants provided informed, written consent both for participation and for publication of the data. The study results are reported in line with the\u0026nbsp;Standards for Reporting Qualitative Research (SRQR)\u0026nbsp;(40)\u0026nbsp;and the Consolidated Criteria for Reporting Qualitative Research (COREQ)\u0026nbsp;(41).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003eThe datasets are available from the corresponding author upon reasonable request. General public availability is not guaranteed for confidentiality reasons.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study was funded by a PhD grant awarded to the first author by The Western Norway Health Region. No grant number applies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Marie Aln\u0026aelig;s, Brita Skodvin, Margrethe Schaufel, Oddvar Oppegaard, B\u0026aring;rd Kittang and Torgeir Storaas constructed the study and recruited participants.\u0026nbsp;\u003cbr\u003e\u0026nbsp;Marie Aln\u0026aelig;s, Brita Skodvin\u003csup\u003e\u0026nbsp;\u003c/sup\u003eand Margrethe Schaufel created the interview guide.\u003cbr\u003e\u0026nbsp;Marie Aln\u0026aelig;s conducted the interviews and transcribed them.\u003cbr\u003e\u0026nbsp;Marie Aln\u0026aelig;s, Brita Skodvin,\u0026nbsp;Margrethe Schaufel,\u0026nbsp;Jan Anker Jahnsen\u0026nbsp;and Grete Velure Kalleklev\u0026nbsp;performed the analysis.\u003cbr\u003e\u0026nbsp;All the authors participated in writing the article in equal terms, and all contributed to refining the study and the article throughout.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;We are deeply grateful for the time and thoughts the interviewed colleagues shared with us and the departments participating in the project. In particular, we thank Anine Lie for her valuable input in reviewing this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ecommission Eu. EU Guidelines for the prudent use of antimicrobials in human health. 2017.\u003c/li\u003e\n\u003cli\u003eL. H. Garvey LKT, J. Hjortlund et al. . DSA-Retningslinjer for udredning af antibiotika-allergi med s\u0026aelig;rligt fokus p\u0026aring; penicilliner.\u003c/li\u003e\n\u003cli\u003eBlumenthal Kimberly MD Mea. Recorded Penicillin Allergy and Risk of Mortality: a Population-Based Matched Cohort Study. Journal of General Internal Medicine. 2019;34(34):1685-78.\u003c/li\u003e\n\u003cli\u003eStaicu ML, Vyles D, Shenoy ES, Stone CA, Banks T, Alvarez KS, et al. Penicillin Allergy Delabeling: A Multidisciplinary Opportunity. J Allergy Clin Immunol Pract. 2020;8(9):2858-68 e16.\u003c/li\u003e\n\u003cli\u003eAln\u0026aelig;s M ea. A new pathway for penicillin delabeling in Noray. World allergy Organization Journal. 2023;16(11).\u003c/li\u003e\n\u003cli\u003eorganization WH. Global acation plan on antibicrobal resistance. 2015.\u003c/li\u003e\n\u003cli\u003eStone CA, Jr., Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy. 2020;75(2):273-88.\u003c/li\u003e\n\u003cli\u003eSantillo M, Wanat M, Davoudianfar M, Bongard E, Savic S, Savic L, et al. Developing a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice and subsequently change antibiotic use. BMJ Open. 2020;10(10):e035793.\u003c/li\u003e\n\u003cli\u003ePowell N, Wilcock M, Roberts N, Sandoe J, Tonkin-Crine S. Focus group study exploring the issues and the solutions to incorrect penicillin allergy-labelled patients: an antibiotic stewardship patient safety initiative. Eur J Hosp Pharm. 2021;28(2):71-5.\u003c/li\u003e\n\u003cli\u003eAlagoz E, Saucke M, Balasubramanian P, Lata P, Liebenstein T, Kakumanu S. Barriers to penicillin allergy de-labeling in the inpatient and outpatient settings: a qualitative study. Allergy Asthma Clin Immunol. 2023;19(1):88.\u003c/li\u003e\n\u003cli\u003eagency NS. The specialist health service in numbers 2023 [Available from: https://www.ssb.no/en/statbank/table/13982.\u003c/li\u003e\n\u003cli\u003eGouvernement TN. The Norwegian National strategy against Antibiotic resistance 2015-2020 2015 [Available from: https://www.regjeringen.no/contentassets/5eaf66ac392143b3b2054aed90b85210/antibiotic-resistance-engelsk-lavopploslig-versjon-for-nett-10-09-15.pdf.\u003c/li\u003e\n\u003cli\u003eAntibiotics TNAUfuo. Norwegian guidelines for the use of antibiotics [Available from: https://www.antibiotika.no/.\u003c/li\u003e\n\u003cli\u003eFlottorp Sea. A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. 2013.\u003c/li\u003e\n\u003cli\u003eHennink MM, Kaiser BN, Marconi VC. Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough? Qual Health Res. 2017;27(4):591-608.\u003c/li\u003e\n\u003cli\u003eMalterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res. 2016;26(13):1753-60.\u003c/li\u003e\n\u003cli\u003eMalterud K. Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health. 2012;40(8):795-805.\u003c/li\u003e\n\u003cli\u003eWieringa S, McGuire H, Wang Q, Wees Pvd, Shaw B. Making sustainable healthcare decisions: three turns towards sustainable guidelines. BMJ Evidence-Based Medicine. 2023:bmjebm-2023-112352.\u003c/li\u003e\n\u003cli\u003eBauer MS, Kirchner J. Implementation science: What is it and why should I care? Psychiatry Res. 2020;283:112376.\u003c/li\u003e\n\u003cli\u003eKhan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, et al. Drug allergy: A\u0026amp;#xa0;2022 practice parameter update. Journal of Allergy and Clinical Immunology. 2022;150(6):1333-93.\u003c/li\u003e\n\u003cli\u003eChua KYL, Vogrin S, Bury S, Douglas A, Holmes NE, Tan N, et al. The Penicillin Allergy Delabeling Program: A Multicenter Whole-of-Hospital Health Services Intervention and Comparative Effectiveness Study. Clin Infect Dis. 2021;73(3):487-96.\u003c/li\u003e\n\u003cli\u003eKleven \u0026Oslash;. Norwegians at the top of trusting in Europe. In: statistics Naf, editor. No2016.\u003c/li\u003e\n\u003cli\u003ePaus S. Fatal mistakes. Tidsskr Nor Laegeforen. 2022;142(5).\u003c/li\u003e\n\u003cli\u003eWanat M, Anthierens S, Butler CC, Wright JM, Dracup N, Pavitt SH, et al. Patient and Prescriber Views of Penicillin Allergy Testing and Subsequent Antibiotic Use: A Rapid Review. Antibiotics (Basel). 2018;7(3).\u003c/li\u003e\n\u003cli\u003eTrubiano JA, Stone CA, Grayson ML, Urbancic K, Slavin MA, Thursky KA, et al. The 3 Cs of Antibiotic Allergy\u0026mdash;Classification, Cross-Reactivity, and Collaboration. The Journal of Allergy and Clinical Immunology: In Practice. 2017;5(6):1532-42.\u003c/li\u003e\n\u003cli\u003eSavic L, Thomas C, Fallaha D, Wilson M, Hopkins PM, Savic S, et al. DALES - a prospective cross-sectional study of incidence of penicillin allergy labels, risk of true allergy and attitudes of patients and anaesthetists to de-labelling strategies 2020.\u003c/li\u003e\n\u003cli\u003eRaun I. Healthcare professionals\u0026apos; attitudes to penicillin allergy labels. Danish medical journal 2023.\u003c/li\u003e\n\u003cli\u003eAl-Ahmad M, Rodriguez-Bouza T. Drug allergy evaluation for betalactam hypersensitivity: Cross-reactivity with cephalosporines, carbapenems and negative predictive value. Asian Pac J Allergy Immunol. 2018;36(1):27-31.\u003c/li\u003e\n\u003cli\u003eGerace KS, Phillips E. Penicillin allergy label persists despite negative testing. The Journal of Allergy and Clinical Immunology: In Practice. 2015;3(5):815-6.\u003c/li\u003e\n\u003cli\u003eSifaki-Pistolla D, Melidoniotis E, Dey N, Chatzea V-E. How trust affects performance of interprofessional health-care teams. Journal of Interprofessional Care. 2020;34(2):218-24.\u003c/li\u003e\n\u003cli\u003eGillespie BM, Gwinner K, Chaboyer W, Fairweather N. Team communications in surgery \u0026ndash; creating a culture of safety. Journal of Interprofessional Care. 2013;27(5):387-93.\u003c/li\u003e\n\u003cli\u003eGrailey KE, Murray E, Reader T, Brett SJ. The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773.\u003c/li\u003e\n\u003cli\u003eWieringa S, Greenhalgh T. 10 years of mindlines: a systematic review and commentary. Implementation Science. 2015;10(1):45.\u003c/li\u003e\n\u003cli\u003eWeiner BJ. A theory of organizational readiness for change. Implementation Science. 2009;4(1):67.\u003c/li\u003e\n\u003cli\u003eKirchner JE, Smith JL, Powell BJ, Waltz TJ, Proctor EK. Getting a clinical innovation into practice: An introduction to implementation strategies. Psychiatry Res. 2020;283:112467.\u003c/li\u003e\n\u003cli\u003eWilcock M, Powell N, Sandoe J. A UK hospital survey to explore healthcare professional views and attitudes to patients incorrectly labelled as penicillin allergic: an antibiotic stewardship patient safety project. Eur J Hosp Pharm. 2019;26(6):329-33.\u003c/li\u003e\n\u003cli\u003eGigerenzer G, Todd PM. Fast and frugal heuristics: The adaptive toolbox. Simple heuristics that make us smart. Evolution and cognition. New York, NY, US: Oxford University Press; 1999. p. 3-34.\u003c/li\u003e\n\u003cli\u003eIslam R, Weir C, Del Fiol G. Heuristics in Managing Complex Clinical Decision Tasks in Experts\u0026apos; Decision Making. IEEE Int Conf Healthc Inform. 2014;2014:186-93.\u003c/li\u003e\n\u003cli\u003ePugh DS. Organization Theory; Selected Readings.: Penguin; 1990.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Academic Medicine. 2014;89(9):1245-51.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6):349-57.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Penicillin allergy delabelling, nurse, doctor, facilitators, barriers, focus group interview, qualitative research, implementation.","lastPublishedDoi":"10.21203/rs.3.rs-4592154/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4592154/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\n Penicillin allergy delabelling (PAD) is a key target in antibiotic stewardship, but uptake of the procedure outside clinical studies is limited. We aimed to explore factors that need to be addressed to sustainably implement a clinical pathway for PAD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\n We conducted a qualitative study based on semi-structured interviews with focus groups consisting of a purposive sample of twenty-five nurses and physicians working on three different hospitals in Western Norway. Systematic text condensation was applied for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003cbr\u003e\n \u003c/strong\u003ePsychological safety was reported as crucial for clinicians to perform PAD. A narrative of uncertainty and anticipated negative outcomes were negatively associated with PAD performance. Education, guidelines, and colleague- and leadership support could create psychological safety and empower health personnel to perform PAD. Key factors for sustainable implementation of PAD were to facilitate the informant’s profound motivation for providing optimal health care and for reducing antimicrobial resistance. Informants were motivated by the prospect of a simplified PAD procedure.\u003cbr\u003e\n We identified three main needs for implementation of PAD: 1) creating psychological safety; 2) utilising clinicians’ inherent motivation and 3) optimal organisational structures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cbr\u003e\n A planned implementation of PAD must acknowledge clinicians’ need for psychological safety and aid reassurance through training, leadership, and guidelines. To implement PAD as an everyday practice it must be minimally disruptive and provide a contextually adaptive logistic chain. Also, the clinician’s motivation for providing the best possible healthcare should be utilised to aid implementation. The results of this study will aid sustainable implementation of PAD in Norway.\u003c/p\u003e","manuscriptTitle":"“What if the patient has a severe reaction, and it is my fault?” A qualitative study exploring factors for sustainable implementation of penicillin allergy delabelling.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 16:02:10","doi":"10.21203/rs.3.rs-4592154/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-24T12:48:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-18T22:44:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-18T22:43:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Antimicrobial Resistance \u0026 Infection Control","date":"2024-06-17T06:32:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55cd1d25-f156-4bd9-b6ba-87e69042373e","owner":[],"postedDate":"July 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:11:49+00:00","versionOfRecord":{"articleIdentity":"rs-4592154","link":"https://doi.org/10.1186/s13756-024-01456-8","journal":{"identity":"antimicrobial-resistance-and-infection-control","isVorOnly":false,"title":"Antimicrobial Resistance \u0026 Infection Control"},"publishedOn":"2024-09-02 15:57:11","publishedOnDateReadable":"September 2nd, 2024"},"versionCreatedAt":"2024-07-16 16:02:10","video":"","vorDoi":"10.1186/s13756-024-01456-8","vorDoiUrl":"https://doi.org/10.1186/s13756-024-01456-8","workflowStages":[]},"version":"v1","identity":"rs-4592154","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4592154","identity":"rs-4592154","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}