{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T03:58:09Z","timestamp":1793159889641,"version":"4.5.0"},"reference-count":78,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2026,1,23]],"date-time":"2026-01-23T00:00:00Z","timestamp":1769126400000},"content-version":"unspecified","delay-in-days":22,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"HEE\/NIHR","award":["ICACDRF-2018-04-ST2-019"],"award-info":[{"award-number":["ICACDRF-2018-04-ST2-019"]}]},{"name":"NIHR Applied Research Collaboration Southwest Peninsula"},{"name":"NIHR Exeter Biomedical Research Centre"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,12,31]]},"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>There is an urgent need to improve surgical antimicrobial stewardship (AMS), to enhance individual care and reduce population-level antimicrobial resistance, but it is a complex issue.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>We aimed to conduct an ethnographic study asking what would work in practice to improve surgical antibiotic prescribing behaviour?<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Adopting a socio-cultural-historical perspective, we undertook ethnographic observations of clinical practice (43.5\u2009hours) and semistructured interviews (n=31) with surgical staff, AMS staff and patients at two English National Health Service hospitals. Interview transcripts and observational fieldnotes were analysed using the Framework Approach. Additionally, we integrated stakeholder engagement throughout to ensure the findings were meaningful.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Our analysis of all fieldnotes (based on 43.5\u2009hours of observation) and interview transcripts (n=31 from interviews with 31 different participants) identified that, while surgical staff were aware of antimicrobial resistance, they seldom considered AMS urgent or important in the acute setting where lack of time and the desire to mitigate perceived risk often prevailed. Other\n                      <jats:italic>surgical<\/jats:italic>\n                      issues were perceived to dominate senior decision-makers\u2019 focus, thus perpetuating the status quo. Furthermore, attention to AMS was not always prioritised at the organisational level or by resource-limited AMS teams. Consequently, there was an absence of relationships and tools that foreground AMS. Electronic prescribing systems frequently hindered antimicrobial review and exacerbated patterns of siloed inter-disciplinary working, and feedback on antimicrobial prescribing and patient outcomes was largely absent. To improve AMS, surgical teams wanted sustainable improvements which effectively account for the hierarchical relationships, division of labour, rapid workflow and high staff turnover. Infection experts should better integrate into surgical teams to build relationships and trust, and to proactively contribute to patient care.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>We offer data-driven, theoretically informed strategies to support change. Contextually appropriate improvements that address the status and visibility of AMS in surgery will be key. Further research is needed to assess the impact and sustainability of the suggested approaches.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-112333","type":"journal-article","created":{"date-parts":[[2026,1,23]],"date-time":"2026-01-23T13:25:13Z","timestamp":1769174713000},"page":"e112333","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Strategies to improve antimicrobial stewardship in surgery: insights from an ethnographic study"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8569-5718","authenticated-orcid":false,"given":"Hazel","family":"Parker","sequence":"first","affiliation":[{"name":"Pharmacy Department, Royal Devon University Healthcare NHS Foundation Trust, Exeter, England, UK"},{"name":"Health and Community Sciences, University of Exeter, Exeter, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5164-3036","authenticated-orcid":false,"given":"Jo","family":"Day","sequence":"additional","affiliation":[{"name":"Health and Community Sciences, University of Exeter, Exeter, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3503-5911","authenticated-orcid":false,"given":"Julia","family":"Frost","sequence":"additional","affiliation":[{"name":"Health and Community Sciences, University of Exeter, Exeter, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1855-0639","authenticated-orcid":false,"given":"Rob","family":"Bethune","sequence":"additional","affiliation":[{"name":"Colorectal Surgery, Royal Devon University Healthcare NHS Foundation Trust, Exeter, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marianne","family":"Hollyman","sequence":"additional","affiliation":[{"name":"Upper GI Surgery, Somerset NHS Foundation Trust, Taunton, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kieran","family":"Hand","sequence":"additional","affiliation":[{"name":"Medical Directorate, NHS England, London, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anu","family":"Kajamaa","sequence":"additional","affiliation":[{"name":"Faculty of Education, University of Oulu, Oulu, Northern Ostrobothnia, Finland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen","family":"Mattick","sequence":"additional","affiliation":[{"name":"Health and Community Sciences, University of Exeter, Exeter, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,1,23]]},"reference":[{"key":"2026012305250882000_16.1.e112333.1","unstructured":"Institute for Health Metrics and Evaluation . \u201cThe burden of antimicrobial resistance (AMR) in United Kingdom\u201d 2023. pdf (viewed on 5 July 2025), 2023. Available: https:\/\/www.healthdata.org\/sites\/default\/files\/2023-09\/United_Kingdom"},{"key":"2026012305250882000_16.1.e112333.2","unstructured":"UK Govenment . Confronting antimicrobial resistance 2024 to 2029. 2024."},{"key":"2026012305250882000_16.1.e112333.3","unstructured":"HM Govenment . Contained and controlled The UK\u2019s 20-year vision for antimicrobial resistance, 2019. Available: https:\/\/assets.publishing.service.gov.uk\/media\/5c48896a40f0b616fe901e91\/uk-20-year-vision-for-antimicrobial-resistance.pdf [Accessed 23 Jul 2025]."},{"key":"2026012305250882000_16.1.e112333.4","unstructured":"Govenment H . National risk register 2025 edition. 2025. Available: https:\/\/assets.publishing.service.gov.uk\/media\/67b5f85732b2aab18314bbe4\/National_Risk_Register_2025.pdf"},{"key":"2026012305250882000_16.1.e112333.5","doi-asserted-by":"publisher","DOI":"10.1016\/j.cmi.2017.08.026"},{"key":"2026012305250882000_16.1.e112333.6","unstructured":"HMGovernment . Tackling antimicrobial resistance 2019\u20132024. the UK\u2019s five-year national action plan. In: Global and Public Health Group EPaHPPD. 2019."},{"key":"2026012305250882000_16.1.e112333.7","unstructured":"UK Health Security Agency . Start smart then focus: antimicrobial stewardship toolkit for inpatient care settings, 2023. Available: https:\/\/www.gov.uk\/government\/publications\/antimicrobial-stewardship-start-smart-then-focus\/start-smart-then-focus-antimicrobial-stewardship-toolkit-for-inpatient-care-settings [Accessed 9 Jul 2025]."},{"key":"2026012305250882000_16.1.e112333.8","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/ciw118"},{"key":"2026012305250882000_16.1.e112333.9","unstructured":"Scottish Antimicrobial Prescribing Group (SAPG) . Good Practice Recommendations for antimicrobial management teams on hospital antimicrobial stewardship in NHS Scotland, 2022. Available: https:\/\/www.sapg.scot\/media\/4104\/20220614-gprs-for-hospital-antimicrobial-stewardship.pdf [Accessed 9 Jul 2025]."},{"key":"2026012305250882000_16.1.e112333.10","unstructured":"Australian Commission on Safety and Quality in Health Care . Antimicrobial Stewardship Clinical Care Standard, 2020. Available: https:\/\/www.safetyandquality.gov.au\/sites\/default\/files\/2020-11\/saq10001_ccs_antimicrobial_v4_film_web.pdf [Accessed 9 Jul 2025]."},{"key":"2026012305250882000_16.1.e112333.11","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dkt241"},{"key":"2026012305250882000_16.1.e112333.12","unstructured":"(UKHSA) UHSA . English surveillance programme for antimicrobial utilisation and resistance (espaur) report 2022 to 2023. UKHSA; 2022."},{"key":"2026012305250882000_16.1.e112333.13","unstructured":"Darzi A . Independent Investigation of the National Health Service in England, 2024. Available: https:\/\/assets.publishing.service.gov.uk\/media\/66f42ae630536cb92748271f\/Lord-Darzi-Independent-Investigation-of-the-National-Health-Service-in-England-Updated-25-September.pdf"},{"key":"2026012305250882000_16.1.e112333.14","unstructured":"UK Health Security Agency . Point prevalence survey on healthcareassociated infections, antimicrobial use and antimicrobial stewardship in England, 2023. Available: https:\/\/assets.publishing.service.gov.uk\/media\/6827325d010c5c28d1c7e728\/HCAI-AMU-PPS-2023-report.pdf [Accessed 9 Jul 2025]."},{"key":"2026012305250882000_16.1.e112333.15","unstructured":"European Centre for Disease Prevention and Control . Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals 2022\u20132023, 2024. Available: https:\/\/www.ecdc.europa.eu\/sites\/default\/files\/documents\/healthcare-associated-point-prevalence-survey-acute-care-hospitals-2022-2023.pdf [Accessed 26 Jul 2025]."},{"key":"2026012305250882000_16.1.e112333.16","doi-asserted-by":"crossref","DOI":"10.1186\/s13756-019-0603-6","article-title":"Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study","volume":"8","author":"Charani","year":"2019","journal-title":"Antimicrob Resist Infect Control"},{"key":"2026012305250882000_16.1.e112333.17","article-title":"Tailored interventions to address determinants of practice","volume":"2015","author":"Baker","year":"2015","journal-title":"Cochrane Database Syst Rev"},{"key":"2026012305250882000_16.1.e112333.18","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dkx194"},{"key":"2026012305250882000_16.1.e112333.19","doi-asserted-by":"crossref","DOI":"10.3389\/fsoc.2020.00005","article-title":"Finding \u201cWhat\u2019s Wrong With Us\u201d: Antibiotic Prescribing Practice Among Physicians in the United States","volume":"5","author":"Rynkiewich","year":"2020","journal-title":"Front Sociol"},{"key":"2026012305250882000_16.1.e112333.20","doi-asserted-by":"crossref","first-page":"2394","DOI":"10.1093\/jac\/dkaa154","article-title":"The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review","volume":"75","author":"Talkhan","year":"2020","journal-title":"J Antimicrob Chemother"},{"key":"2026012305250882000_16.1.e112333.21","article-title":"Interventions to improve antibiotic prescribing practices for hospital inpatients","volume":"2","author":"Davey","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"2026012305250882000_16.1.e112333.22","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0209847","article-title":"Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries-A qualitative study","volume":"14","author":"Charani","year":"2019","journal-title":"PLoS ONE"},{"key":"2026012305250882000_16.1.e112333.23","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2020-012372"},{"key":"2026012305250882000_16.1.e112333.24","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1007\/s15010-018-1156-y","article-title":"Improvisation versus guideline concordance in surgical antibiotic prophylaxis: a qualitative study","volume":"46","author":"Broom","year":"2018","journal-title":"Infection"},{"key":"2026012305250882000_16.1.e112333.25","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1016\/j.ajic.2017.09.004","article-title":"How do professional relationships influence surgical antibiotic prophylaxis decision making? A qualitative study","volume":"46","author":"Broom","year":"2018","journal-title":"Am J Infect Control"},{"key":"2026012305250882000_16.1.e112333.26","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1016\/j.cmi.2017.03.013","article-title":"Understanding antibiotic decision making in surgery-a qualitative analysis","volume":"23","author":"Charani","year":"2017","journal-title":"Clin Microbiol Infect"},{"key":"2026012305250882000_16.1.e112333.27","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0225011","article-title":"Influences on surgical antimicrobial prophylaxis decision making by surgical craft groups, anaesthetists, pharmacists and nurses in public and private hospitals","volume":"14","author":"Ierano","year":"2019","journal-title":"PLoS ONE"},{"key":"2026012305250882000_16.1.e112333.28","doi-asserted-by":"crossref","first-page":"645","DOI":"10.1017\/ice.2020.48","article-title":"Perioperative antimicrobial decision making: Focused ethnography study in orthopedic and cardiothoracic surgeries in an Australian hospital","volume":"41","author":"Peel","year":"2020","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2026012305250882000_16.1.e112333.29","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1017\/ice.2020.71","article-title":"Understanding antibiotic prophylaxis prescribing in pediatric surgical specialties","volume":"41","author":"Malone","year":"2020","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2026012305250882000_16.1.e112333.30","doi-asserted-by":"crossref","first-page":"1455","DOI":"10.1016\/j.cmi.2020.12.013","article-title":"Investigating infection management and antimicrobial stewardship in surgery: a qualitative study from India and South Africa","volume":"27","author":"Singh","year":"2021","journal-title":"Clin Microbiol Infect"},{"key":"2026012305250882000_16.1.e112333.31","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1089\/sur.2020.181","article-title":"Qualitative Thematic Analysis of Knowledge and Practices of Surgical Antimicrobial Prophylaxis at a Tertiary Care Teaching Hospital","volume":"22","author":"Khan","year":"2021","journal-title":"Surg Infect (Larchmt)"},{"key":"2026012305250882000_16.1.e112333.32","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-046685","article-title":"Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals","volume":"11","author":"Broom","year":"2021","journal-title":"BMJ Open"},{"key":"2026012305250882000_16.1.e112333.33","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhin.2019.09.002"},{"key":"2026012305250882000_16.1.e112333.34","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/ciy844"},{"key":"2026012305250882000_16.1.e112333.35","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1111\/ans.14414","article-title":"Addressing social influences reduces antibiotic duration in complicated abdominal infection: a mixed methods study","volume":"89","author":"Broom","year":"2019","journal-title":"ANZ J Surg"},{"key":"2026012305250882000_16.1.e112333.36","doi-asserted-by":"crossref","DOI":"10.1186\/s12887-016-0739-y","article-title":"Surgical antibiotic prophylaxis in children: a mixed method study on healthcare professionals attitudes","volume":"16","author":"Giusti","year":"2016","journal-title":"BMC Pediatr"},{"key":"2026012305250882000_16.1.e112333.37","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0271454","article-title":"Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings","volume":"17","author":"Parker","year":"2022","journal-title":"PLoS One"},{"key":"2026012305250882000_16.1.e112333.38","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2014-003627"},{"key":"2026012305250882000_16.1.e112333.39","doi-asserted-by":"crossref","unstructured":"Hammersley M , Atkinson P . Ethnography Principles and Practice 4th ed. London and New York: Routledge, 2019.","DOI":"10.4324\/9781315146027"},{"key":"2026012305250882000_16.1.e112333.40","doi-asserted-by":"crossref","unstructured":"Emerson R , Fretz R , Shaw L . Writing Ethnogaphic Fieldnotes 2nd ed. The University of Chicago Press, 2011.","DOI":"10.7208\/chicago\/9780226206868.001.0001"},{"key":"2026012305250882000_16.1.e112333.41","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.321.7273.1400"},{"key":"2026012305250882000_16.1.e112333.42","doi-asserted-by":"crossref","DOI":"10.1093\/jacamr\/dlab150","article-title":"Understanding antibiotic use: practices, structures and networks","volume":"3","author":"Tompson","year":"2021","journal-title":"JAC Antimicrob Resist"},{"key":"2026012305250882000_16.1.e112333.43","doi-asserted-by":"crossref","DOI":"10.1111\/tct.70005","article-title":"How to Approach Qualitative Observational Research in Workplace Learning","volume":"22","author":"Noble","year":"2025","journal-title":"Clin Teach"},{"key":"2026012305250882000_16.1.e112333.44","doi-asserted-by":"crossref","DOI":"10.1177\/2633489521992743","article-title":"A scoping review of the use of ethnographic approaches in implementation research and recommendations for reporting","volume":"2","author":"Gertner","year":"2021","journal-title":"Implement Res Pract"},{"key":"2026012305250882000_16.1.e112333.45","doi-asserted-by":"publisher","DOI":"10.1177\/1049732315617444"},{"key":"2026012305250882000_16.1.e112333.46","unstructured":"Green J , Thorogood N . Qualitative methods for health research . 4th edn. 1 Oliver\u2019s Yard, 55 City Road London EC1Y 1SP United States, Available: https:\/\/sk.sagepub.com\/book\/mono\/qualitative-methods-for-health-research-4e\/toc"},{"key":"2026012305250882000_16.1.e112333.47","doi-asserted-by":"publisher","DOI":"10.1177\/1049732302250723"},{"key":"2026012305250882000_16.1.e112333.48","unstructured":"Johnson J . Selecting Ethnographic Informants. Sage Publications, 1990."},{"key":"2026012305250882000_16.1.e112333.49","doi-asserted-by":"crossref","DOI":"10.1186\/s13012-022-01245-0","article-title":"The updated Consolidated Framework for Implementation Research based on user feedback","volume":"17","author":"Damschroder","year":"2022","journal-title":"Implement Sci"},{"key":"2026012305250882000_16.1.e112333.50","unstructured":"Ritchie J , Spencer L . Qualitative Data Analysis for Applied Policy Research. Anylizing Qualitative Data: Routledge, 1994."},{"key":"2026012305250882000_16.1.e112333.51","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.a949","article-title":"Why use theories in qualitative research?","volume":"337","author":"Reeves","year":"2008","journal-title":"BMJ"},{"key":"2026012305250882000_16.1.e112333.52","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-6-42"},{"key":"2026012305250882000_16.1.e112333.53","doi-asserted-by":"crossref","unstructured":"Johnson and Dornan . Activity theory: mediating research in medical education. In: Researching medical education. Chichester: Wiley Blackwell, 2015: 93\u2013103.","DOI":"10.1002\/9781118838983.ch9"},{"key":"2026012305250882000_16.1.e112333.54","unstructured":"NVivo (version 14) [computer software] [program]. 2023. Available: https:\/\/lumivero.com\/products\/nvivo"},{"key":"2026012305250882000_16.1.e112333.55","unstructured":"Redmond, WA: Microsoft Corporation . Microsoft excel for microsoft 365 [computer program]. 2023."},{"key":"2026012305250882000_16.1.e112333.56","doi-asserted-by":"crossref","unstructured":"Eakin JM , Gladstone B . \u201cValue-adding\u201d Analysis: Doing More With Qualitative Data. Int J Qual Methods 2020;19. doi:10.1177\/1609406920949333","DOI":"10.1177\/1609406920949333"},{"key":"2026012305250882000_16.1.e112333.57","doi-asserted-by":"crossref","unstructured":"Kotter J . Leading Change. Harvard Business Review Press, 2012:208.","DOI":"10.15358\/9783800646159"},{"key":"2026012305250882000_16.1.e112333.58","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2019-001590","article-title":"Quick fix for care, productivity, hygiene and inequality: reframing the entrenched problem of antibiotic overuse","volume":"4","author":"Denyer Willis","year":"2019","journal-title":"BMJ Glob Health"},{"key":"2026012305250882000_16.1.e112333.59","doi-asserted-by":"crossref","unstructured":"Pearson M , Chandler C . Knowing antimicrobial resistance in practice: a multi-country qualitative study with human and animal healthcare professionals. Glob Health Action 2019;12. doi:10.1080\/16549716.2019.1599560","DOI":"10.1080\/16549716.2019.1599560"},{"key":"2026012305250882000_16.1.e112333.60","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1080\/13698575.2024.2345614","article-title":"Risk individualisation and moral injury in the treatment of infection as impediments to the tackling of antimicrobial resistance","volume":"26","author":"Davis","year":"2024","journal-title":"Health Risk Soc"},{"key":"2026012305250882000_16.1.e112333.61","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhin.2016.03.011"},{"key":"2026012305250882000_16.1.e112333.62","doi-asserted-by":"crossref","first-page":"1152","DOI":"10.1111\/bcp.16001","article-title":"A tale of 2 digital hospitals: A qualitative study of antimicrobial stewardship teams","volume":"90","author":"Van Dort","year":"2024","journal-title":"Br J Clin Pharmacol"},{"key":"2026012305250882000_16.1.e112333.63","doi-asserted-by":"publisher","DOI":"10.1136\/ejhpharm-2020-002540"},{"key":"2026012305250882000_16.1.e112333.64","unstructured":"Awad F , Fine N , Phillips J , et al . A Regional MDT Service for the Management of Infected Native and Total Knee Replacements: Development and Results of an Established Service. Leicester: BASK, 2018."},{"key":"2026012305250882000_16.1.e112333.65","doi-asserted-by":"crossref","first-page":"106419","DOI":"10.1016\/j.jinf.2025.106419","article-title":"The impact of antimicrobial stewardship ward rounds on antimicrobial use and predictors of advice, uptake, and outcomes","volume":"90","author":"Eyre","year":"2025","journal-title":"Journal of Infection"},{"key":"2026012305250882000_16.1.e112333.66","doi-asserted-by":"crossref","DOI":"10.1016\/j.bas.2022.100885","article-title":"Multidisciplinary neurosurgical rounds incorporating antimicrobial stewardship. Are they of benefit?","volume":"2","author":"Creedon","year":"2022","journal-title":"Brain Spine"},{"key":"2026012305250882000_16.1.e112333.67","unstructured":"Greenhalgh T . How to Implement Evidence-Based Healthcare. 1st edn. Wiley-Blackwell. 2017:282."},{"key":"2026012305250882000_16.1.e112333.68","doi-asserted-by":"crossref","DOI":"10.1093\/jacamr\/dlae039","article-title":"Quality, availability and suitability of antimicrobial stewardship guidance: a multinational qualitative study","volume":"6","author":"Linde-Ozola","year":"2024","journal-title":"JAC Antimicrob Resist"},{"key":"2026012305250882000_16.1.e112333.69","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1111\/bcp.12953","article-title":"The determinants of antimicrobial prescribing among hospital doctors in England: a framework to inform tailored stewardship interventions","volume":"82","author":"Parker","year":"2016","journal-title":"Br J Clin Pharmacol"},{"key":"2026012305250882000_16.1.e112333.70","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2017-006631"},{"key":"2026012305250882000_16.1.e112333.71","unstructured":"Thaler R , Sunstein C . Nudge Improving Decisions about Health, Wealth and Happiness. London: Penguin Books, 2009."},{"key":"2026012305250882000_16.1.e112333.72","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/S1473-3099(22)00508-4","article-title":"Antibiotic review kit for hospitals (ARK-Hospital): a stepped-wedge cluster-randomised controlled trial","volume":"23","author":"Llewelyn","year":"2023","journal-title":"Lancet Infect Dis"},{"key":"2026012305250882000_16.1.e112333.73","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2020-012479"},{"key":"2026012305250882000_16.1.e112333.74","doi-asserted-by":"publisher","DOI":"10.1007\/s12160-013-9486-6"},{"key":"2026012305250882000_16.1.e112333.75","unstructured":"Schein EH aSP . Humble Leadership The Power of Relationships, Openness and Trust. 2nd edn. Berrett-Koehler Publishers Inc, 2023."},{"key":"2026012305250882000_16.1.e112333.76","doi-asserted-by":"crossref","first-page":"i43","DOI":"10.1136\/bmjqs.2010.046482","article-title":"Beyond evidence: the micropolitics of improvement","volume":"20 Suppl 1","author":"Langley","year":"2011","journal-title":"BMJ Qual Saf"},{"key":"2026012305250882000_16.1.e112333.77","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1111\/medu.14348","article-title":"The applicability of generalisability and bias to health professions education\u2019s research","volume":"55","author":"Varpio","year":"2021","journal-title":"Med Educ"},{"key":"2026012305250882000_16.1.e112333.78","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1007\/S40037-018-0412-2","article-title":"Ethical dilemmas and reflexivity in qualitative research","volume":"7","author":"Reid","year":"2018","journal-title":"Perspect Med Educ"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-112333","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,23]],"date-time":"2026-01-23T13:25:28Z","timestamp":1769174728000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-112333"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":78,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1,23]]},"published-print":{"date-parts":[[2026,1]]}},"alternative-id":["10.1136\/bmjopen-2025-112333"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-112333","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1]]}}}