The role of hospital antimicrobial and infectious diseases pharmacists in the UK: a theoretically underpinned exploration

Abstract Objectives We sought to characterise the role of hospital infection pharmacists in the UK and to understand the core challenges being faced, future role development desires and the required support to address these. Methods We developed a questionnaire underpinned by the theoretical domains framework exploring the barriers and enablers to pharmacists fulfilling their perceived roles and responsibilities. Any pharmacist whose role included ‘specialist antimicrobial’ or ‘infectious diseases’ was invited to complete a questionnaire sent via national infection and pharmacy groups/networks. Descriptive statistics were used to report responses to each item, and a content analysis was undertaken to summarize the key messages from an extended response option. Results Of the 102 respondents, 91 (89.2%) were from English hospitals. Fifty-three (52%) were from district general hospitals and 45 (45.1%) from teaching hospitals. Most (97, 95%) respondents were of a senior grade. The need for a comprehensive educational programme, recognition of research as core to the role and integration with infection/microbiology departments were key requirements along with protected time to engage with the activities. Highlights of the role were opportunities to teach, making a significant contribution to patient care and scope to contribute to strategy and vision. The COVID-19 pandemic negatively impacted on respondents’ capacity to undertake their perceived roles and responsibilities. Conclusions Our study delineates the need for UK infection and pharmacy policy makers to review hospital infection pharmacist developmental pathways and roles. Joint learning, and closer working, with infection/microbiology departments may be an efficient strategy to address the issues raised.


Introduction
Antimicrobial resistance (AMR) represents a serious global threat and is now a leading cause of mortality globally. There were an estimated 4.95 million deaths globally associated with bacterial AMR in 2019. 1 A report conducted by the UK Review on AMR found that AMR could be responsible for the deaths of 10 million people globally by 2050. 2 Effective antimicrobial stewardship (AMS) strategies are paramount to curbing the spread of resistant microorganisms. 2 Since the COVID-19 pandemic commenced, a number of reports have highlighted an increase in antimicrobial prescribing. This trend may accelerate the development and dissemination of resistant strains, thereby counteracting AMS initiatives. [3][4][5] The WHO and public health guidance in a number of countries advocate for an antimicrobial pharmacist to facilitate the delivery of AMS strategies and their implementation. [6][7][8][9][10][11] Previous UK-based research has highlighted the role of the hospital infection pharmacist (HIP) as a key member of the AMS team to support and deliver AMS initiatives, thereby optimizing patient care. The HIP's intended role includes antimicrobial policy and guideline development, responding to complex infection-related clinical queries, monitoring antimicrobial consumption and acting as a link between microbiology and pharmacy departments. [12][13][14][15][16] However, the extent to which these activities are undertaken by HIPs in practice, and whether or not they have changed or expanded in view of the COVID-19 pandemic, is unclear.
We aimed to characterize the current role of UK HIPs and also sought to explore HIP goals for their future roles and development and the support they need to achieve them. We aimed to do this within the context of the current COVID-19 pandemic.

Methods
We undertook a cross-sectional questionnaire, underpinned by the theoretical domains framework (TDF), and invited all HIPs in the UK to respond. To develop the questionnaire, we used our combined experience, which consisted of HIPs (C.M., P.K., R.S. and N.T.), a consultant medical microbiologist (D.A.E.) and a behavioural scientist (S.S.) in addition to relevant literature [12][13][14][15][16][17] to adapt standard TDF domain questionnaire statements [18][19][20] to address the study aim.
To develop the questionnaire, we tried to characterize the role and activities of HIPs. Questionnaire items were underpinned by the TDF. Eleven questionnaire items had response options on a 5-point Likert scale, from strongly disagree to strongly agree, and an extended response option was provided for each.
The questionnaire was piloted with collaborators who were representative of the target audience, but did not participate in the study, to inform minor refinements and to establish face and content validity. The final questionnaire was hosted on Microsoft ® Forms, which also hosted study information, the consent form and a demographic data collection form.

Ethics and participant identification and recruitment
Research ethics approval was obtained from the University of East Anglia Faculty of Medicine and Health Research Ethics Committee. All UK pharmacists whose role includes specialist antimicrobial or infectious diseases were invited via infection networks and organizations, using their usual methods of communication with members, including newsletters, mailing lists and social media platforms. The questionnaire was available for respondents to complete from 1 February to 31 May 2021. Reminders were sent to those who did not respond to our initial e-mail.
Entry into a prize draw for a £50 shopping voucher was offered as an incentive to participate. Respondents could provide an e-mail address if they wanted to be in the prize draw. The winner was notified by e-mail and accepted the prize. Once this was completed, we removed all e-mail addresses prior to analysing the data so it was impossible to identify any individual respondent. The winner was selected via a random number generator and sent the prize electronically.

Data analysis
Descriptive statistics were used to report responses to questionnaire items with a Likert scale responses option, and median and IQRs were calculated for each. Content analysis was undertaken for extended response questions. One researcher (C.M.) coded extended response text inductively for barriers and enablers, which were then mapped to the relevant TDF domain(s). Mapping was checked by a behavioural scientist (S.S.) and any discrepancies resolved through a meeting and discussion. Referral to a second behavioural scientist external to the research team for adjudication was undertaken in the event of disagreement.

Results
The questionnaire was completed by 102 HIPs, and the majority (91, 89.2%) were from England. A total of 97 (95%) identified as senior pharmacists. Nine (8.8%) identified as consultant pharmacists. Just over half (53, 52%) were from district general hospitals, with the remainder from larger teaching and tertiary hospitals. Only 22 (21.6%) of respondents declared that they dedicated 81%-100% of a full-time role to infection-related duties; see Table S1 (available as Supplementary data at JAC-AMR Online). Table 1 provides summary responses to 5-point Likert questionnaire items. Over three-quarters (79.4%) agreed/strongly  agreed that pharmacists should integrate within microbiology/infectious disease departments, and a similar proportion (88%) agreed/strongly agreed that they would like access to current training for speciality registrars in infection/clinical scientists. Almost half (45.1%) disagreed/strongly disagreed that they were able to provide the level of service they wanted in their roles. Although the majority of respondents (68.6%) agreed/strongly agreed that research and development was an important part of their role, most (66, 61.8%) did not feel that they have enough support to undertake these activities. Analysis of the extended responses identified key barriers and enablers mapped to the TDF. TDF domains for knowledge, social/ professional role and emotion were mostly associated with enablers whereas environmental context and resources and social influence were associated with barriers. Table 2 maps each TDF domain to barriers and enablers linked to selected verbatim quotes.

Impact of COVID-19
We asked whether COVID-19 had impacted on the professional and personal lives. The main themes which emerged from the content analysis of this question highlighted the increase in workload to HIPs, especially the increased pharmacy (non-infectionrelated) duties. In addition, many felt that they were not able to perform their routine AMS duties. Some also mentioned the physical and mental impact the pandemic was having on their lives and on the ability to perform their duties.
A snapshot of responses is provided below (see Supplementary data for the full set of responses).

Discussion
To our knowledge, this is the first study that used TDF to explore HIP current roles and future development and training needs in the UK. TDF domains for knowledge, social professional role, goals and reinforcement largely comprised enablers. HIPs were keen to showcase the pharmacy role in AMS, enjoyed learning and teaching others and empowering healthcare professionals. HIPs had a direct impact on improving patient care and wanted to make a difference.
The main barriers were found in the social influence and environmental context and resources TDF domains. Lack of funding and time were the main barriers in the environmental context and resources domain, and lack of engagement from senior managers and conflicts between pharmacy and infection departments were the main barriers in the social influence domain.
HIPs stated that they were unable to deliver the AMS services they wished and felt that they needed more support from senior hospital leadership. Some felt that they did not have adequate training to conduct their role effectively and wanted access to specialist training accessible to medical/scientific colleagues. The COVID-19 pandemic impacted negatively on service delivery and wellbeing of our respondents. This is consistent with a Royal Pharmaceutical Society survey, which found that nearly 90% of pharmacists were at risk of burnout. 21 Interestingly, constant learning and teaching others was an enabler in the knowledge domain, but one of the barriers in environmental context and resources was that organizations do not provide sufficient opportunities to develop knowledge.
Limitations to the study include its UK bias; HIPs may have different roles and responsibilities across the world, which are not reflected here.

Conclusions
Our study has important implications for UK policy makers in the fields of infection and pharmacy. A comprehensive infectiontraining programme, which is already available to speciality registrars and clinical scientists, should be expanded to include infection pharmacists as a matter of priority. Hospital infection pharmacists need to be fully integrated within the wider multidisciplinary infection teams/departments, with clearly defined roles and responsibilities and not used to provide general pharmacy cover, as this greatly restricts the impact of their AMS activities, which in turn affects their ability to deliver on national AMR/ AMS targets and direct patient care. National UK AMR/AMS leads and senior pharmacy managers must work with hospital chief pharmacists and pharmacy leaders to review job descriptions to fully integrate an AMS practice-based research element. Further qualitative research on this topic is urgently warranted.