1
|
Singh S, Degeling C, Drury P, Montgomery A, Caputi P, Deane FP. Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities. Med Decis Making 2024; 44:415-425. [PMID: 38532728 PMCID: PMC11102643 DOI: 10.1177/0272989x241239871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 02/06/2024] [Indexed: 03/28/2024]
Abstract
HIGHLIGHTS The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.
Collapse
Affiliation(s)
- Saniya Singh
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, Wollongong NSW, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, Wollongong NSW, Australia
| | - Peta Drury
- School of Nursing, University of Wollongong, Wollongong NSW, Australia
| | - Amy Montgomery
- School of Nursing, University of Wollongong, Wollongong NSW, Australia
| | - Peter Caputi
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
| | - Frank P. Deane
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
| |
Collapse
|
2
|
Bigdeli S, Baradaran HR, Ghanavati S, Soltani Arabshahi SK. A qualitative approach to identify clinical uncertainty in practicing physicians and clinical residents. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2022; 11:278. [PMID: 36325214 PMCID: PMC9621374 DOI: 10.4103/jehp.jehp_14_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/21/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Clinical decision-making is not only stressful to physicians, but also to patients and even their companions. Thus, managing uncertainty in clinical decision-making is essential which requires knowing its origins. Therefore, this study aimed to understand determinants of uncertainty in clinical decision-making from the perspective of clinical physicians. MATERIALS AND METHODS This is a qualitative study which is done during October to November 2020. An in-depth interview is performed with 24 specialists of clinical groups including obstetrics, surgery, internal medicine, and pediatrics, working in teaching hospitals affiliated to Iran University of Medical Sciences. All the interviews were recorded, transcribed and analyzed according to the steps suggested by Graneheim and Lundman. The interviews were analyzed through comparative method. Then, the interviewer created initial codes, categories, and key concepts and sent them to fourteen physicians for member check. RESULTS According to the participants' view, determinants of uncertainty in clinical decision-making consisted of three themes: individual determinants, dynamics of medical sciences, and diagnostic and instrumental constraint. Individual determinants can be related to the physician or patient. The dynamics of medical sciences could be explained in two categories: variation of medical science and complexity. Diagnostic and instrumental constraint category could be also explained in subcategories such as lack of efficient diagnostic tests and unknown etiology. CONCLUSION To curb uncertainty, the more accessible way is considering interventional programs with a focus on individual determinants related to physicians, such as strengthening doctor-patient relationships, and considering related mandatory retraining courses to reduce insufficient knowledge of physicians.
Collapse
Affiliation(s)
- Shoaleh Bigdeli
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Baradaran
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shirin Ghanavati
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Kamran Soltani Arabshahi
- Center for Educational Research in Medical Sciences, Department of Medical Education, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
3
|
Hall J, Hawkins O, Montgomery A, Singh S, Mullan J, Degeling C. Dismantling antibiotic infrastructures in residential aged care: The invisible work of antimicrobial stewardship (AMS). Soc Sci Med 2022; 305:115094. [PMID: 35690033 DOI: 10.1016/j.socscimed.2022.115094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
Recent social science scholarship has sought to understand the visible and invisible impacts of how antibiotics are entrenched as infrastructures and put to work as a proxy for higher levels of care (clinical or otherwise) within modern healthcare. Using a qualitative research design, in this paper our aim is to draw attention to less visible aspects of antimicrobial stewardship (AMS) in residential aged care and their implications for nurse-led optimization of antibiotic use in these settings. By developing an account of the perceptions, experiences and practices of staff regarding the 'on the ground' work associated with implementing and upholding AMS objectives our study extends research on attempts to dismantle antibiotic infrastructures in Australian residential aged care facilities (RACF). Drawing on a review of relevant policies, empirical data is presented from fifty-six in-depth interviews conducted in 2021 with staff at 8 different RACFs. Interview participants included managers, nurses, and senior and junior personal care assistants. Our results suggest that registered nurses in residential aged care have been tasked with promoting antibiotic optimization and assigned with AMS responsibilities without sufficient authority and resourcing. A host of hidden care work associated with AMS strategies was evident, reinforcing some staff support for empirical antibiotic prescribing as a 'safety net' in uncertain clinical cases. We argue that this hidden work occurs where AMS strategies displace the infrastructural role previously performed by antibiotics, exposing structural gaps and pressures. The inability of organisational accounting systems and the broader AMS policy agenda to capture hidden AMS workflows in RACFs has consequences for future resourcing and organisational learning in ways that mean AMS gaps may remain unaddressed. These results support findings that AMS interventions might not be easily accepted by aged care staff in view of associated burdens which are under recognised and under supported in this domain.
Collapse
Affiliation(s)
- Julie Hall
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia
| | - Olivia Hawkins
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Saniya Singh
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia; School of Psychology, University of Wollongong, NSW, Australia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia; Centre for Health Research Illawarra Shoalhaven Population, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia.
| |
Collapse
|
4
|
Friedemann Smith C, Lunn H, Wong G, Nicholson BD. Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care. BMJ Qual Saf 2022; 31:541-554. [PMID: 35354664 PMCID: PMC9234415 DOI: 10.1136/bmjqs-2021-014529] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/19/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk. OBJECTIVE To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care. METHODS Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives. RESULTS 95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care. CONCLUSIONS We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.
Collapse
Affiliation(s)
| | | | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Cox CL, Miller BM, Kuhn I, Fritz Z. Diagnostic uncertainty in primary care: what is known about its communication, and what are the associated ethical issues? Fam Pract 2021; 38:654-668. [PMID: 33907806 PMCID: PMC8463813 DOI: 10.1093/fampra/cmab023] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Diagnostic uncertainty (DU) in primary care is ubiquitous, yet no review has specifically examined its communication, or the associated ethical issues. OBJECTIVES To identify what is known about the communication of DU in primary care and the associated ethical issues. METHODS Systematic review, critical interpretive synthesis and ethical analysis of primary research published worldwide. Medline, Embase, Web of Science and SCOPUS were searched for papers from 1988 to 2020 relating to primary care AND diagnostic uncertainty AND [ethics OR behaviours OR communication]. Critical interpretive synthesis and ethical analysis were applied to data extracted. RESULTS Sixteen papers met inclusion criteria. Although DU is inherent in primary care, its communication is often limited. Evidence on the effects of communicating DU to patients is mixed; research on patient perspectives of DU is lacking. The empirical literature is significantly limited by inconsistencies in how DU is defined and measured. No primary ethical analysis was identified; secondary analysis of the included papers identified ethical issues relating to maintaining patient autonomy in the face of clinical uncertainty, a gap in considering the direct effects of (not) communicating DU on patients, and considerations regarding over-investigation and justice. CONCLUSIONS This review highlights significant gaps in the literature: there is a need for explicit ethical and patient-centred empirical analyses on the effects of communicating DU, and research directly examining patient preferences for this communication. Consensus on how DU should be defined, and greater research into tools for its measurement, would help to strengthen the empirical evidence base.
Collapse
Affiliation(s)
- Caitríona L Cox
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Isla Kuhn
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Zoë Fritz
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
6
|
Moore A, McKelvie S, Glogowska M, Lasserson DS, Hayward G. Urgent assessment and ongoing care for infection in community-dwelling older people: a qualitative study of patient experience. BMJ Open 2021; 11:e043541. [PMID: 33737432 PMCID: PMC7978258 DOI: 10.1136/bmjopen-2020-043541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To explore the experience of infection from the perspective of community-dwelling older people, including access and preferences for place of care. DESIGN Qualitative interview study, carried out between March 2017 and August 2018. SETTING Ambulatory care units in Oxfordshire, UK. PARTICIPANTS Adults >70 years with a clinical diagnosis of infection. METHODS Semistructured interviews based on a flexible topic guide. Participants were given the option to be interviewed with their caregiver. Thematic analysis was facilitated by NVivo V.11. RESULTS Participants described encountering several barriers when accessing an urgent healthcare assessment which were hard to negotiate when they felt unwell. They valued home comforts and independence if they received care for their infection at home, though were worried about burdening their family. Most talked about hospital admission being a necessity in the context of more severe illness. Perceived advantages included monitoring, availability of treatments and investigations. However, some recognised that admission put them at risk of a hospital-acquired infection. Ambulatory care was felt to be convenient if local, but daily transport was challenging. CONCLUSIONS Providers may need to think about protocols and targeted advice that could improve access for older people to urgent healthcare when they feel unwell. General practitioners making decisions about place of care may need to better communicate risks associated with the available options and think about balancing convenience with facilities for care.
Collapse
Affiliation(s)
- Abigail Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara McKelvie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
7
|
Patel M, Lee SI, Levell NJ, Smart P, Kai J, Thomas KS, Leighton P. An interview study to determine the experiences of cellulitis diagnosis amongst health care professionals in the UK. BMJ Open 2020; 10:e034692. [PMID: 33055110 PMCID: PMC7559118 DOI: 10.1136/bmjopen-2019-034692] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To explore healthcare professionals (HCPs) experiences and challenges in diagnosing suspected lower limb cellulitis. SETTING UK nationwide. PARTICIPANTS 20 qualified HCPs, who had a minimum of 2 years clinical experience as an HCP in the national health service and had managed a clinical case of suspected cellulitis of the lower limb in the UK. HCPs were recruited from departments of dermatology (including a specialist cellulitis clinic), general practice, tissue viability, lymphoedema services, general surgery, emergency care and acute medicine. Purposive sampling was employed to ensure that participants included consultant doctors, trainee doctors and nurses across the specialties listed above. Participants were recruited through national networks, HCPs who contributed to the cellulitis priority setting partnership, UK Dermatology Clinical Trials Network, snowball sampling where participants helped recruit other participants and personal networks of the authors. PRIMARY AND SECONDARY OUTCOMES Primary outcome was to describe the key clinical features which inform the diagnosis of lower limb cellulitis. Secondary outcome was to explore the difficulties in making a diagnosis of lower limb cellulitis. RESULTS The presentation of lower limb cellulitis changes as the episode runs its course. Therefore, different specialties see clinical features at varying stages of cellulitis. Clinical experience is essential to being confident in making a diagnosis, but even among experienced HCPs, there were differences in the clinical rationale of diagnosis. A group of core clinical features were suggested, many of which overlapped with alternative diagnoses. This emphasises how the diagnosis is challenging, with objective aids and a greater understanding of the mimics of cellulitis required. CONCLUSION Cellulitis is a complex diagnosis and has a variable clinical presentation at different stages. Although cellulitis is a common diagnosis to make, HCPs need to be mindful of alternative diagnoses.
Collapse
Affiliation(s)
- Mitesh Patel
- Division of Primary Care & National Institute for Health Research, School of Medicine, University of Nottingham, Nottingham, UK
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Siang Ing Lee
- Division of Primary Care & National Institute for Health Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nick J Levell
- Dermatology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Peter Smart
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joe Kai
- Division of Primary Care & National Institute for Health Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Paul Leighton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| |
Collapse
|
8
|
Infection in older adults: a qualitative study of patient experience. Br J Gen Pract 2020; 70:e312-e321. [PMID: 32253191 DOI: 10.3399/bjgp20x709397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/25/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Infection is common in older adults. Serious infection has a high mortality rate and is associated with unplanned hospital admissions. Little is known about the factors that prompt older patients to seek medical advice when they may have an infection. AIM To explore the symptoms of infection from the perspective of older adults, and when and why older patients seek healthcare advice for a possible infection. DESIGN AND SETTING A qualitative interview study among adults aged ≥70 years with a clinical diagnosis of infection recruited from ambulatory care units in Oxford, UK. METHOD Interviews were semi-structured and based on a flexible topic guide. Participants were given the option to be interviewed with their carer. Thematic analysis was facilitated using NVivo (version 11). RESULTS A total of 28 participants (22 patients and six carers) took part. Patients (aged 70-92 years) had experienced a range of different infections. Several early non-specific symptoms were described (fever, feeling unwell, lethargy, vomiting, pain, and confusion/delirium). Internally minimising symptoms was common and participants with historical experience of infection tended to be better able to interpret their symptoms. Factors influencing seeking healthcare advice included prompts from family, specific or intolerable symptoms, symptom duration, and being unable to manage with self-care. For some, not wanting to be a burden affected their desire to seek help. CONCLUSION Tailored advice to older adults highlighting early symptoms of infection may be beneficial. Knowing whether patients have had previous experience of infection may help healthcare professionals in assessing older patients with possible infection.
Collapse
|