Decisional issues in antibiotic prescribing in French nursing homes: An ethnographic study

Preventing urinary tract infection in older people living in care homes: the 'StOP UTI' realist synthesis

BACKGROUND

Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes.

OBJECTIVE

To identify interventions for recognising and preventing UTI in older people living in care homes in the UK and explain the mechanisms by which they work, for whom and under what circumstances.

METHODS

A realist synthesis of evidence was undertaken to develop programme theory underlying strategies to recognise and prevent UTI. A generic topic-based search of bibliographic databases was completed with further purposive searches to test and refine the programme theory in consultation with stakeholders.

RESULTS

56 articles were included in the review. Nine context-mechanism-outcome configurations were developed and arranged across three theory areas: (1) Strategies to support accurate recognition of UTI, (2) care strategies for residents to prevent UTI and (3) making best practice happen. Our programme theory explains how care staff can be enabled to recognise and prevent UTI when this is incorporated into care routines and activities that meet the fundamental care needs and preferences of residents. This is facilitated through active and visible leadership by care home managers and education that is contextualised to the work and role of care staff.

CONCLUSIONS

Care home staff have a vital role in preventing and recognising UTI in care home residents.Incorporating this into the fundamental care they provide can help them to adopt a proactive approach to preventing infection and avoiding unnecessary antibiotic use. This requires a context of care with a culture of personalisation and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to support preventative action by knowledgeable care staff.

Nursing home nurses' opinions on the potential evolution of their role in antibiotic stewardship: A French national cross-sectional survey

AIMS

To assess French nursing home nurses' opinions on the potential evolution of their antibiotic stewardship role, facilitators and barriers, and nurses' characteristics associated with their opinion toward new roles regarding antibiotic prescribing.

DESIGN

We conducted a cross-sectional study in French nursing homes with ≥20 beds and for which an email address was available in a national database managed by the French government between May and June 2022.

METHODS

A self-administered internet-based questionnaire of 43 closed-ended Likert items was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Data analysis included descriptive statistics and χ2 tests.

RESULTS

7215 nursing homes were sent the online questionnaire; 1090 participants completed it partially or totally and 923 fully filled in the questionnaire. A majority of nurses supported strengthening and expanding their antibiotic stewardship role. Regarding new roles, over 70% agreed that nurses could collect urine samples to perform a urine culture on their own initiative, prescribe microbiological laboratory tests, and change the drug formulation or the administration route of the antibiotic prescribed by the general practitioner. One-third declared that they could initiate antibiotics for some infections and/or change the empirical antibiotic treatment prescribed by the general practitioner. Nurses from public nursing homes with connection to a hospital (27.5% vs. >35% for other status) and with recent experience in nursing homes (31% for <5 years of practice vs. 41% for 10 years or more) were less likely to agree to prescribe antibiotics.

CONCLUSIONS

This quantitative questionnaire survey identified potential new nurses' roles in antibiotic stewardship that seem to be acceptable and feasible for participants. These new nurses' roles need to be explored in future experimentations before considering implementation.

REPORTING METHOD

The study adhered to relevant EQUATOR guidelines and followed the STROBE reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

A self-administered internet-based questionnaire was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Nurses and head nurses who were interested and willing could complete the questionnaire online partially or fully.

TRIAL AND PROTOCOL REGISTRATION

This study is not a clinical trial and is not eligible for trial registration. We used another suitable study registration site, the Center for Open Science.

Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities

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.

What influences antibiotic initiation? Developing a scale to measure nursing behaviour in residential aged-care facilities

AIM

The purpose of the current study was to develop and assess the psychometric properties of a measure that captures nursing behaviours that have the potential to influence the initiation of antibiotics in residential aged-care facilities.

DESIGN

Cross-sectional online survey.

METHOD

One hundred and fifty-seven nurses completed an online survey. The survey consisted of two clinical vignettes and measures of tolerance of uncertainty and anxiety. The vignettes consisted of the most common presentations (urinary tract infections and upper respiratory tract infections) of two hypothetical residents in aged-care facilities. The vignettes provided participants with incremental information with varying levels of symptoms, input from other people and availability of test results. Both vignettes were subjected to exploratory factor analysis.

RESULTS

The results focus on the 16 items in the second vignette which resulted in the extraction of three factors. The derived factors were labelled as follows: (i) Noting and Calling GP, (ii) Consult a Colleague and (iii) Immediate Assessment and Antibiotics. Reliability analysis revealed excellent to satisfactory reliability. All three scales were significantly correlated with measures of clinical tolerance of uncertainty, and the 'noting and calling GP' scale was also negatively correlated with measures of anxiety and general tolerance of uncertainty. The measure showed satisfactory reliability and validity for capturing nursing behaviours that have the potential to influence decisions regarding antibiotics. As such, the current study provides a first step towards addressing the lack of ecologically valid measures that capture the complex and nuanced context of nurses' behaviours in RACF that have the potential to inform future stewardship interventions.

A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses' activities in daily practice regarding antibiotic use

Background

Antimicrobial stewardship (AMS), the set of actions to ensure antibiotics are used appropriately, is increasingly targeted at all those involved in the antimicrobial pathway, including nurses. Several healthcare organizations have issued position statements on how bedside nurses can be involved in AMS. However, it remains unclear how nurses, in reality, contribute to appropriate antibiotic use.

Objectives

To systematically search the literature to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, in relation to the activities proposed by the aforementioned position statements.

Methods

We searched MEDLINE, Embase, CINAHL and grey literature until March 2021. Studies were included if they described activities regarding antibiotic use performed by bedside nurses. Methodological rigour was assessed by applying the Mixed Method Appraisal Tool.

Results

A total of 118 studies were included. The majority of the proposed nurses' activities were found in daily practice, categorized into assessment of clinical status, collection of specimens, management of antimicrobial medication, prompting review and educating patient and relatives. Nurses may take the lead in these clinical processes and are communicators in all aspects of the antimicrobial pathway. Patient advocacy appears to be a strong driver of bedside nurses' activities.

Conclusions

Nurses' activities are already integrated in the day-to-day nursing practice and are grounded in the essence of nursing, being a patient advocate and showing nursing leadership in safeguarding the antimicrobial treatment process. An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial pathway. Educating, engaging and empowering nurses in this already integrated role, could lead to a solid, impactful nursing contribution to AMS.

Misconceptions and Knowledge Gaps on Antibiotic Use and Resistance in Four Healthcare Settings and Five European Countries-A Modified Delphi Study

Misconceptions and knowledge gaps about antibiotics contribute to inappropriate antibiotic use and antimicrobial resistance. This study aimed to identify and prioritize misconceptions and knowledge gaps about antibiotic use from a healthcare professionals' perspective. A modified Delphi study with a predefined list of statements, two questionnaire rounds, and an expert meeting was conducted. The statements were rated by healthcare professionals from France, Greece, Lithuania, Poland, and Spain, and from general practice, out-of-hour services, nursing homes, and pharmacies. A total of 44 pre-defined statements covered the following themes: (1) antimicrobial resistance in general, (2) use of antibiotics in general, (3) use of antibiotics for respiratory tract infections, and (4) use of antibiotics for urinary tract infections. Consensus was defined as ≥80% agreement between the professionals during the second Delphi round. For 30% of the statements, professionals from the four settings together reached consensus. In each setting individually, at least 50% of the statements reached consensus, indicating that there are still many misconceptions and knowledge gaps that need to be addressed. Six educational tools (leaflets, posters, checklists) were developed to address the knowledge gaps and misconceptions. These can be used by patients and healthcare professionals to improve the use of antibiotics in practice.

How do aged-care staff feel about antimicrobial stewardship? A systematic review of staff attitudes in long-term residential aged-care

Background

Antimicrobial resistance (AMR) is a problem in residential aged care facilities (RACF). There is a gap in our understanding of how psychosocial barriers such as risk perceptions shape staff attitudes towards antimicrobial stewardship (AMS). We sought to ascertain the attitudinal domains that have been identified to be of importance to AMS in RACF and comment on how they have been measured empirically. Our aim was to consolidate what is known regarding staff attitudes and perceptions in order to inform future stewardship.

Method

We searched PsycINFO, PsycARTICLES, CINAHL Plus, MEDLINE, PubMed, Web of Science, Cochrane, and Scopus databases for primary studies of healthcare workers attitudes to AMS in RACF (1990-February 2021).

Results

14 Studies were included in the review, within which 10 domains were identified: attitudes towards antimicrobial prescribing; guidelines; educational interventions; self-confidence regarding clinical assessment and prescribing; awareness of AMR as a problem and stewardship as a priority; self-efficacy; perception of role; perception of risk; team culture and resident/family members expectations. 46 measures were developed across the 14 studies to measure the 10 domains. The variability in the attitudinal domains and how these domains were measured was large. Only 13% included psychometric data regarding reliability and/or internal consistency.

Conclusions

Attitudes are generally defined as having three evaluative bases: cognitive, behavioural, and affective. Findings from the current review suggest that the measures commonly used to capture healthcare staff attitudes to AMS do not sufficiently capture affect; particularly with respect to staff’s risk perceptions, perceptions of their role, and family members’ expectations. Given that affective processes have been postulated to influence medical decision making, these findings highlight the importance of understanding how staff, especially nurses feel about implementing AMS strategies and other peoples’ (e.g. residents and their families) perceptions of stewardship. It is expected that a more nuanced understanding of RACF nurses affective experiences when applying AMS, and their perceptions of the risks entailed, will help in reducing barriers to overprescribing antibiotics.

Nurse role and contribution to antimicrobial stewardship: An integrative review

AIM

To examine existing published literature regarding nurses and antimicrobial stewardship, and their potential role and contribution, to identify what is known, to evaluate methodologies used in published research, and to review and integrate findings to inform practice and future priorities for research.

DESIGN

Integrative review.

METHODOLOGY

The approach to this review was informed by Whittemore and Knafl's integrative review methodology. Electronic databases were searched for papers published since the start of the database to November 2019, with abstracts available, related to humans and published in English. Papers were included regardless of practice setting (acute, aged, and primary care) and if they were research based, included nurses as participants and reported specifically on results from nurses or that had implications for nursing practice. Excluded were conference abstracts, and papers focussed solely on nurse prescriber, nurse practitioner, or nurse manager roles.

RESULTS

Fifty-two papers were included in the review. Identified themes were: i) nursing knowledge, learning needs and education; ii) nurse perceptions of the nursing role and motivations for involvement; iii) nursing brokerage and influence on information flow to and from patients; iv) nursing workflow, workload and workarounds; and v) nurse leadership. Methodological quality of the included papers varied, limiting transferability and applicability of findings for some of the included studies.

CONCLUSION

Formal inclusion of nurses in antimicrobial stewardship activities has been associated with improved nurse knowledge, nurse confidence, and in some cases improved clinical outcomes for patients. The review reinforces nursing values as a motivator of nursing actions, and reveals the complex yet significant influence of nurses on antimicrobial prescribing. Potential opportunities to enhance nurses' participation and contribution to antimicrobial stewardship include; formal acknowledgement of the nurse role, educating nurses so that they are aware of how they can contribute, collaborating with nurses in planning and implementing local stewardship activities, and ensuring nurse leaders are involved. However, evidence on this topic remains limited. Research is needed to facilitate greater understanding about the nature, scope and influence of the nurse role in antimicrobial stewardship, how nurses enact and carry out their role, and nurses' support needs. Tweetable abstract: Integrative review explores #nurse role in #antimicrobialstewardship. Nurse contribution, influence significant, but not well understood.