The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: A qualitative study

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Abstract

Background

The excessive use of antimicrobials in aged-care homes is a widely recognised phenomenon. This is problematic because it can harm residents, and is detrimental to public health. Residents in the final month of life are increasingly likely to be prescribed an antimicrobial, commonly without having signs and symptoms of infection that support antimicrobial use.

Objectives

We aimed to describe the perspectives of health professionals on antimicrobial use near the end of life in aged-care homes and investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes.

Design

One-on-one, semi-structured, qualitative interviews.

Settings and participants

Twelve nurses, six general practitioners and two pharmacists providing routine care to residents of aged-care homes in Victoria, Australia were interviewed. Diversity in terms of years of experience, aged-care funding type (government, private-for-profits and not-for-profits) and location (metropolitan and regional) were sought.

Methods

Interviews were transcribed and open coded in a descriptive manner using validated frameworks for understanding behaviour change. The descriptive code was then used to build an interpretive code structure based on questions founded in grounded theory.

Results

Thematic saturation was reached after fourteen interviews, and an additional six interviews were conducted to ensure emergent themes were consistent and definitive. There are opportunities for aged-care home nurses to undertake antimicrobial stewardship activities near the end of life in the provision of routine care. Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care because of their leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources. Nurses also have social influence among residents, families and medical professionals during critical conversations near the end of life. Past negative social interactions within the aged-care home environment between nurses and families can result in ‘fear-based’ social influences on antimicrobial prescribing.

Conclusions

The work of facilitating advance care planning, care coordination, care delivery, and communicating with families and medical professionals provide important opportunities for aged-care home nurses to lead appropriate antimicrobial stewardship activities near the end of life.

Section snippets

What is already known about the topic?

  • Nurses are important participants in antimicrobial use in aged-care homes.

  • Antimicrobials are frequently prescribed for residents of aged-care homes who are near the end of life, commonly without residents having signs or symptoms of infection to support such use.

What this paper adds

  • Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care.

  • Nurse leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources are opportunities for nurses to lead antimicrobial stewardship near the end of life in aged-care homes.

  • Past negative social interactions within the aged-care home environment between nurses and families can result in ‘fear-based’ social influences on

Background

Internationally, the inappropriate use of antimicrobials in aged-care homes is a widely recognised phenomenon (Loeb et al., 2001; National Centre for Antimicrobial Stewardship and Australian Commission on Safety and Quality in Health Care, 2018; Pettersson et al., 2008). This is problematic because it can harm residents (Daneman et al., 2015), and is detrimental to public health (Medew, 2015; O'Fallon et al., 2009; Tenover, 2006). There is compelling evidence that antimicrobial resistance

Methods

One-on-one semi-structured qualitative interviews were conducted with health professionals (i.e., nurses, general practitioners and pharmacists) working in aged-care homes in Victoria, Australia.

Results

No interview participants withdrew from the study after participating, and three people declined to participate at the time of interview without offering specific reasons. The demographics of the 20 participants are listed in Table 1. The mean interview duration was 29 min and 07 s (Range: 16 min and 29 s to 59 min and 35 s). Two participants (General Practitioner 3 and Pharmacist 2) were not audio recorded.

There was a high degree of concordance between AR and LD's descriptive coding and the

Discussion

To our knowledge, this is the first study to describe specific nursing opportunities to participate in antimicrobial activities near the end of life, within the environmental contexts and social influences of aged-care homes. In aged-care homes, nurses take on required leadership roles and have substantial social influence within a context of stopgap and visiting medical resources. This includes facilitating advance care planning and having critical conversations with families about decisions

Conclusions

Nurses have important roles in facilitating advance care planning, care coordination, care delivery and communication with families and medical professionals, and these activities present important opportunities for nurses to lead antimicrobial stewardship activities appropriate for care near the end of life in aged-care homes.

Acknowledgments

This research is funded by the National Health and Medical Research Council (NHMRC) of Australia, Grant Number: APP1079625.

Leslie Dowson receives an Australian Government Research Training Program Scholarship.

The authors would like to acknowledge all those who participated in, and supported, this project.

CRediT authorship contribution statement

Leslie Dowson: Conceptualization, Methodology, Investigation, Data curation, Writing - original draft, Writing - review & editing, Project administration. N. Deborah Friedman: Conceptualization, Methodology, Resources, Writing - review & editing, Supervision. Caroline Marshall: Conceptualization, Methodology, Resources, Writing - review & editing, Supervision. Rhonda L. Stuart: Conceptualization, Methodology, Resources, Writing - review & editing, Supervision. Kirsty Buising: Conceptualization,

References (41)

  • Australian Institute of Health and Welfare, 2018. Palliative Care in Residential Aged Care....
  • R.E. Bernacki et al.

    Communication about serious illness care goals: a review and synthesis of best practices

    JAMA Intern. Med.

    (2014)
  • J.A. Billings

    Advance care planning safeguards

    J Gen. Intern. Med.

    (2012)
  • V. Braun et al.

    Using thematic analysis in psychology

    Qual. Res. Psychol.

    (2006)
  • A. Broom et al.

    Nurses as antibiotic brokers: institutionalized praxis in the hospital

    Qual. Health Res.

    (2016)
  • J. Cane et al.

    Validation of the theoretical domains framework for use in behaviour change and implementation research

    Implem. Sci.

    (2012)
  • ChengV.C.C. et al.

    Emergence of carbapenem-resistant acinetobacter baumannii in nursing homes with high background rates of MRSA colonization

    Infect. Control Hosp. Epidemiol.

    (2016)
  • E. D'Agata et al.

    Patterns of antimicrobial use among nursing home residents with advanced dementia

    Arch. Intern. Med.

    (2008)
  • N. Daneman et al.

    Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents

    JAMA Intern. Med.

    (2015)
  • A. Fleming et al.

    Antibiotic prescribing in long-term care facilities: a qualitative, multidisciplinary investigation

    BMJ Open

    (2014)
  • View full text