Nurses' perceptions of the potential evolution of their role in antibiotic stewardship in nursing homes: a French qualitative study

Exploration of interprofessional collaboration for the diagnosis of infections and antibiotic prescription in nursing homes using multiple case study observational research

Background

Antibiotic resistance in nursing homes (NHs) is inconsistently tackled by antimicrobial stewardship programmes. The literature on individual determinants of antibiotic prescriptions (APs) in NHs is extensive. However, less is known about the structural determinants of AP in NHs.

Objectives

To examine how different organizational contexts influenced interprofessional collaboration in the diagnosis and treatment of infections in NHs.

Methods

We conducted multiple case study observational research through field notes and sketches from pictures of NH layouts.

Results

We observed three NHs for 10 days (i.e. 82 h). We inductively identified four successive steps: (i) trigger by an assistant nurse, (ii) internal decision-making, (iii) calling on an external general practitioner (GP) and (iv) GP intervention. Diagnosis and treatment of infections involved various degrees of interprofessional collaboration within NHs, resulting in a range of actions, more or less directly involving AP by external GPs. In the case of onsite AP, external GPs barely relied on information about residents provided by NH professionals and did not provide any feedback regarding their decision, resulting in limited interprofessional collaboration. In contrast, remote AP (through phone calls) relied on interprofessional collaboration through mandatory exchanges between external GPs and NH nurses about the resident's symptoms and signs.

Conclusions

Diagnosis and treatment of infections through AP involved two distinct organization types (institutional versus private practices) and often lacked interprofessional collaboration. Future antimicrobial stewardship in NHs should consider (i) improving the connection between these two organizations and (ii) developing tools to support remote interprofessional collaboration to sustain prescription.

Nursing home nurses' opinion profiles on the potential evolution of their role in antimicrobial stewardship and associated factors: a national cross-sectional study in France

Background

Antibiotic resistance is a major public health threat, especially in nursing homes (NHs). Nursing home nurses (NHNs) can play a crucial role in antimicrobial stewardship (AMS), but research on their opinions regarding potential expanded AMS roles is limited.

Objectives

To identify different profiles of NHNs according to their opinions on the potential evolution of their AMS roles and to study facilitators/barriers to implementing new AMS roles and the demographic and professional characteristics associated with these profiles.

Methods

Data were collected from a national cross-sectional online survey conducted from May to July 2022 among French NHNs. Profiles were identified via hierarchical clustering. Factors associated with the identified profiles were studied via Fisher's exact tests.

Results

Among the 922 participants included in the analysis, three distinct profiles were identified. NHNs 'more favourable to the evolution of the AMS role' (40% of the sample) expressed strong support for the potential evolution of their AMS role. NHNs 'moderately favourable to the evolution of the AMS role' (46%) were less prone to reinforce discussion with general practitioners about antibiotic prescription. NHNs 'less favourable to the evolution of the AMS role' (14%) showed little or no agreement regarding several potential new AMS roles. Being a head nurse was associated with more favourable opinions on the evolution of the AMS role as opposed to practicing in NHs connected to a hospital.

Conclusions

These findings could help healthcare managers and policy-makers tailor the implementation of these new roles among NHNs, if they prove effective and safe.

Antimicrobial Stewardship in Healthcare: Exploring the Role of Nurses in Promoting Change, Identifying Barrier Elements and Facilitators-A Meta-Synthesis

BACKGROUND

Antimicrobial stewardship (AMS) involves a coordinated set of actions aimed at promoting the appropriate use of antibiotics within healthcare settings. This systematic review of qualitative studies assessed nurses' knowledge and perceptions of the barriers and facilitators that impact their involvement in AMS programs.

METHODS

This meta-synthesis followed the Joanna Briggs Institute methodology for systematic reviews of qualitative evidence. Relevant studies published between 2018 and 2023 were identified through searches on PubMed, CINAHL, EMBASE, PsycINFO, and Google Scholar. The studies were critically appraised using the CASP checklist, with 19 articles meeting the inclusion criteria from five continents.

RESULTS

Six recurring themes emerged from the analysis of nurses' experiences and opinions regarding their roles in AMS programs. These themes included the organization of AMS programs, availability of resources, training and education, communication, and the evolving role of nurses in AMS.

CONCLUSIONS

Nurses at every level of the profession might play a crucial role in antimicrobial stewardship. Although active involvement of nurses in antibiotic stewardship requires further exploration and research, this topic is being examined internationally. The literature on this subject primarily analyzes the phenomenon from a quantitative perspective rather than a qualitative one, and it is contextualized more within hospital settings rather than community settings.

Barriers to the implementation of antimicrobial stewardship programmes in long-term care facilities: a scoping review

BACKGROUND

Long-term care facilities (LTCFs) present specific challenges for the implementation of antimicrobial stewardship (AMS) programmes. A growing body of literature is dedicated to AMS in LTCFs.

OBJECTIVES

We aimed to summarize barriers to the implementation of full AMS programmes, i.e. a set of clinical practices, accompanied by recommended change strategies.

METHODS

A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase and Cochrane Central. Studies addressing barriers to the implementation of full AMS programmes in LTCFs were included. Implementation barriers described in qualitative studies were identified and coded, and main themes were identified using a grounded theory approach.

RESULTS

The electronic search revealed 3904 citations overall. Of these, 57 met the inclusion criteria. All selected studies were published after 2012, and the number of references per year progressively increased, reaching a peak in 2020. Thematic analysis of 13 qualitative studies identified three main themes: (A) LTCF organizational culture, comprising (A1) interprofessional tensions, (A2) education provided in silos, (A3) lack of motivation and (A4) resistance to change; (B) resources, comprising (B1) workload and staffing levels, (B2) diagnostics, (B3) information technology resources and (B4) funding; and (C) availability of and access to knowledge and skills, including (C1) surveillance data, (C2) infectious disease/AMS expertise and (C3) data analysis skills.

CONCLUSIONS

Addressing inappropriate antibiotic prescribing in LTCFs through AMS programmes is an area of growing interest. Hopefully, this review could be helpful for intervention developers and implementers who want to build on the most recent evidence from the literature.

Are Nurses Aware of Their Contribution to the Antibiotic Stewardship Programme? A Mixed-Method Study from Qatar

The antibiotic stewardship programme (ASP) is a new concept initiated by WHO, but nurses are not yet ready to adopt the program. The training and empowerment of nurses are the best strategies for enhancing their knowledge and engagement in ASP. This mixed-method study was used to assess perceived roles and barriers of nurses' involvement in ASP. An online survey was conducted among 420 clinical nurses to identify their role, and 23 individual interviews were performed among nurses and infection control practitioners to explore the barriers and recommendations to overcome the identified barriers. The majority of the nurses agreed with the sixteen identified roles in ASP, of which 'antibiotic dosing and de-escalation' (82.61%), 'IV to PO conversion of antibiotic, outpatient antibiotic therapy' (85.23%), and 'outpatient management, long-term care, readmission' of the patients (81.19%) had the lowest agreement from the participants. The major themes generated through the qualitative interviews were a lack of knowledge about ASP, poor communication between multidisciplinary teams, lack of opportunity and multidisciplinary engagement, lack of formal education and training about ASP, lack of ASP competency and defined roles in policy, role conflict or power/position, availability of resources, and lack of protected time. Nurses play an integral role in the successful implementation of antibiotic stewardship programs. The empowerment of nurses will help them to adopt the unique role in ASP. Nurses can significantly contribute to antibiotic stewardship efforts and improve patient outcomes through addressing these challenges.

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.

Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies

BACKGROUND

Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes.

METHOD

We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings.

RESULTS

Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1).

CONCLUSIONS

Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.