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

Abstract

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.

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

“…However, systematic reviews of antibiotic use and stewardship in RACFs suggest that staff report being aware of antimicrobial resistance as a problem, endorse guidelines and algorithms as diagnostic tools, and report high levels of confidence in their ability to determine changes in a resident’s clinical status due to an infection. 24 These findings suggest that factors other than a lack of education and awareness may drive some of the inappropriate antibiotic initiation in RACFs. Large variations in practices and the availability of resources across RACFs, a lack of engagement of nurses, and perceived pressure from family members further challenge the uptake and sustainability of educational interventions as a means of managing these tensions.…”

“…23 As such, risk perceptions in the RACF environment appear to be shaped by a complex interplay of high uncertainty, resource constraints, and pressure from family members on RACF staff that have not been addressed by educational stewardship. 24 In RACFs, RNs and ENs are required to manage residents with complex presentations in conditions of high uncertainty and resource constraints and make decisions based on guidelines on whether to escalate risk to a prescriber. However, there is a paucity of data regarding how RNs manage uncertainty and make decisions based on knowledge, risk, and probability in RACFs.…”

“… 23 As such, risk perceptions in the RACF environment appear to be shaped by a complex interplay of high uncertainty, resource constraints, and pressure from family members on RACF staff that have not been addressed by educational stewardship. 24 …”

“… 1 While these interventions appear to be useful in addressing scientific uncertainty (e.g., remediating knowledge gaps in differentiating and interpreting different signs and symptoms), these interventions alone do not address the high levels of practical and personal uncertainty that staff experience in these settings. 24 It is expected that understanding the relationship between nursing behaviors adjacent to prescribing might inform interventions that address some of the inappropriate prescribing that occurs in RACFs.…”

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

“…Prescribers have a clearly defined role in antimicrobial stewardship (AMS) and have been the primary focus of measurement of outcomes (e.g., prolonged duration of therapy; high rates of (as required) prescriptions; poor documentation; and prolonged prophylaxis for conditions that are not supported by guidelines) (ACSQHC, 2018 ; Hall et al., 2022 ). Antimicrobial overprescribing has been conceptualised as a problem of knowledge deficit with the dissemination of educational AMS interventions (e.g., development of guidelines, educational seminars, audit and feedback for prescribers) (Singh et al., 2022 ). However, these interventions have been insufficient in addressing the complexities of resident care in RACF (e.g., resident frailty, multiple comorbidities, lack of resources and rotating staff) (Katz et al., 2017 ; Wu et al., 2018 ).…”