The dilemmas of antimicrobial stewardship in aged care: The perspectives of the family members of older Australians

Degeling, Chris; Hall, Julie; Montgomery, Amy; Singh, Saniya; Mullan, Judy; Williams, Jane

doi:10.1016/j.gerinurse.2023.01.016

Cited by 4 publications

(9 citation statements)

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“…Conversely, family members report describing prescribers, rather than nurses as the holders of information regarding antibiotics and associate prescriber involvement with higher-quality care (Ahouah et al, 2019;Degeling et al, 2023). These findings taken together highlight the tensions that nurses might experience in disclosing uncertainty regarding a resident's medical status and maintaining the relationship with family members.…”

Section: Discussionmentioning

confidence: 98%

“…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). Risk aversion among prescribers; interprofessional tensions between prescribers and nurses and pressure from nurses and family members are cited as significant barriers to reducing prescribing (Broom et al, 2019;Degeling et al, 2023;McElligott et al, 2017).…”

Section: Introductionmentioning

confidence: 99%

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

Singh,

Degeling,

Drury

et al. 2024

Nursing Open

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AimThe 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.DesignCross‐sectional online survey.MethodOne 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.ResultsThe 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.

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Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

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

Singh,

Degeling,

Drury

et al. 2024

Nursing Open

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“…[31][32][33][34][35][36] Nurses report experiencing feelings of anger and frustration during uncertainty 25 and find it difficult to manage prescribers' and family members' expectations. 15 It might be useful to explore how their past experiences with residents (e.g., deterioration or death), their families (e.g., attitudes toward nurses; attitudes toward death), and prescribers (e.g., anger, dismissal of concerns) might further influence decisions that have not been explored in this study. Lastly, the current study did not link antibiotic initiation with prescribing behaviors.…”

Section: Discussionmentioning

confidence: 99%

“…14 In Australia, the responsibility for prescribing antibiotics usually rests with visiting general practitioners (GPs), and phone prescribing remains common practice. 15 In some local health districts, specialized nurse practitioners with prescribing authority can be called in an emergency, but GPs have the primary responsibility for the medical needs of residents under their care. 16 The staff of RACFs usually includes a nurse facility manager, registered nurses (RNs), enrolled nurses (ENs), and personal care assistants.…”

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confidence: 99%

“…GPs report pressure from staff and family members to prescribe; however, the mechanisms by which this happens are unclear and warrant further investigation. 15 , 19 Therefore, the current study aims to examine whether nurses’ anxiety and clinical tolerance of uncertainty contributes to nursing behaviors that favor initiation of antibiotics (e.g., calling the GP to initiate antibiotics earlier) or immediate assessment of the resident. It is hypothesized that the relationship between uncertainty and decisions favoring antibiotic initiation are mediated by the experience of situational anxiety.…”

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confidence: 99%

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

Singh,

Degeling,

Drury

et al. 2024

Med Decis Making

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Aim. Diagnostic uncertainty, risk perceptions, time constraints, and pressure from resident/family members and nurses have been identified as potential barriers to reducing antibiotic prescribing in residential aged-care facilities. The current study investigated the relationship between nurses’ anxiety, clinical tolerance of uncertainty, and behaviors that favor antimicrobial initiation. Methods. A cross-sectional online survey was used to present a clinical vignette with measures of situational anxiety, clinical tolerance to uncertainty using the Physicians Reactions to Uncertainty Scale (adapted for nurses), and self-reported behavior on the Immediate Assessment and Antibiotics scale. The vignette described a hypothetical resident with a potential upper respiratory tract infection. Incremental information was provided with varying levels of symptoms, input from aged-care staff, and the availability of test results. Results. A total of 157 registered and enrolled nurses completed the survey from August 2021 to August 2022. Nurses’ anxiety fully mediated on the relationship between clinical tolerance of uncertainty and perceived need for antibiotics and immediate assessment ( P = 0.004), with 6% of variation explained by the model. Significant effects of clinical tolerance of uncertainty on anxiety ( P < 0.001) and anxiety on antibiotic initiation ( P = 0.002) were found, but there was no significant direct effect between clinical tolerance of uncertainty and antibiotic initiation ( P = 0.34). Conclusions. This is the first study that links perceived need for antibiotics and assessment to nurses’ anxiety and clinical tolerance of uncertainty. Thus, it may be that providing strategies for the management of anxiety related to uncertainty could nullify some processes contributing to inappropriate prescribing in aged-care settings 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.

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Distributive justice and value trade-offs in antibiotic use in aged care settings

Williams,

Chawraingern,

Degeling

2024

Monash Bioeth. Rev.

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Residential aged care facilities (RACF) are sites of high antibiotic use in Australia. Misuse of antimicrobial drugs in RACF contributes to antimicrobial resistance (AMR) burdens that accrue to individuals and the wider public, now and in the future. Antimicrobial stewardship (AMS) practices in RACF, e.g. requiring conformation of infection, are designed to minimise inappropriate use of antibiotics. We conducted dialogue groups with 46 participants with a parent receiving aged care to better understand families’ perspectives on antibiotics and care in RACF. Participants grappled with value trade offs in thinking about their own parents’ care, juggling imagined population and future harms with known short term comfort of individuals and prioritising the latter. Distributive justice in AMR relies on collective moral responsibility and action for the benefit of future generations and unknown others. In RACF, AMS requires value trade-offs and compromise on antimicrobial use in an environment that is heavily reliant on antimicrobial drugs to perform caring functions. In the context of aged care, AMS is a technical solution to a deeply relational and socio-structural problem and there is a risk that carers (workers, families) are morally burdened by system failures that are not addressed in AMS solutions.

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The dilemmas of antimicrobial stewardship in aged care: The perspectives of the family members of older Australians

Cited by 4 publications

References 28 publications

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

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

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

Distributive justice and value trade-offs in antibiotic use in aged care settings

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