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8 What influences antibiotic initiation? Developing a scale to measure nursing behaviour in residential aged-care facilities
  1. Saniya Singh,
  2. Chris Degeling,
  3. Frank Deane,
  4. Amy Montgomery,
  5. Peta Drury,
  6. Peter Caputi
  1. University of Wollongong, Wollongong, Australia

Abstract

Abstract in Full – Workshops & Seminars Antibiotic overprescribing and resistance remains a significant global concern, particularly in residential aged-care facilities (RACF). Primary stewardship strategies, such as prescriber feedback, educational seminars, audit and feedback interventions conceptualise the problem of overprescribing as a knowledge deficit for prescribers. However, these interventions have been insufficient in addressing the complexities of resident care in these facilities (e.g., resident frailty, multiple comorbidities, limited access to testing, rotating prescribers) and the impact of medical-decision making in this context has not been studied. Psychosocial barriers such as risk aversion in prescribers, interprofessional tensions between prescribers and nurses, anxiety from family members and perceived pressure to prescribe have been cited as common barriers to reducing prescribing in these settings. More recently, there is an acknowledgement that registered nurses (RNs) and enrolled nurses (ENs) play a significant role in influencing prescribing. RACF nurses are proximal in monitoring and escalating resident care (e.g., urine testing, calling the prescriber or sending a resident to hospital); collaborating and relaying information; and managing relationships with off-site prescribers and residents and their family members, as well as managing personal care assistants. The aim of the current study was to develop and assess the psychometric properties of a measure that captures nursing behaviours that influence antibiotic initiation and prescribing in residential aged-care facilities. This was a cross-sectional vignette based study. 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 described two hypothetical residents with signs and symptoms of two of the most common presentations (urinary tract infections and upper respiratory tract infections) in RACF. 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. The results focus on the 16 items in the second vignette which resulted in the extraction of three factors. The derived factors were labelled: Noting and Calling GP (NCGP), Consult a Colleague (CC) and Immediate Assessment and Antibiotics (IAA). Reliability analysis revealed excellent to satisfactory reliability. All three scales were correlated with measures of clinical tolerance of uncertainty, and the NCGP scale was also correlated with measures of state anxiety and general tolerance of uncertainty. To the authors knowledge, this is the first measure that captures nursing behaviours that influence antibiotic initiation with satisfactory reliability and validity. Further, factors in this measure are related to nurses' clinical and general uncertainty and state anxiety, which are likely contribute to antibiotic decisions regarding antibiotic initiation and prescribing. The 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. It adds insight into clinician-related factors, such as tolerance of uncertainty and anxiety in antibiotic overprescribing; and informs future stewardship interventions.

Objectives Antibiotic overprescribing and resistance remains a significant global concern, particularly in residential aged-care facilities (RACF). RACF nurses are proximal in monitoring and escalating resident care (e.g., urine testing, calling the prescriber or sending a resident to hospital); collaborating and relaying information; and managing relationships with off-site prescribers and residents and their family members, as well as managing personal care assistants. The aim of the current study was to develop and assess the psychometric properties of a measure that captures nursing behaviours that influence antibiotic initiation and prescribing in residential aged-care facilities.

Method This was a cross-sectional vignette based study. 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 described two hypothetical residents with signs and symptoms of two of the most common presentations (urinary tract infections and upper respiratory tract infections) in RACF. 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: Noting and Calling GP (NCGP), Consult a Colleague (CC) and Immediate Assessment and Antibiotics (IAA). Reliability analysis revealed excellent to satisfactory reliability. All three scales were correlated with measures of clinical tolerance of uncertainty, and the NCGP scale was also correlated with measures of state anxiety and general tolerance of uncertainty.

Conclusions To the authors knowledge, this is the first measure that captures nursing behaviours that influence antibiotic initiation with satisfactory reliability and validity. Further, factors in this measure are related to nurses’ clinical and general uncertainty and state anxiety, which are likely contribute to antibiotic decisions regarding antibiotic initiation and prescribing. The 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. It adds insight into clinician-related factors, such as tolerance of uncertainty and anxiety in antibiotic overprescribing; and informs future stewardship interventions.

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