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

Int J Nurs Stud. 2020 Apr;104:103502. doi: 10.1016/j.ijnurstu.2019.103502. Epub 2019 Dec 11.

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.

Keywords: Aged care; Anti-bacterial agents; Anti-infective agents; Antimicrobial stewardship; End-of-life; Long-term care; Nursing homes; Palliative care; Qualitative research.

MeSH terms

  • Adult
  • Advance Care Planning
  • Aged
  • Anti-Bacterial Agents / adverse effects
  • Antimicrobial Stewardship*
  • Attitude of Health Personnel
  • Female
  • Homes for the Aged*
  • Humans
  • Male
  • Nurse's Role*
  • Nursing Homes*
  • Qualitative Research
  • Terminal Care*
  • Victoria

Substances

  • Anti-Bacterial Agents