Decisional Issues in Antibiotic Prescribing in French Nursing Homes: An Ethnographic Study

Abstract

Background:Medication prescription is generally the responsibility of doctors. In nursing homes, the nursing staff is often the first to suspect an infection. Today, physicians are more confident with nursing assessment, relying primarily on nursing staff information. Very few studies have investigated the nurses’ influence on decision of medical prescription. This study investigates the role of nurses in antibiotic prescribing for the treatment of suspected infections in nursing home residents.Design and methods:An ethnographic study based on semi-structured interviews and participant observations was conducted. Sixteen nurses and five doctors working in five nursing homes in Paris, France participated between October 2015 and January 2016.Results:Given their proximity to elderly residents, registered nurses at the nursing homes occasionally assisted doctors in their medical diagnostic. However, nurses who are theoretically incompetent have met difficulties in their ability to participate in their decisions to prescribe antibiotics when managing residents’ infections.Conclusion: if proximity and nursing skills reinforce the relevance of the clinical judgment of nurses, the effective and collaborative communication between the nurse and the doctor may help the nurse to enhance their role in the antibiotic prescribing in nursing homes, which would enhance antimicrobial stewardship efficiency.Significance for public healthThe study described in this paper is significant for the field of public health for several reasons. The consumption of antibiotics is a serious worldwide problem. Before implementing an antibiotic stewardship in NH, we needed to better know how antibiotic were prescribed. The knowledge from this study should be used in practice to optimize the role of nurses in reducing inappropriate prescribing of antibiotics. The efficient interaction of nurses during the decision-making process of the antibiotic prescribing produce an appropriate care in NH, which would be contributed to decrease the microbial resistance and therefore the cost of health services.

Nursing home nurses' opinions on the potential evolution of their role in antibiotic stewardship: A French national cross‐sectional survey

“…Regarding their role in antibiotic prescribing, we found that most nursing home nurses agreed to discuss more with general practitioners about the relevance of prescribing an antibiotic. This result is similar to that reported in a French study conducted by Chaaban et al which showed that nurses were motivated to take part in an educational training program on antibiotic therapy to improve their knowledge and to be able to discuss antibiotic prescriptions with the general practitioner (Chaaban et al, 2019). Even if the responsibility for prescribing antibiotics is clearly assigned to physicians, nursing home nurses could participate in the resident's management by providing useful information or suggesting to delay the prescription and wait a few days to reconsider the need for an antibiotic in case of diagnostic uncertainty, provided that severity criteria are absent (Fleming et al, 2014).…”

“…Using a structured approach to provide data on residents' clinical assessments to general practitioners can help nurses communicate accurately and help the general practitioners make diagnoses (Baier et al., 2022). They could support general practitioners in their infection management and development of an optimal antibiotic treatment plan (Chaaban et al., 2019) when communication between off‐site physicians and on‐site nurses is harmonious (Gahr et al., 2007). In our study, most nursing home nurses agreed to have the possibility of adapting the antibiotic drug formulation to each resident based on their knowledge of the residents' clinical situation.…”

“…However, nursing home nurses were less prone to discuss other criteria of the prescription (e.g. molecule, dose and duration) with general practitioners, perhaps because of their lack of experience and in‐depth knowledge on this topic (Chaaban et al., 2019).…”

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

“…Findings from studies suggest agreement among nurses’ regarding their role in stewardship. 85.3% of nurses perceive themselves as being sources of information for patients regarding antibiotics [ 15 ], and agreed (5-point scales) that their assessment of the patient (M = 3.8), communication with providers (prescribers) (M = 4.1), knowledge of a patients’ baseline (M = 3.8), clinical assessment of a patient and communication with patient and family members (M = 3.8) influenced whether the patient received antibiotics [ 63 ]. However, it is unclear how other RACF staff (e.g.…”

“…Nurses have been identified as central to GP decision-making about treatment in RACF contexts [ 15 , 52 ]. Role responsibilities include instigating the escalation of care when needed (e.g.…”