Nurse prescriber’s understanding of their antimicrobial stewardship role: a qualitative study
Anecita Gigi Lim 1 , Dianne C. Marshall
1 * , Kenzie Roberts 1 , Michelle L. L. Honey 1
1 School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand.
Journal of Primary Health Care 15(3) 274-280 https://doi.org/10.1071/HC23006
Published: 20 July 2023
Abstract
Antimicrobial resistance is an infectious disease threat to public health globally, and antimicrobial stewardship among healthcare professionals is one key way to address this potential problem. Registered nurse designated prescribers are the newest group of health professionals to gain prescribing authority in Aotearoa New Zealand, yet little is known about their understanding of their antimicrobial stewardship role.
The aim of this study was to explore registered nurse designated prescribers’ understanding of their antimicrobial stewardship role through their prescribing practices and approaches to clinical reasoning.
This exploratory descriptive qualitative study used individual semi-structured interviews with six registered nurse designated prescribers. Thematic analysis was used to analyse the interviews.
Four themes were identified: antibiotic prescribing practices and antimicrobial resistance; clinical indicators for prescribing antibiotics, with the sub-themes of history taking, presence of infection and bacterial versus viral infection; patient education; and safety and monitoring. These themes provide insight into registered nurse designated prescribers’ understanding of their antimicrobial stewardship role and prescribing of antibiotics.
This research found that the registered nurse designated prescribers had an awareness of the importance of their antimicrobial stewardship role in relation to antibiotic prescribing and reducing antimicrobial resistance. Education about antimicrobial resistance and antimicrobial stewardship for this professional group can be effective, but further research is needed to understand their ongoing educational needs.
Keywords: antibiotics, antibiotic efficacy, antibiotic resistance, antimicrobial agents, antimicrobial resistance, antimicrobial stewardship, nursing, nurse prescribers.
| WHAT GAP THIS FILLS |
| What is already known: Registered nurses often demonstrate elements of antimicrobial stewardship across many healthcare settings and in their clinical work directly with patients. |
| What this study adds: Registered nurse designated prescribers are engaging and using antimicrobial stewardship approaches when prescribing antibiotics. Further education about the appropriate use of antibiotics is recommended to enable nurses to reach their potential for full participation in antimicrobial stewardship. |
Introduction
Antimicrobial resistance (AMR) poses a major threat to public health as it can lead to common infections becoming untreatable, which can lead to increased morbidity and mortality. Infections caused by resistant microorganisms are responsible for an estimated 700 000 deaths annually worldwide.1 If no action is taken, it has been estimated that this rate may rise to more than 10 million deaths annually by 2050.2 The global and economic impact of antibiotic resistance among humans is described as having the potential to be catastrophic.3
AMR occurs when microorganisms, including bacteria, viruses, fungi and parasites, change in ways that render the medications used to treat the infections they cause ineffective.4 Resistant microorganism strains can develop naturally but using antibiotics improperly accelerates the process.5 Exposure to antibiotics creates selective pressure that makes surviving bacteria more likely to be resistant.6 This is compounded as surviving bacteria multiply and pass on genes with resistance properties.7 Therefore, the emergence and proliferation of resistant bacteria are directly related to the amount of antibiotics in the microorganism’s environment.7,8
While AMR is a multifactorial phenomenon, numerous studies indicate a causal relationship between its development and the inappropriate prescribing of antibiotics.9–11 Inappropriate prescribing of antibiotics occurs when medicines are not prescribed or administered in accordance with guidelines based on scientific evidence to ensure their safe, effective and economic use.12 Research also indicates that underuse, through lack of access to antibiotics, inadequate dosing and poor adherence to therapy, may play an important role in AMR.13 In addition, the use of broad-spectrum antibiotic agents as a substitute for precise diagnostics or to enhance the likelihood of therapeutic success increases AMR.7
The World Health Organization Global Action Plan on AMR5 identified antimicrobial stewardship (AMS) as a key action point. AMS refers to a collection of coordinated, interprofessional, focused strategies to optimise antibiotic use by ensuring that patients receive antibiotics only when clinically indicated, and at the right dose, duration and route of administration.14 Surveillance of resistant pathogens, infection prevention and control and continuing professional education to all practitioners contribute to the AMS strategy.1,15
The goal of AMS is to achieve the best clinical outcomes related to antibiotic use while simultaneously minimising toxicity, adverse events and the emergence of antibiotic-resistant bacterial strains.5 AMS programmes decrease unnecessary exposure to antibiotics, improve cure rates, reduce adverse drug reactions, slow the emergence of antibiotic resistance and reduce hospital costs.1,16,17 Research shows that essential AMS principles should be included in the education of all health professionals responsible for prescribing and administering antimicrobials.16,18,19
Registered nurse prescribing in New Zealand
In Aotearoa New Zealand (NZ), health professionals who can prescribe antibiotics include doctors, registered nurses (RNs), midwives, dentists and pharmacists.20 Among the discipline of nursing, there are three groups of RNs who are regulated to prescribe after having undertaken additional educational preparation: nurse practitioners, RN community prescribers and RN designated prescribers.20 These three levels of prescriptive authority for RN prescribers in NZ each have their own educational requirements. For example, nurse practitioners have a distinct scope of practice and are authorised prescribers. This means they are authorised to prescribe nearly all medicines.21 The next level of prescriptive authority for RNs is for the RN community prescribers and RN designated prescribers who work in primary health or specialty teams and who can prescribe from a schedule of medicines for common and long-term conditions. The RN designated prescribers were included from 2016 and these nurses can prescribe from a schedule of medicines for common and long-term conditions including diabetes, hypertension, asthma, chronic obstructive pulmonary disease (COPD), anxiety, depression, heart failure, gout, palliative care, contraception, vaccines, common skin conditions and infections.21 RN designated prescribers are the newest group of health professionals to gain prescribing authority in NZ.22
Although the roles of nurses, in terms of AMS, have not formally been recognised in guidelines for implementing and operating AMS programmes, nurses have always performed numerous functions that are integral to successful AMS.23 For example, nurses are the health professional most involved in monitoring patients and therefore maintaining their safety through awareness of the patient status and their response to antibiotic therapy. Additionally, risk reduction, ensuring adherence to antibiotic guidelines, reviewing indications and the need for antibiotics are critical roles that nurses perform as antimicrobial stewards.24 As the largest group of health professionals involved in patient care, it is imperative that nurses are active participants in the AMS process. As RN designated prescribers are the newest group of health professionals to gain prescribing authority, this study aimed to explore their prescribing practices to gain an understanding of the role they perform as antimicrobial stewards.
Methods
This study utilised an exploratory descriptive qualitative approach.25 The consolidated criteria for reporting of qualitative research (COREQ) checklist guided the reporting of this study’s methods and findings.26
Study participants
At the time of identifying potential participants for this study (late 2018), there were less than 50 NZ RN designated prescribers. Therefore, recruitment used a non-probability sampling technique and snowball method.25 An email explaining the reasons and processes for doing the study and inviting nurse prescribers to participate was sent to the nurse networks of two authors (GL, MH). The email also asked that the message be sent to other potential participants. The recruitment process resulted in six RN designated prescribers volunteering to participate. Ethical approval for the study was obtained from the University of Auckland Human Participants Ethics Committee (Reference 021916).
Data collection
Individual semi-structured interviews were undertaken by the third author (KR) who was a nursing student undertaking a summer student scholarship and with no relationship with the participants. Prior to conducting the interviews, practice and pilot interviews were undertaken to refine the interview technique and the flow of questions, in addition to testing the recording equipment. All interviews were carried out by the same interviewer (KR) with the aid of an interview guide (Fig. 1) to maximise consistency. The interview guide consisted of questions about the RNs antibiotic prescribing, asking for examples based on patients they had recently cared for.
The interviews took place from November to December 2018 at a time and location convenient to the participants and lasted from 20 to 30 min. The interviews were either face-to-face, via phone or videoconferencing (Skype or Zoom). The interviews were transcribed verbatim by KR and returned to participants for checking.
Data analysis
Thematic analysis using an inductive process was undertaken by all authors; three who were PhD level researchers (GL, DM, MH) and one, a nursing student (KR). Data analysis was guided by Braun and Clarke’s27 approach for analysing qualitative data. This included reading and re-reading the transcripts, identifying initial codes, collating the codes and identifying initial themes. Further analysis refined and finalised the themes along with identifying illustrative quotes.
Results
Participants
Minimal identifying information about participants was collected, except to ask about their current area of work to provide some context for the situations where they might prescribe antibiotics (Table 1). Irrespective of their area or scope of practice, all participants indicated awareness of the importance of AMS.
| Participant | Area of practice | Scope of practice | |
|---|---|---|---|
| 1 | Primary health care | Adults with common and long-term conditions | |
| 2 | Primary health care | Adults with common and long-term conditions | |
| 3 | Primary health care | Young people aged 18–24 years with common and long-term conditions | |
| 4 | Primary health care | Rural nurse specialist providing a range of services from antenatal to palliative care | |
| 5 | Secondary care | Adults with respiratory conditions | |
| 6 | Secondary care | Adults with respiratory conditions |
Four themes were identified: antibiotic prescribing practices and AMR; clinical indicators for prescribing antibiotics, with the sub themes of history taking, presence of infection and bacterial versus viral infection; patient education; and safety and monitoring. Illustrative participant quotes are presented.
Theme one: antibiotic prescribing and antimicrobial resistance
RN designated prescribers are fully aware of the relationship between antibiotic prescribing and AMR. They cited common conditions where prescribing antibiotics would be justified and were able to articulate the rationale for using narrow spectrum antibiotics versus broad spectrum, or those from other antibiotic groups. In addition, the RN designated prescribers described symptomatology and presentations, as well as diagnostic tests and prescribing guidelines to access to ensure appropriate antibiotic prescribing.
RN designated prescribers described prescribing antibiotics for common conditions seen in their area of practice. For instance, two general practice nurses identified respiratory infections (which they portrayed as having the potential to worsen COPD and asthma), urinary tract infections, sexually transmitted infections and skin conditions. ‘Strep throat and otitis media’ were additional areas cited where antibiotics might be prescribed. Similarly, the rural nurse specialist prescribed antibiotics for lower chest infections, chronic sinus infections, urinary tract infections and skin infections (including cellulitis).
For the majority, when prescribing penicillin-type antibiotics, amoxicillin was the antibiotic drug of choice. The RN designated prescribers working in a general practice setting and those who worked as rural nurse specialists described prescribing a wider range of antibiotics, as one participant stated ‘… across the board there is a huge range [of antibiotics] depending on what the condition is’ (Participant 3).
In addition to amoxicillin, a broad-spectrum formulation, for example Augmentin, and other antibiotics such as cephalosporins (cephalexin), macrolides, beta lactams, quinolones and trimethoprim were also cited as antibiotic groups often prescribed for common conditions. Oral formulation in the form of tablets, capsules and suspensions were described, with rural nurse specialists also administering intravenous antibiotics.
Theme two: clinical indicators for prescribing antibiotics
The RN designated prescribers recognised that appropriate use of antibiotics was an important factor to consider when prescribing. For the majority, antibiotics were not prescribed without taking an accurate history, seeing strong indications of the presence of infection and being sure the presentation was clearly bacterial and not viral.
Participants were very aware of the need to carefully assess each patient and use their communication skills to collect an accurate history. Participants considered the patient’s presentation when considering the use of an antimicrobial. For example, one participant said:
There are certain clinical indicators that would obviously lead off into that decision-making process, so for impetigo, things like lesions, erythema, extending beyond 10 millimetres … (Participant 1)
Furthermore, participants described considering the wider factors that might be important, such as what has contributed to a patient’s infection, their antibiotic history and if they had any allergies. As an example, a participant described identifying factors in a patient’s ‘lifestyle at home, housing, their ability to self-care or do household chores’ with the option to ‘refer them to services to help them through that’ (Participant 1). Another participant described the effects of ‘socioeconomic status’ (Participant 2). Overall, these findings indicate that participants considered all aspects that were contributing to an infection in order to treat it appropriately, with a participant saying ‘It’s thinking about the management of the patient as a whole’ (Participant 5).
Participants were also aware of the presentations that would indicate a patient had an infection and situations where antibiotics were necessary:
There was a patient that I saw in clinic, and they were complaining of increased shortness of breath, increased sputum production and that the sputum was changing colour. On auscultation I could hear rhonchi throughout, so a really bad wheezy chest infection going on. They were feeling unwell; so, all those sorts of reasonings. Their respiratory rate was high, oxygen saturation was slightly lower than normal and yeah those symptoms. (Participant 1)
Symptomatology of infections such as redness, heat, swelling and pain in addition to fever and shortness of breath were classical presentations noted by the majority of RN designated prescribers as indicative of needing antibiotic use. Ensuring that further testing was completed to confirm bacterial infection and to establish a final diagnosis was described:
I had a 62-year-old woman, a busy working woman who had come in with a scalp condition. It looked fungal to me, but her job involves her wearing a headset and this infection was at the base of her scalp, sort of the occipital bit. One ear was very inflamed, and I could see she had been scratching her ear and had caused a little infection, possibly from something under her nails. There were a couple of pustules there as well. The pinna was really quite enlarged so I did a swab of the moist part of the ear where it had a discharge. (Participant 2)
RN designated prescribers were aware that antibiotics can sometimes be used inappropriately if prescribed for viral infections:
You really need to look at the presentation and then from there you may determine that this thing [infection] is more likely to be viral and will not need antibiotics. You need to be mindful that they [antibiotics] are warranted. You don’t want to be overusing them. (Participant 3)
Theme three: patient education
All participants mentioned the importance of providing patient education about antibiotic use and other treatment options. Participant 4 highlighted how education can support AMS when stating:
… if everybody is pushing in the same direction then patients won’t come in with the expectation of getting an antibiotic. (Participant 4)
In addition, educating patients about AMR was described: ‘There is a significant part of my job that is around educating people that antibiotics aren’t required for common colds’ (Participant 4). One RN designated prescriber described how they communicate with patients:
People are time poor, concerned [and] just want to get better now, but a [cold] doesn’t necessarily need an antibiotic. I try to reinforce [that it’s the] length or duration of illness, severity of illness [and] underlying conditions, [the patient] might need some rest, a bit of time off, fluids [and] analgesia. An antibiotic targeting a virus is just not good practice. (Participant 2)
Another form of health education described was teaching about alternative or adjuvant treatment options with a participant saying ‘Antibiotics are often an adjuvant to other therapy that’s going on’ (Participant 4). Examples given included: ‘wound cares [to] draw out [the infection]’ (Participant 3); ‘rest and elevation’ (Participant 4); ‘increased fluids’ (Participant 4) and for someone with COPD ‘looking out for three things – being more breathless, increased sputum production and change in colour of the sputum’ (Participant 5).
Theme four: safety and monitoring
Following up with patients was described as being undertaken. For example, participants were aware of monitoring and safety parameters, with participants saying ‘I can provide health education first, then get the patient to come back if things aren’t improving’ (Participant 3). Another example given was when a throat swab had been taken: ‘… and then I waited for the results before letting the patient know whether they needed antibiotics or not’ (Participant 6).
Discussion
The study findings indicate that RN designated prescribers engage and participate in AMS activities related to AMR reduction within their prescribing practices. The main themes generated from the interviews showed that they understood that inappropriate use, misuse and overuse of antibiotics have contributed to the burden of antimicrobial resistance (AMR).
As RNs in NZ work across the primary and secondary healthcare sectors, they are ideally positioned to implement approaches to reducing AMR. They administer drugs, educate patients about their medications and some also prescribe. There is an opportunity to improve all nurses’ awareness of the issue of AMR and the importance of AMS. This would require focused education on microbiology and pharmacology.18
The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics.28 This study has shown that RN designated prescribers are aware and involved in AMS roles when prescribing antibiotics. In addition, their antibiotic prescribing practice considers a detailed aspect of antibiotic suitability, patient factors and clinical indications. This also illustrates their ability to collect an accurate antibiotic history and provide education on antibiotic use using interactions with patients that are underpinned by strong communication skills that aid the development of a therapeutic relationship.
The RN designated prescribers in this study have shown that they have some understanding of AMR and the relationship between overuse of antibiotics and how they use communication to improve understanding by and education of patients. Communication and health education are known to reduce inappropriate patient and family expectations for antibiotics.29–31 Patient education leaflets can be utilised to support explanations when an antibiotic is not prescribed.32 However, the nurses in this study did not describe their use of printed material or other resources, and this is an area that could be explored in future research.
This study also found that the RN designated prescribers provided health education to patients about alternative or adjuvant treatments to antibiotics. This finding concurs to analysis of a primary care prescription database from 2006 to 2010 for the United Kingdom’s National Health Service that found the largest volume of items prescribed by nurses was adjuvant treatments. For instance, gel or colloid wound dressings, medicated stockings, incontinence products and stoma devices, rather than medications.33
Although all participants acknowledged that AMS principles will reduce problems of AMR and that it is a key strategy for improving the appropriate use of antibiotics, it was not clear that they had received education about this during their preparation to become a prescriber. This finding suggests a stronger emphasis on AMR and AMS is required in nursing education. Furthermore, it aligns with previous research that strongly advocates for improving nurses’ education related to AMS as a shift towards combatting AMR.1,15,16
Health professional education is widely recognised as one of the cornerstones of successful AMS programmes.34 This is because education is considered to provide a foundation of knowledge and an environment that facilitates and supports optimal antibiotic prescribing.35 Other sources of information that can be easily accessed and utilised to support AMS are pharmacists.34,35 The RNs in this study identified pharmacists as a source of knowledge and information. This finding supports interprofessional collaborations to promote effective AMS and concurs with previous research that revealed consultant pharmacists facilitate the implementation of policies and procedure to assist prescribers in understanding how to use the organisation’s resources.36
Limitations and areas for future research
A limitation of this study is the small sample size. We used an exploratory descriptive qualitative study design as not much is known about this topic. It would be useful to repeat this study when there are more RN designated prescribers. Alternatively, a survey may attract a larger sample of RN designated prescribers. This would also allow for other recruitment approaches to be utilised as there is a risk of selection bias as nurses self-selected, and only those who were aware of AMS may have consented to participate. Additionally, this study could be extended to discover how nurse prescribing education concerning antibiotics is delivered and what supporting resources are utilised, or if this is a need that should be addressed. Furthermore, future research could audit AMS awareness across all RNs.
Conclusion
AMS remains a cornerstone of efforts aimed at improving antibiotic-related patient safety and slowing the spread of AMR. It is therefore important to ensure that AMS principles are embedded in nursing education. Additionally, nursing prescriber curricula must include AMS to ensure that the requisite knowledge and skills of appropriate and rational prescribing of antimicrobials is cemented to mitigate the risk and increasing issues of AMR.
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