Knowledge

It was decided to merge the domains ‘Knowledge’ and ‘Skill’ as the constructs emerging were overlapping and most findings related to the knowledge factors. The participants did not report that the challenge in diagnosing and treating patients in an LTCF was due to a lack of skills or need for further training in undertaking physical tasks. Knowledge of antibiotic guidelines was variable among all participants. Many participants, from all professions, were not aware of the Guidelines for Antimicrobial Prescribing in Primary Care 2011 or of the Health Protection Surveillance Centre (HPSC) guidelines for the management of catheter-related and non-catheter-related urinary tract infections.24 ,25 In most cases, participants report a passive, rather than active, disregard of guidelines. Nurses in the public setting were more aware of HPSC guidelines but reported that they are not often adhered to. so we have all the antibiotic guidelines, we have the primary care guidelines for antibiotic prescribing which don't give you exact antibiotics to prescribe. Like generally we use the CUH [Cork University Hospital], MUH [Mercy University Hospital] ones do you know those antimicrobial guidelines. (GP2)

The interpretation of urine samples from catheterised patients poses a challenge in LTCFs. Asymptomatic bacteriuria is an area where doctors and nurses felt unsure about whether to prescribe antibiotics or not. Several consultants identified that this is often an area of antibiotic overuse. That is a big bug bear of mine, the UTI, the old person with a UTI, it drives me crazy. Every old person has a UTI and I'd say at least once a day I say to somebody ‘you know if you take a room full of frail old people half of them will have dirty urine, it doesn't mean they have a UTI’. (C2) (UTI=Urinary Tract Infection)

Many participants conveyed confidence in their clinical knowledge due to their years of experience in LTCF practice and their in-depth knowledge of the individual patients. So it can be very difficult to know, you are going by a bit of guesswork, a bit of analysis of results, a bit of examination, a bit of the history from the nurse, it depends on how well the nurse knows them as well, how changed they are from their usual baseline. Then you make a decision. You probably have a lower threshold for using antibiotics in long term care facilities because of all of those factors. (GP9)

In terms of clinical knowledge of the different antibiotics and their indications, it was evident that this varies between participants. Detailed knowledge of antibiotic microbiological coverage or recommended infection indication was not displayed or reported in the findings. Participants were more likely to refer to ‘strong antibiotics’ and only rare references to ‘first line antibiotics’ were made. All participants are aware that AMR is a growing public health problem and that overuse of antibiotics is a contributory factor, but few had any insight into local AMR data or referred to AMR as a serious problem in their LTCF. … we only have a problem with resistance when it comes to urine infections because that is where I think we are over-treating. (GP4)

Closely aligned to ‘Knowledge’ findings are the themes from the ‘Belief of capabilities’ domain. Nurses expressed confidence in providing a high quality of care for the patients and that the more qualified nurses, nurse prescribers and clinical nurse managers provide valuable support to all nurses. ...she is very good (nurse manager) and very with it and she links up with the doctors quite a bit. If she has an issue they really listen to her as well. (N4)

Doctors also expressed professional confidence in caring for LTCF patients with infection. Guidelines are seen as a useful reference, but deviations from the guidelines were justified by relying on their own, or on the nurse’s, clinical judgement and expertise. nothing in medicine is black and white so you can't have guidelines, guidelines are just that, they are guidelines not protocols. I mean that is the difference people need to understand, protocols are something you have to stick to. (GP4) I have no issue with guidelines you know. I think the most important thing is that when veering away from guidelines is justifying what we are doing. (GP7) You don't want them (nurses) to see somebody in the bed who they are worried about and say oh she's not ticking such a box so I'm not going to ask the doctor to see her. (GP1)

The Pharmacists interviewed expressed confidence in the medicines management service they provide to the LTCFs but are less empowered in terms of expanding their clinical role. The reasons for this are the lack of time and the need for further training and guidelines in this area. I think if they had more structured antibiotic CPD for antibiotics in nursing homes and even for pharmacies if we had more specific stuff it would be a big help. (P4). (CPD=Continuing Professional Development) I would be fairly confident but sure I have all the resources here so I can have a quick look and go through them, I wouldn't know all of it off the top of my head, some of it I would. (P9) I would like to be involved in some sort of you know developing some sort of protocol or guidelines within the nursing home, provided we are given the resources and the time to do that with a multidisciplinary team.... (P2)

Social/professional role and identity

The responsibility for antibiotic prescribing was clearly assigned to the doctor, but interestingly the key role of the nurse in that process was also conveyed by all professions. I would be the one dealing with the GPs all the time on their rounds…so even though I think so and so might need an antibiotic or whatever, it is the doctors call in the end. (N3) the way we operate is it is a nursing led facility and we come in to support that nursing lead. We are very lucky with the level of clinical nurse specialists that are there. So they have that higher training in dealing with elderly people, so they provide the care effectively and they rope us in then if there are issues that they are unhappy with or if there are issues as regards to prescribing. So we get involved if they have a concern about a patient or regarding a possibility or probability of infection. (GP7)

It was reported that between doctors, antibiotic prescribing practices vary in terms of the volume and choice of antibiotics prescribed. It was reported several times that out-of-hours doctors are often more likely to prescribe antibiotics. The main reason to explain this is that the patient is generally sicker if a doctor has to visit out of hours and an antibiotic is prescribed to avoid hospitalisation or a revisit. you know if they are calling SouthDoc the patient has a fever, clinical signs, a bad cough, you are probably more likely to prescribe than not. (GP9) (SouthDoc is the out-of-hours doctors service in the greater Cork region)

The difficulties, as reported by an out-of-hours doctor, are that they do not know the patient's medical history, they have limited diagnostic equipment, the patient is often very ill and they may be under pressure from the patient's family or nurse to prescribe. Some GPs reported that out-of-hours doctors may not prescribe first-line antibiotics. …you are called as an out of hours doctor you often times have little option but to prescribe an antibiotic because you don't know the patient, you don't know the staff, you often don't know the background and you may not have complete notes in the history. (GP5)

The role of the pharmacist in antimicrobial stewardship has not developed considerably in LTCFs based on the reports of those interviewed. Some reported that they already attend clinical multidisciplinary meetings with the GPs and nurses and would welcome the opportunity to engage in this further, with support and appropriate training to improve knowledge. Others referred to the lack of time to engage in antimicrobial stewardship and that the priorities for pharmacists in LTCFs were other medicines management issues. In terms of antibiotics I don't know necessarily if there is a huge role there, there are roles in other medicines management issues but not particularly antibiotics. (P9)

Social influences

The social context within which antibiotics are prescribed in LTCFs is clearly evident in the findings. The influence of nurses on doctors’ decisions when managing patients with infection, especially when the decision to prescribe an antibiotic or not is made, was referred to frequently and by all groups of professionals. The nurses act in a gatekeeper role by communicating patient care issues and organising clinical assessments by the doctor when they visit the LTCF. In some cases, their influence in the decision-making process of whether to prescribe an antibiotic can be felt as a pressure by doctors. ...they certainly guide us in our prescribing, they are probably, I don't know is this a fair or unfair thing to say but they are probably happier when we prescribe because at least they know something has been treated. (GP2) You sometimes feel that you do come under pressure to prescribe, and you have to sort of avoid that you know. (GP8) Sometimes the doctors are guided by what we would suggest and what we feel or think. I suppose they just kind of, they are of the opinion we are with the patient so much more than they are but some doctors, definitely not all of them, some of them would defer to the nurse a little bit. (N9)

On the other hand, some nurses also discussed their influence on doctors in terms of delaying antibiotic prescriptions by suggesting ‘watchful waiting’ or that the doctor would reassess the patient in a few days and reconsider the need for an antibiotic at that point.

The role of the pharmacist is mainly in screening for drug interactions and providing medicines information, rather than influencing the antibiotic prescribing process. The influence of the resident’s family on doctors and nurses to assess their relative occurs but was not linked to a pressure to prescribe an antibiotic. Families tend to be satisfied once the doctor has made a clinical assessment, even if they do not prescribe an antibiotic. The importance of including the families in the decision-making process and establishing goals of care for patients was underlined by many doctors, and interestingly by all the consultant geriatricians. ...the family would be insistent on them being seen by a doctor most of time and influence the nurse to call you but once you come and see them and assess them, no it would be uncommon that they would insist on an antibiotic. (GP9) My feeling about prophylactic antibiotics for UTIs and stuff is I ask the family and the patient ‘do you feel it is helping or making a difference’ and if it isn't I stop it. (C2)

Environmental context and resources

The key contextual issue raised is that the management of infection in LTCFs is complicated by a high level of comorbidity, cognitive impairment and dementia in these patients. The lack of diagnostic equipment and interpretation of microbiology results is a significant challenge for doctors and nurses. They also reported that these elderly patients do not always have a high temperature on infection and are often not able to communicate their symptoms. This links to ‘Social Influences’ as doctors depend greatly on the nurse’s support to detect the patient’s signs of infection. The restricted access to a doctor was also a challenge to this process as many LTCFs do not have an on-site medical officer but receive care from GPs who visit infrequently or only on request. Often, owing to time constraints, this can lead to antibiotic prescribing ‘over the phone’, which one GP referred to as prescribing for ‘doctor reasons rather than patient reasons or bacteriological reasons’ (GP6). These challenges are all explicitly linked to an increase in antibiotic prescribing by many participants. I think most of them end up getting an antibiotic to treat as a caution even though maybe it is not as indicated as it would be in the community. (GP2) You sometimes feel that you are prescribing in those situations without a very definite bug or infection. (GP6) Occasionally if it is symptomatic UTI you may prescribe over the phone and see how they go. If it is not responding then you obviously need to go see them. (GP5)

Owing to the plethora of clinical issues for discussion at the clinical multidisciplinary team meetings, antimicrobial stewardship was not reported as a key item on the agenda. There are numerous other competing demands on time during the doctor’s visit to the LTCF and during the clinical meetings. Participants reported that the regulation of LTCFs by the Health Information and Quality Authority (HIQA) ensures that medication management procedures and pharmacist medication reviews are implemented. It was implied that antibiotic audits are only ever conducted to fulfil quality improvement requirements rather than to influence clinical practice. The organisational culture within LTCFs, however, impedes many extra clinical and quality improvement activities because time, and perhaps motivation, is not available. at the moment there is a linked up thinking between the nursing home and the pharmacy…the triangle isn't complete yet where the GP is involved...there are some GPs who would be going to clinical meetings and having clinical meetings, others wouldn't be. (P7) since HIQA have leant on them a small bit it is far more detailed, there is a far more joined up thinking between the pharmacy and the home and we have established a set of I suppose a complete medicine management system. (P7) Then I suppose all it needs is someone like HIQA or the ICGP or the pharmacy crowd to come and say ‘look lads you are not practicing properly unless you are doing this’ then GPs do adhere to it, they will certainly adhere to it if they are told it is best practice and they all try to adhere to best practice. (GP2) (ICGP: Irish College of General Practitioners)

The domains ‘Environmental context and resources’ and ‘Beliefs about Consequences’ are closely aligned. The potential harm or hospitalisation of a vulnerable, comorbid LTCF patient if an antibiotic is not prescribed is a matter of concern to doctors and nurses. The general consensus was that over-treatment with antibiotics and subsequent care in the LTCF is preferred and that hospitalisation should be avoided if at all possible. The domain ‘Emotion’ is relevant here as participants spoke about fear of the patient coming to harm because of their decision. …if that means you prescribe the odd antibiotic excessively, I think for the resident most times it's a better scenario for the individual than ending up in an A&E department because of an untreated infection. It's a balancing act really. (GP1) ...you say look we will hold off on the antibiotic and I have certainly been caught once with a patient who then developed pyelonephritis and was sick and so that learns you alright. (GP7)

There is a lack of acknowledgement that antibiotic prescribing in LTCFs contributes to the public health problem of AMR. Many references to AMR associated it with antibiotic prophylaxis and that it was not common among the patients in the LTCF. There was little discussion about how to avoid the development of AMR and a sense of inevitability regarding this unavoidable problem was evident. ..writing a prescription for an antibiotic is seen as an action or a response, a quick action or a quick response to some problem… I would doubt that resistance is at the forefront of that decision at that time. (C3)

Memory, attention and decision processes

The variability and complexity of the decision-making process is evident by the findings attributed to the aforementioned TDF domains. For many Doctors, this decision-making process is a culmination of the factors already outlined resulting in a ‘balancing act’ as they make a risk-benefit assessment of the patient’s need for an antibiotic. The fear of the consequences for the patient and the uncertainty around the diagnosis of infection in LTCF patients was clearly linked to the overprescribing of antibiotics in LTCFs by many participants. Much discussion centred on the decision of whether to prescribe an antibiotic or not, with much less thought being given to the decision around which antibiotic to prescribe. I think if you wait and if the person gets sicker you are kind of damned and if you give them an antibiotic and they really did not have an infection and something else happens to them you are damned. (C1) you probably do end up prescribing more for the elderly than you would for you or me who are younger, in the fact that you are always slightly worried that if you don’ t prescribe then they will get worse. (GP8)

The decision-making autonomy and individual patient care approach dominates the decision-making process for doctors and nurses. Their attention is focused on the patient's clinical presentation, medical history and in some cases the overall care plan. As outlined in ‘Beliefs about consequences’, the public health threat of AMR does not influence this decision. I would look to see do they have a temperature, not all the elderly will develop a temperature, some of them are immuno-compromised for various reasons so they don't always necessarily have a temperature. So looking at sats, looking at clinical findings, looking at have they gone off food, are they obviously unwell in themselves. I think that is one thing that sometimes guidelines don't capture. They don't capture that sort of, they will have criteria set down but they don't cover that sort of knowing the patient bit. (GP1)

Several participants acknowledged the valuable support of guidelines to help clinical decision-making. Nurses and pharmacists reported that guidelines are an effective way to ensure that all healthcare professionals were practising evidence-based medicine and that they are a necessity when dealing with outbreaks of infection. I think there needs to be clear guidelines and protocols in each setting regarding antibiotic use. I do tend to think that there is just generic broad spectrum prescribing of different types of infections without actually doing any sensitivity testing. (P2)

This leads to the important domain of ‘Behavioural regulation’. The extent of self-monitoring by means of antibiotic surveillance or audit is low and any reported activities generally consisted of participation in the HALT point prevalence studies in some, but not all, of the LTCFs. Participants from all groups welcomed the idea of surveillance and reviewing antibiotic prescribing practices and felt that this would contribute to improving patient care. Doctors were somewhat cautious and several expressed doubt about conducting audits which judge an antibiotic prescription as being appropriate or not. Benchmarking audit results with other centres was not viewed as being a particularly useful exercise by many doctors. Comparing to other centres, yes but so what? What you are going to do is compare your errors really to their errors. What you need to do is to compare to what you should be doing and see if that can be implemented, if you can do that. (GP6)

A few participants made suggestions for information technology solutions such as decision support systems to guide decision-making but added that a lack of resources would rule out that option. So I suppose the first thing is the guidance is there, the second thing then is education around the guidance and then you have got to audit it. So it is a cycle, you know the cycle, but whether the government is willing to actually you know follow through with that, that is the big problem, with that is that some investment needs to be made in the education and then people can use it as an audit for their continuing medical education and their medical counsel requirements. (GP1)