Assignment: Masters In Psychology

Participants noted that the presence of a study

leader or ‘champion’ would improve the implementation of

a new pathway or process by providing extra support and

reassurance for nursing staff [14]. In order to support the

implementation of AMS interventions, it was identified that

skills training and education for doctors and nurses was

needed [15, 17]. The overall positive experiences of using a

pathway, as reported by the participants in the trials

300 A. Fleming et al.

conducted by Carusone et al. and Lohfield et al. [14, 16,

17], provided useful information for future strategies. The

nurses, medical directors and administrators could see the

benefit for patients when implementing the pathways, as a

faster diagnosis was made and patient care was reportedly

improved [14, 16, 17]. Participants recommended that

guidelines or education specifically regarding infection

diagnosis and treatment in LTCFs would be beneficial [15].

Schweizer et al. [18] made specific recommendations to

introduce protocols to guide the management of UTIs, in-

cluding how and when to take a urine sample. It was also

noted that flexibility in terms of deviating from a guideline

or protocol must be allowed, as not every case is likely to

fit a treatment pathway [17].

The concept and principles of AMS were welcomed by

participants in most studies. The facilitators of AMS in-

cluded acceptance by nurses of implementation of quality

improvement initiatives and clinical pathways [15]. The

pharmacists reported willingness to expand their clinical

role in this area but acknowledged that funding would be

required to support this [15]. The promotion of evidence-

based practice was accepted by all health care professionals

as being a key benefit of AMS.

Barriers to implementing AMS and raising awareness of

growing AMR were identified in several studies [14–17].

The strategies involved in AMS and securing the willing-

ness of doctors to accept policies or guidelines can affect

how the interventions are adopted into daily practice [15].

Concern was expressed that non-acceptance of a strategy

by doctors would be problematic for nurses who are willing

to implement new strategies in the LTCF [15]. Some nurses

were concerned about the extra workload and level of re-

sponsibility demanded by these strategies [16]. This related

to lack of confidence and fear of change, which were

highlighted by participants in one study [17]. On the other

hand, it was also reported that nurses’ confidence increased

on implementation of the pathway, as they felt more em-

powered [16]. Another barrier to implementing AMS

pathways was the influence of families, who could pres-

surize nurses and doctors to act against the pathway [17].

4 Discussion

This review is the first to systematically incorporate the

findings of all qualitative investigations of antibiotic pre-

scribing in LTCFs. This study outlines the many factors

that influence antibiotic prescribing in LTCFs and also the

challenges facing AMS strategies in LTCFs. The key issues

are the contextual features of LTCF care, coupled with

variable knowledge and practices in managing infection,

which are all subject to heavy social factors. The inter-

dependent relationship between nurses and doctors in

LTCFs is a unique one, as most doctors are not on-site. It

was encouraging to find that many participants in these

studies welcomed the opportunity for further training or

education, suggesting that there is an acceptance of change

and AMS in LTCFs. One challenge in changing antibiotic

prescribing behaviours in LTCFs is that many participants,

as identified in this study, were not self-critical regarding

antibiotic prescribing at their LTCF. This synthesis study

has contributed a greater understanding of the factors in-

fluencing antibiotic prescribing in LTCFs. There was a

noteworthy similarity in themes emerging from all of the

included studies, which reinforces the validity of the

findings of this review.

LTCF context: – Lack of LTCF resources

(doctors, diagnos�c equipment).

– Care in LTCF priority over hospitalisa�on.

Social Factors: – Central role of nurse – Influence of family

Knowledge & prac�ce: –