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

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The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: a qualitative study Leslie Dowson , N. Deborah Friedman , Caroline Marshall , Rhonda L. Stuart , Kirsty Buising , Arjun Rajkhowa , Fiona Gotterson , David C.M. Kong PII: DOI: Reference:

S0020-7489(19)30309-8 https://doi.org/10.1016/j.ijnurstu.2019.103502 NS 103502

To appear in:

International Journal of Nursing Studies

Received date: Revised date: Accepted date:

30 May 2019 29 November 2019 4 December 2019

Please cite this article as: Leslie Dowson , N. Deborah Friedman , Caroline Marshall , Rhonda L. Stuart , Kirsty Buising , Arjun Rajkhowa , Fiona Gotterson , David C.M. Kong , The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: a qualitative study, International Journal of Nursing Studies (2019), doi: https://doi.org/10.1016/j.ijnurstu.2019.103502

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Title: The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: a qualitative study Author names and affiliations: Leslie Dowson, MBioethics a,b N. Deborah Friedman, MBBS, MD, MPH a,f,g Caroline Marshall, MBBS, PhD, Grad Dip Clin Epi a,c,d,e Rhonda L. Stuart, MBBS, FRACP, PhD a,i,j Kirsty Buising, MBBS, MPH, MD a,c,d Arjun Rajkhowa, PhDa Fiona Gotterson, MACN, RN, MN a,c *David C. M. Kong, BPharm, MPharm, PhD a,b,h a

National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria, Australia, 3000 b Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria, Australia, 3052 c Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, Victoria, Australia, 3010 d Victorian Infectious Diseases Service at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria, Australia, 3000 e Infection Prevention and Surveillance Service, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3052 f School of Medicine, Deakin University, 75 Pigdons Rd, Geelong, Victoria, Australia, 3216 g Department of General Medicine and Department of Infectious Diseases, Barwon Health, Ryrie St & Bellerine St, Geelong, Victoria, Australia, 3220 h Pharmacy Department, Ballarat Health Services, 1 Drummond St N, Ballarat, Victoria, Australia, 3350 i Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, Australia, 3800 j Monash Infectious Diseases and Infection Control and Epidemiology, Monash Health, 246 Clayton Rd, Clayton, Victoria, Australia, 3168

*Corresponding author: David C. M. Kong Monash University Centre for Medicine Use and Safety 381 Royal Parade, Parkville, VIC, Australia, 3052 E: [email protected] P: + 61 3 5320 4106

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 homes 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.

Contribution of the paper What is already known about the topic? 

Nurses are important participants in antimicrobial use in aged-care homes.



Antimicrobials are frequently prescribed for residents of aged-care homes who are near the end of life, commonly without residents having signs or symptoms of infection to support such use.

What this paper adds 

Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care.



Nurse leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources are opportunities for nurses to lead antimicrobial stewardship near the end of life in aged-care homes.



Past negative social interactions within the aged-care home environment between nurses and families can result in „fear-based‟ social influences on antimicrobial prescribing near the end of life.

Manuscript Background

Internationally, the inappropriate use of antimicrobials in aged-care homes is a widely recognised phenomenon.(Loeb et al., 2001, National Centre for Antimicrobial Stewardship and Australian Commission on Safety and Quality in Health Care, 2018, Pettersson et al., 2008) This is problematic because it can harm residents,(Daneman et al., 2015) and is detrimental to public health.(Medew, 2015, O'Fallon et al., 2009, Tenover, 2006) There is compelling evidence that antimicrobial resistance develops more rapidly with inappropriate antimicrobial use.(Bruyndonckx et al., 2017, Cheng et al., 2016, Tenover, 2006, World Health Organization, 2015, Wurster et al., 2016) Globally, drug-resistant organisms are increasing in prevalence,(Gu et al., 2018, Laxminarayan et al., 2015, Liu et al., 2016) and the World Health Organization has urged action, before we enter into an era in which even the most common infections become untreatable.(World Health Organization, 2015) As such, antimicrobial stewardship, which is an ongoing effort by health care providers to optimise antimicrobial use,(Australian Commission on Safety and Quality in Health Care, 2012) should be implemented in aged-care homes. The opportunities for aged-care home nurses to engage in antimicrobial stewardship, however, are not well understood. Nurses have previously been described as antimicrobial „brokers‟ in acute hospital settings.(Broom et al., 2016)

Residents of aged-care homes who receive antimicrobials include those who are near the end of life. The term „end of life‟ was previously used to refer to a time prior to death when all active treatment and medications were ceased, except those administered for comfort. The definition of end of life however, has more recently been broadened to include the entire period when someone is living with a life-limiting condition, even if the trajectory is unknown.(Australian Commission on Safety and Quality in Health Care, 2015) This time

period may be years. Not all aged-care home residents are at the end of life; however, for permanent residents in Australian aged-care homes, most separations (83.9%, 53 903/64 245 in 2016-2017) are due to death.(Australian Institute of Health and Welfare, 2018) Even though as many as 75% of residents of aged-care homes have indicated that they would refuse antimicrobials in some scenarios of advanced illness,(Gjerdingen et al., 1999) a resident in the final month of life is increasingly likely to be prescribed an antimicrobial (42.4% of residents two weeks before death v. 7.2% of residents eight weeks before death, P<0.001),(D'Agata and Mitchell, 2008) commonly without having signs and symptoms of infection that support antimicrobial use (56% of episodes treated with an antimicrobial in this study did not meet minimum criteria for initiation).(Mitchell et al., 2014)

It is known that most residents who will die in Australian aged-care homes will not be cared for by palliative care specialists, and, if impending death is recognised beforehand, that recognition is most likely to occur on the day of death or on the day prior to death.(Australian Institute of Health and Welfare, 2018, Williams, 2018) In 2016-17, only 1.9% (4 509/239 600) of Australians entering aged-care homes were appraised for palliative care specialty services.(Australian Institute of Health and Welfare, 2018) The time „near‟ the end of life during which residents with advanced illnesses are receiving routine care is, therefore, an important time to consider for appropriate antimicrobial stewardship activities.

Under current Australian aged-care home governance structures there is no requirement for an onsite medical professional.(Australian Government, 1997, Australian Government, 2014) Offsite general practitioners are, in most cases, primarily responsible for residents‟ medical care (including medical care near the end of life) and after-hours locum general practitioners s frequently attend to residents when the primary general practitioners are unavailable. In

day-to-day operations, aged-care homes s usually have one registered nurse facility manager, and at least one registered nurse onsite and available to provide clinical care to residents (depending on the size and structure of the aged-care home ). A number of enrolled nurses and personal care assistants also provide direct activities-of-daily-living support to residents. There are no minimum staffing ratios.(Australian Government, 1997, Australian Government, 2014) While aged-care home residents have access to community and hospitalbased health care services, a resident‟s ability to use these services is often limited by transportation and care requirements. Many community health services and hospitals, therefore, also offer in-reach (or sometimes called out-reach) services, where clinicians will visit residents in their aged-care homes. .(State Government of Victoria, 2018) The health care and assistance offered by these in-reach services varies depending on location.

We aimed to describe the perspectives of health professionals on antimicrobial use near the end of life in aged-care homes s and investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes.

Methods

One-on-one semi-structured qualitative interviews were conducted with health professionals (i.e., nurses, general practitioners and pharmacists) working in aged-care homes in Victoria, Australia. Data collection

In this study, we define antimicrobial use near the end of life as antimicrobials prescribed when a resident is in the advanced stages of a life-limiting illness (including life-limiting diseases of old age such as dementia and frailty) but receiving active treatments, and not on an end-of-life pathway, nor under the care of a palliative care specialist. Health professionals responsible for the routine care of residents near the end of life within aged-care homes were recruited. Specialist clinicians such as geriatricians, speciality palliative care clinicians and infectious diseases clinicians were purposely not included in this study as our aim was to examine what routinely occurs in an aged-care home in Australia.

Participants were recruited through purposive, convenience and snowball sampling. Diversity in terms of years of experience, aged-care home funding type (government, private-forprofits and not-for-profits) and location (metropolitan and regional) was sought. Interviews were conducted until data saturation. Data saturation was when no new themes emerged in six consecutive interviews (covering the range of health professionals in the sample). Qualitative multidisciplinary studies of antimicrobial prescribing in aged care have previously reported a high degree of thematic concordance between the views of nurses, doctors and pharmacists.(Fleming et al., 2014, Lim et al., 2014)

Participants were approached for one interview, after which no further contact was initiated by the researchers. Early themes were validated in later interviews. Three of the nurse participants [Nurse 1; Nurse 10, Nurse 11] were approached face-to-face and were known to the interviewer (LD) prior to this research. The remainder of participants were unknown to the interviewer before this research and were approached via email or telephone about participation.

One-on-one interviews took place in a setting of the participant‟s choice. This included agedcare homes s, doctors‟ clinics, and public spaces. After providing informed consent, participants indicated whether they agreed to being audio recorded. The interviewer (LD) was a female PhD candidate with a Master‟s Degree in Bioethics, who had nine years of prior experience in mixed-methods research with older people. A demographic questionnaire recording the age, profession, years in the profession, and years with their current aged-care home was facilitated by the interviewer. Demographic details about the aged-care homes where participants were employed were also recorded by the interviewer. All participants were provided with information explaining that the interviewer was researching antimicrobial stewardship for care near the end of life in aged-care homes for a PhD study. No other biases of the interviewer were reported to the participants. The interviewer had never been employed in a clinical or administrative context in an aged-care home, and thus did not bring biases to the interviews based on prior personal professional experiences in aged-care homes.

For participants who agreed to be audio recorded the recorder was turned on after completion of the demographic questionnaire. The interviews followed a pre-set semi-structured interview guide, with early interviews and data analysis informing exploration in later interviews. The semi-structure interview guide was pilot tested with an experienced aged-care nurse and revised once prior to the start of the interviews on the basis of that pilot testing. Extensive field notes were written by the interviewer during, and immediately after, the interviews for participants who were not audio recorded. As applicable, field notes were written for audio recorded participants for context. The audio recordings were transcribed by an independent professional transcriptionist. The interviewer checked the transcripts for correctness and familiarisation. Interviews occurred between January 2017 and July 2018.

Data analysis Transcripts and field notes were uploaded into NVivo® Software, Version 11, by QSR International Pty. Ltd. (Doncaster, VIC, Australia) for data analysis. The code structure generated by investigator LD was created with two levels. The transcripts were first coded in an open (Ryan and Bernard, 2003) and descriptive (Braun and Clarke, 2006) manner, coding line-by-line and summarising in a few words the literal topic of a passage of data. The descriptive code was used to then build interpretive code through an integrated process of inductive (Braun and Clarke, 2006) and deductive coding.(Braun and Clarke, 2006)

LD used validated frameworks [the „COM-B‟ and Theoretical Domain Framework (Cane et al., 2012, Mitchie et al., 2011)] for understanding behaviour change to identify potential opportunities for aged-care home nurses to engage in antimicrobial stewardship activities near the end of life. How the „COM-B‟ maps onto the Theoretical Domain Framework is described elsewhere.(Cane et al., 2012) According to the „COM-B‟ and Theoretical Domain Framework, opportunities for behavior are based on social and physical factors, i.e., social influences, and environmental contexts and resources.(Cane et al., 2012, Mitchie et al., 2011) Environmental contexts and resources, in our exploration and as adapted from the Theoretical Domain Framework,(Cane et al., 2012) refer to „any circumstances in the aged-care situation or environment that discourages (or encourages) antimicrobial prescribing near the end of life when an antimicrobial is unlikely to provide benefit to a resident.‟ Social influences, in our exploration and as adapted from theTheoretical Domain Framework ,(Cane et al., 2012) refer to „interpersonal processes that can change thoughts, feelings and/or behaviours discouraging (or encouraging) antimicrobial prescribing near the end of life when an antimicrobial is unlikely to provide benefit to a resident.‟

The process of descriptive coding was started with some pre-set codes based on the „COM-B‟ and Theoretical Domain Framework (Cane et al., 2012, Mitchie et al., 2011) as well as successful antimicrobial stewardship activities in the peer-reviewed literature. In building the interpretive code, investigator LD used the descriptive code and sought to answer four question adapted from a study by Broom et al. (Broom et al., 2016) that examined nursing behaviours related to antimicrobial use in acute hospitals. The questions were adapted by Broom et al. (Broom et al., 2016) from Charmaz‟s (Charmaz, 1990) grounded theory approach to data analysis. Our questions were: 1. What is the environmental context and social basis of nurse participation in antimicrobial prescribing near the end of life in aged care homes? 2. What does this assume implicitly or explicitly about aged-care nurses and their workplace relationships? 3. Of what larger process is this behaviour a part? 4. What are the implications of such nurse behaviours for residents, general practitioners s and families in aged-care homes with regards to antimicrobial prescribing near the end of life? A 25% sample was double coded by a second investigator (AR) to test and verify the code structure. Differences were resolved by discussion between LD and AR. Specific recommended antimicrobial stewardship activities for care near the end of life in aged-care homes s from this study will be reported elsewhere. Human Research Ethics Approvals This multi-site study was approved by Monash University‟s (Project CF16/16602016000867) and Monash Health‟s Human Research Ethics Committees (Project

HREC/16/MonH/236). Research governance approvals at aged-care home sites were also obtained.

Results

No interview participants withdrew from the study after participating, and three people declined to participate at the time of interview without offering specific reasons. The demographics of the 20 participants are listed in Table 1. The mean interview duration was 29 minutes and 07 seconds (Range: 16 minutes and 29 seconds to 59 minutes and 35 seconds). Two participants (General Practitioner 3 and Pharmacist 2) were not audio recorded.

Table 1: List of participants Profession

Gender

Years in the

Agency type

profession

Agency location

Nurse, 1 (Enrolled Nurse)

Female

4

Private-for-profit

Metropolitan

Nurse, 2 (Enrolled Nurse)

Female

4 months

Private-not-for-

Metropolitan

profit Nurse, 3 (Registered Nurse)

Female

27

Mixed

Metropolitan

Nurse, 4 (Registered Nurse)

Female

18

Private-not-for-

Metropolitan

profit Nurse, 5 (Registered Nurse)

Female

6

Private-for-profit

Metropolitan

Nurse, 6 (Registered Nurse)

Female

40

Government

Regional

Nurse, 7 (Registered Nurse)

Female

26

Government

Regional

Nurse, 8 (Registered Nurse)

Female

22

Government

Regional

Nurse, 9 (Registered Nurse)

Female

10

Government

Regional

Nurse, 10 (Registered Nurse)

Female

12

Government

Metropolitan

Nurse, 11 (Registered Nurse)

Female

25

Government

Metropolitan

Nurse, 12 (Registered Nurse)

Female

25

Private-not-for-

Metropolitan

profit General Practitioner, 1

Male

30

Private-for-profit

Metropolitan

General Practitioner, 2

Female

41

Mixed

Metropolitan

General Practitioner, 3

Male

42

Mixed

Metropolitan

General Practitioner, 4

Female

1

Private-for-profit

Metropolitan

General Practitioner, 5

Male

2

Mixed

Regional

General Practitioner, 6

Female

40

Mixed

Regional

Pharmacist, 1

Male

7

Mixed

Metropolitan

Pharmacist, 2

Female

37

Mixed

Regional

(Registrar)

There was a high degree of concordance between AR and LD‟s descriptive coding and the major interpretive themes identified were confirmed by both coders. Thematic saturation was reached after fourteen interviews. An additional six interviews were conducted (covering the range of health care professions included in the sample), to further validate emergent data and ensure no new interpretive themes emerged.

Table 2 illustrates the key interpretive themes in the data that pertain to opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes. The main opportunities were identified as being in routine care.

Table 2: Main interpretive themes After agreement to stop

Routine Care

active treatment Judicious antimicrobial use

Antimicrobials are used in routine care near the end of life

occurs after clear agreement

when unlikely to benefit residents: the risks of treatment are

to stop active treatment,

minimised and families influence decision-making.

although mistakes

Nurses are influential in routine care antimicrobial decisions

sometimes occur.

near the end of life in aged-care homes. Environmental contexts of

Social influences of nurses:

nursing influence:

 Nurses can lead decision-

Stopgap and visiting medical care Nurses have responsibility for advance care planning

making with families  Nurses have social influence during decisionmaking  Nurses perceive negative social influences during decision-making from past negative social interactions in the care environment

Overarching themes Judicious antimicrobial use occurs after clear agreements to stop active treatment Most participants maintained that if there was clear agreement (usually between health professionals and family members) to stop active treatments because the death of a resident

was imminent, or if palliative care specialists were involved, use of antimicrobials in agedcare homes was generally judicious. Nurses reported good adherence to the expected transition in care to prioritising symptom relief and comfort. General practitioner participants reinforced the validity of these nursing perspectives, reporting that, in their experience, few nurses would „expect‟ antimicrobials to be prescribed at this stage. A general practitioner participant argued, however, that antimicrobials may well be prescribed for symptom relief at the end of life, and, as such, may be deemed by the treating team to be a suitable and efficacious component of a palliative approach. “When they start to really move to that phase where they… show signs of shutdown…we start to look at what care we‟re actually focussing on.” Nurse 10 “I don‟t think there's any nurses that would expect antibiotics in that last stage of life.” General Practitioner 2 “And if you believe you can provide some symptom relief without harm, then there's an argument for it…” General Practitioner 1 Mistakes in judicious antimicrobial use after agreements to stop active treatment Examples of ambiguity in documentation which lead to hospital transfers and initiation of antimicrobial therapy contravening agreements to cease active treatments were provided by both general practitioner and nurse participants. Some nurse participants emphasised the importance of being seen to be extending themselves and undertaking all possible actions to „save‟ residents‟ lives even at the end of life, which could contribute to antimicrobial use that might otherwise be deemed unnecessary and inefficacious. “We‟ve had some issues recently where people have been sent to the hospital [and given intravenous antimicrobials ] when they didn‟t want to be, but their information wasn‟t clear enough.” Nurse 11

“It‟s about saving the life and doing it at every cost and not being blamed for it.” Nurse 4 Antimicrobials in routine care near the end of life: the risks of treatment are minimised and families influence decision-making Antimicrobials are sometimes prescribed in aged-care homes s for residents near the end of life as part of routine care even when health professionals believe they are unlikely to benefit the resident. Two reasons for this were evident. First, some nurse and general practitioner participants gave credence to, and affirmed the perception that routinely treating infections with antimicrobials at the end of life, even if such treatment is futile, poses minimal risks, and that the benefits of such treatment (in terms of providing reassurance to the resident‟s family) outweigh conceivable risks. “You feel like the benefits probably outweigh the risk even if in the end it‟s completely futile...” General Practitioner 4 “I think if it gives family peace of mind and you know it‟s not going to do anything, then yes, I can see where prescribing it would be useful.” Nurse 10 Second, the futile antimicrobial treatment was considered acceptable if it served the purpose of either appeasing the family or helping the family to cope with the residents‟ illness or the loss of the resident. The primacy accorded to families‟ wishes and preferences was affirmed by all participants. Family expectations and wishes were deemed to serve as a major driver of antimicrobial use at the end of life, with such social influences constituting a significant determinant of prescribing decisions. “It depends on whether the family wants it to happen or not ... Because I think they‟ve got to deal with it and if it's going to cause them more grief and distress, then I‟m happy to try and relieve that if I can...” General Practitioner 6

“Look, it's understandable what the „GP‟ did [prescribed an antimicrobial he believed was futile] because sometimes you just do things to make the family happy.” Nurse, 12 Nurses are influential in routine care antimicrobial decisions near the end of life in ACHs Nurses are influential in antimicrobial prescribing near the end of life in aged-care homes. Specifically, the importance of the role of nurses in care co-ordination and delivery in an environment of stopgap and visiting medical resources emerged as a standout theme from the interviews. Nursing roles in advanced care planning and nurses‟ perceived social influences also emerged as important themes. “It's easier now not to treat I think, because nurses are more informed.” General Practitioner 2 “If we see that suddenly a resident is going down quickly, or deteriorating, we will refer them to their „GP‟, and then we‟ll have a chat with the „GP‟ to say „no, this is what's happening‟” Nurse 11

Commentary on the environmental contexts and social bases of nurses‟ influences is instantiated below, interpreted via themes and subthemes elicited from the interviews. Interpretive themes: Nursing influences on antimicrobial prescribing near the end of life 

Environmental contexts: Stopgap and visiting medical care

Two themes regarding aged-care home medical care emerged from the data. The first is that currently available resources in the aged-care home environment do not often enable timely responses from residents‟ primary general practitioners in cases of suspected infection near the end of life. Primary general practitioners are often unavailable to physically attend to

acutely unwell residents. Nurses, therefore, routinely coordinate resident care around the predictable unavailability of primary general practitioners by contacting the residents‟ family, asking for telephone orders, contacting locum general practitioners, contacting hospital-based services and/or transferring residents to hospital. “Availability of the medical staff, I think is a big thing. There‟s one nursing home in particular, the doctor visits one day a month and that‟s it, and the rest of the time there‟s no availability, they don‟t even answer calls.” Nurse 3 “Doctors come at useless times – like they come in the middle of the day when most family members can't visit … we are not really available after hours to visit as their primary „GP‟ unfortunately.” General Practitioner 4 Secondly, even when physically present in an aged-care home, general practitioners are visitors or “outsider[s]” [General Practitioner 5], and hence nurses frequently must “service” [Nurse 11] general practitioners during their visits. During this time, it emerged that nurses help, inform and guide general practitioners with regards to paper work (including advance care planning documents), current resident status, family wishes and any outstanding issues the nurses would like the general practitioner to resolve or consider. This is also a time when nurses have the opportunity to greatly influence antimicrobial prescribing. “You also have to tell this locum doctor who‟s not familiar with our paperwork, that this is where this is and this is what it says.” Nurse 11 “Yes, you are very dependent on them [the nurses].” General Practitioner 4 

Environmental contexts: Nurses have responsibility for advance care planning

It emerged that aged-care home nurses have primary responsibility for initiating and following up advance care plans after a resident enters into aged care. Advance care plans are

often initiated as part of the routine paperwork a resident or family receives upon entry into an aged-care home.. Whilst statutory directives must be signed by a medical doctor, the extent to which a resident‟s primary general practitioner is involved in the drafting, updating and use of a resident‟s advance care plan appears to be highly variable. “So, the „GP‟ does have a level of responsibility for ensuring the documentation is completed and that they‟ve had those conversations but they use our paperwork – so that‟s where we all take the responsibility for it as well…depends on the „GP‟ too. We‟ve got some „GPs‟ who are heavily involved and they will sit down with the family and have those conversations – we‟ve also got „GPs‟ who will come and [just] sign the document.” Nurse 10 “I don‟t do the actual advance care plans at the nursing homes as a rule.” General Practitioner 6 There was little consensus among participants on how advance care plans are used to make antimicrobial prescribing decisions. Some general practitioners found advance care planning documents more helpful than others. It emerged that the nurses primarily used the plans to advocate for residents during critical conversations. “I don‟t find the document useful at all. I don‟t think I‟ve ever referred to a document.” General Practitioner 1 “If they're clinically…very unwell, and many times, you know, I have to deal with that… I look at it straight away…” General Practitioner 5 “I felt hugely responsible for what I‟ve done. It hasn‟t stopped me from going down that path again when you know that it‟s what somebody wants.” Nurse 11

“The „RN‟ will tell us, you know, [she‟s] not well today we think she‟s near end of life and, you know, she‟s not going to go to hospital; the family doesn‟t want her to go to hospital, she doesn‟t want this and she doesn‟t want that.” Nurse 1



Social influences: Nurses can lead antimicrobial decision-making with families

Participants reported that an attempt to have a conversation with a resident‟s family (or other substitute decision-maker) will almost always be made when there is a potentially life-ordeath medical decision (including initiating antimicrobial treatment) and a resident is near the end of life. No evidence of complete reliance on the advance care planning documentation, nor on prior conversations, for these decisions was offered in the interviews. “Even though we have a plan, 99.9% of the time we ring the family and say do you want to go ahead with this plan?” Nurse 8 Whilst some general practitioners indicated they would lead these critical conversations whenever possible, there was evidence of nurses being primarily responsible for leading these conversations. “I always have the discussion with the family myself…” General Practitioner 2 “If there's a critical decision on something, yes I will [ring the family], …or the staff may have already done so by the time I get there…” General Practitioner 6 “Staff do it, yeah.” [Response to the question: And is it, your staff here that is then charged with ringing the family, it‟s not the locum doctor who‟s trying to ring the family?] Nurse 11 

Social influences: Nurses have social influence during decision-making

It emerged from the interviews that nurses have social influence among residents, general practitioners and families. It was reported that some nurses use their social influence either to encourage or discourage antimicrobial prescribing near the end of life during decisionmaking. The conscious use of social influence during decision-making was a stronger theme in the views of the more experienced nurses. “The younger ones [general practitioners] tend to be a little bit more easily talked into maybe looking at a different point of view” Nurse 9 “So, yes, the more vulnerable the family get, the more easily they are led by a nurse who goes no, no, no, this [treatment/antimicrobial] will help…” Nurse 8 “If it's family, I‟ll go „GP‟, if it's „GP‟, I‟ll go family. I use any side entrance I can to get in, and there's nothing wrong with that, because I feel I am the resident‟s advocate...” Nurse 8 

Social influences: Nurses perceive negative social influences during decisionmaking from past negative social interactions in the care environment

It emerged that when critical decision-making conversations occur, the resident, family and nurses, in most cases, will already have a history of social interaction within the aged-care home environment, and past negative social interactions can weigh heavily on antimicrobial decision-making. The decision to treat a resident with an antimicrobial can primarily be informed by fear there will be an unpleasant confrontation or a complaint from family. This may result in antimicrobial prescribing because the nurses fear the repercussions of not initiating antimicrobial therapy. Sound clinical decision-making and the resident‟s known wishes were often lesser considerations. “The bigger issues actually were around fear that the family would make complaints if they hadn‟t done the right thing.” Nurse 11

“And they‟re not always pleasant in the way they provide that feedback to the staff, and so there is a kind of a fear that develops around, well, we could get shouted at by someone, they could be very abusive if we‟ve done the wrong thing...” Nurse 4 “A lot of it is because of fear. And I think if you and I were in their shoes we would possibly do the same...” Pharmacist 1 “The situation may be quite litigious, so they will go to hospital as well.” Nurse 10

Discussion

To our knowledge, this is the first study to describe specific nursing opportunities to participate in antimicrobial activities near the end of life, within the environmental contexts and social influences of aged-care homes. In aged-care homes, nurses take on required leadership roles and have substantial social influence within a context of stopgap and visiting medical resources. This includes facilitating advance care planning and having critical conversations with families about decisions for care near the end of life.

Unlike acute care nurses, aged-care home nurses‟ role in antimicrobial use does not significantly involve circumventing institutional controls,(Broom et al., 2016) as antimicrobial controls in aged-care homes are largely non-existent. For the most part, an aged-care home nurse does not prescribe antimicrobials, but rather undertakes, initiates and influences routines which can result in antimicrobial prescribing. A routine refers to a regularly followed procedure.(Oxford English Dictionary, 2019) In aged-care homes s, these routines include nurses leading advance care planning, nurses leading critical conversations with families, nurses coordinating resident care around unavailable primary general practitioners, and nurses „servicing‟ outside antimicrobial prescribers when they enter an

aged-care home. . Aged-care home nurses lead many routines in aged-care homes and other health professionals, for the most part, are required to fit into the routines of the aged care homes where they practice. Therefore, aged-care home routines offer several opportunities for nurses to engage in antimicrobial stewardship activities.

The work of facilitating advance care planning presents a key opportunity for nurses to influence antimicrobial prescribing near the end of life when an antimicrobial is unlikely to provide benefit to a resident. Prior advance care planning and being certain about a resident‟s wishes enables nurses to advocate for residents and discourage the prescribing of unnecessary or unwanted antimicrobials during critical conversations. Although residents should also be involved in all treatment decisions if able, active resident voices in this context were rarely mentioned by participants in this study. This might be reflective of the large number of agedcare home residents who have cognitive impairment, the unlikelihood of an acutely unwell resident near the end of life being able to make an informed decision, or family wishes taking precedence. There is room for general practitioners to expand their roles in aged care homes in relation to advance care planning, and to become consistent participants in the process, which has been shown to improve satisfaction with end-of-life care.(Bernacki and Block, 2014) Decisions about antimicrobials could also be used to trigger further end-of-life care discussions between aged-care home health professionals and families.

Social influences and interpersonal processes are extremely important in decision-making near the end of life, because decisions are usually finalised during critical conversations, and how these conversations are framed by health professionals can impact the on final decision.(Bernacki and Block, 2014, Billings, 2012) Furthermore, negative social interactions (perceived or real) were identified by some nurses as causing fear about delivering

appropriate clinical care in aged-care homes. Nurses are relied upon extensively as communication conduits (and care coordinators) between medical professionals and families, because residents‟ primary general practitioners s are often unavailable. This role can cause nurses to request an unnecessary antimicrobial, because of fear about potential complaints or negative confrontations. While the participants in this study described many examples where social pressure for antimicrobials appeared real, it should be noted that studies in primary care have demonstrated that in many cases a desire for antimicrobials from patients can be perceived by general practitioners s even when patients report not having an expectation for antimicrobials.(Van Driel et al., 2006, Welschen et al., 2004) A study in 2014 by Fleming et al. about antimicrobial use in aged-care homes in Ireland s also suggests that families are satisfied once they are included in discussions and a doctor makes an assessment, whether an antimicrobial is prescribed or not.(Fleming et al., 2014) This suggests the availability of a resident‟s primary general practitioner to speak directly to family in these situations might be a critical factor, for both unnecessary prescribing and family satisfaction with resident care. How nurses and families can be better supported by aged-care home general practitioners in situations near the end of life requires further exploration. Related issues which also deserve further exploration include, appropriate identification of infection in aged-care home residents, social expectations of medical versus nursing care, traditional hierarchies among health professionals, and assumptions about medical versus nursing knowledge among family members.

In a recent study in seven aged-care homes of a single private-not-for-profit aged-care home provider in Victoria, Australia, hierarchical communication structures and professional boundaries were identified as barriers to communication about resident transitions to end-oflife care.(Omori et al., 2018) This study found not only that the nurses were primarily

responsible for communicating with families, but also that families were generally passive information recipients when it came to communicating with the nurses. The families commonly wished to be regarded as members of the „care team‟ rather than just passive recipients of information.(Omori et al., 2018) This is important as a clear agreement among the care team (including family) was identified as enabling appropriate antimicrobial use in the current study.

In 2018, the Government of Australia announced a Royal Commission (a public inquiry) into aged care in Australia, after several complaints about poor care in the sector. The Royal Commission was announced near the conclusion of the interviews for this study, and media coverage of aged care during the time of this study was notably negative. Negative media portrayals were cited by some participants as leading to fear and anxiety about family confrontations and other negative consequences. Accordingly, the media environment when our study was conducted may have influenced the results.

Lastly, during our interview phase, legislative changes regarding medical treatment decisionmaking for people without decision-making capacity came into effect (The State Government of Victoria‟s Medical Treatment Planning and Decisions Act 2016 came into effect on 12.03.2018).(State Government of Victoria, 2016) The changes gave statutory recognition to advance care directives and were promoted as creating clearer obligations for health practitioners. Statutory advance care directives included both values directives (what a person values) and instructional directives (what specific treatment someone may consent to and refuse, and in what circumstances).(State Government of Victoria, 2016) The changes were beginning to take effect when the interviews concluded, however it is unclear if these changes will affect practice in aged-care homes. Many adults in aged-care homes have

significant cognitive impairment (Australian Institute of Health and Welfare, 2018) and thus would not have capacity to complete a statutory advance care directive and most adults in Australia (approximately 85%) do not undertake any advance care planning before entering into aged care.(Smith et al., 2018) Therefore, a medical treatment decision-maker (usually family member) is still required under the new legislation. Future research could assess the impacts of these changes after they have been fully implemented. Conclusions

Nurses have important roles in facilitating advance care planning, care coordination, care delivery and communication with families and medical professionals, and these activities present important opportunities for nurses to lead antimicrobial stewardship activities appropriate for care near the end of life in aged-care homes. Acknowledgements

This research is funded by the National Health and Medical Research Council (NHMRC) of Australia, Grant Number: APP1079625. LD receives an Australian Government Research Training Program Scholarship. The authors would like to acknowledge all those who participated in, and supported, this project. Competing interests

DK has sat on advisory boards for Becton Dickinson Pty Ltd and MSD, and received financial support from MSD. All unrelated to the current work. FG has received personal fees from the Australasian College for Infection Prevention and Control, the Australian Commission on Safety and Quality in Health Care and from the University of Wollongong, outside the submitted work.

CRediT author statement RE: The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: a qualitative study

Leslie Dowson: Conceptualisation, Methodology, Formal analysis, Investigation, Data curation, Writing - Original draft, Writing – Review & Editing, Project administration N. Deborah Friedman: Conceptualisation, Methodology, Resources, Writing – Review & Editing, Supervision Caroline Marshall: Conceptualisation, Methodology, Resources, Writing – Review & Editing, Supervision Rhonda L. Stuart: Conceptualisation, Methodology, Resources, Writing – Review & Editing. Supervision Kirsty Buising: Conceptualisation, Methodology, Resources, Writing – Review & Editing. Supervision Arjun Rajkhowa: Validation, Formal analysis, Writing – Review & Editing Fiona Gotterson: Conceptualization, Validation, Writing – Review & Editing David C. M. Kong: Conceptualisation, Methodology, Resources, Writing – Review & Editing, Supervision

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