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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: –
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