Nursing home residents’ experiences and perceptions of antibiotic use: A qualitative descriptive study

Abstract

Background:

Antibiotics are commonly used in the nursing home (NH) setting. Little is known of NH residents’ perceptions and experiences regarding antibiotic use.

Methods:

This was a qualitative descriptive study. We conducted individual, semi-structured interviews with NH residents. Interview transcripts were analyzed using conventional content analysis.

Results:

Twenty-six residents were interviewed. Four themes emerged: (1) perceived benefits and risks to antibiotics; (2) information needs regarding antibiotic treatment; (3) approaches to address information needs; and (4) resident involvement in antibiotic treatment decisions. The perceived benefits of antibiotics were described as symptom-relief and cure; risks included gastrointestinal symptoms and antibiotic resistance. Informational needs included the indication for antibiotics, risks and side-effects of antibiotics, and potential interactions between antibiotic treatments and medication regimens. Residents performed information seeking behaviors to address informational needs but described difficulty obtaining and recalling desired information. Diverse involvement in antibiotic treatment decisions were described, in which a subset of participants reported seeking antibiotics from their prescriber.

Conclusions:

Future efforts aiming to improve collaborative decision making and antibiotic use in the NH setting should address the unmet information needs of NH residents regarding their antibiotic treatment plans.

INTRODUCTION

Antibiotics are commonly used among residents in the nursing home (NH) setting in the absence of sufficient evidence to indicate a bacterial infection,¹ placing residents at increased risk for the development of adverse drug reactions and antibiotic resistance.² In 2016, the Centers for Medicare and Medicaid Services required participating NHs to implement antimicrobial stewardship programs to improve the responsible use of antibiotics.³ While most policies of these programs pertain to the collection of data on antibiotic use and the review of antibiotic use for appropriateness,⁴ increasing efforts are underway to engage NH residents and their families in antibiotic use. In 2017, the Centers for Disease Control and Prevention (CDC) published fact sheets for NH residents and their families that include descriptions of the risks of antibiotics and questions for residents and their families to ask healthcare providers about antibiotics.⁵ Similarly, in 2021, the Agency for Healthcare Research and Quality published a toolkit that includes resources to guide NH practitioners and nursing staff in communicating antibiotic risks to residents and family members.⁶ These resources reflect a shift in the culture of care of NHs, in which person-centered care and collaborative decision making are prioritized,^7,8 and were likely designed to address the reported influence of NH residents and/or their families on antibiotic prescribing.⁹ We sought to describe the experiences and perceptions of NH residents regarding antibiotics, with the goal of better understanding the decision-making needs of residents regarding their antibiotic treatments and to inform NH antibiotic stewardship efforts.

MATERIALS AND METHODS

This was a qualitative descriptive study^10,11 conducted in a large (>700 bed), not-for-profit NH located in a large city in the northeast United States. At the time of the study, the NH had an existing antibiotic stewardship program and resident and family council—neither of which focused on the active engagement of residents in antibiotic treatment decisions. Eligible participants were recruited from a parent study consisting of long-stay NH residents with multiple chronic conditions, in which NH staff assisted in the identification of residents with capacity to participate in research. Residents interested in study participation were asked the following questions by research personnel as secondary confirmation of residents’ mental status: residents’ name, current date, and current place. From August 2019 to February 2020, 2 researchers conducted individual, in-person interviews in a private location of the NH, following the iterative development and pilot testing of an interview guide (Fig 1). The interview guide began with an introductory-type question,¹² in which participants were asked to describe a recent experience with antibiotics to facilitate participants’ vivid recall and to become acclimated to the topic of interest. In the event participants recalled antibiotic use outside the NH setting, the interviewer asked additional follow-up questions specifically pertaining to antibiotic use in the NH. To minimize respondent burden and fatigue, interviews were limited to 30 minutes in duration. Study participants received a $30 gift card upon interview completion. All interviews were audio recorded and professionally transcribed.

Fig 1.

Interview guide.

Interview transcripts were analyzed using conventional content analysis.¹³ Three researchers with backgrounds in nursing ((EC, CD) and public health (GM) independently coded the first 3 interview transcripts to develop a codebook establishing definitions, boundaries for application, and exemplars of codes.¹⁴ Each remaining transcript was coded by 2 researchers to ensure consistency in the application of codes; an audit trail of codebook iterations with study procedures was developed and maintained. Codebook iterations were discussed with additional members of the research team (PS, JS, MG) as a form of peer debriefing during monthly research meetings.¹⁵ NVivo 12 (QSR International) was used to manage the data. Data collection ended when a chronological saturation table demonstrated that we had reached data adequacy.¹⁶

Because qualitative descriptive approaches consider uncommon responses equally as important as common responses, we chose not to report the number of responses. However, the following classification scheme provides an estimate of frequency: “most” when endorsed by >75% of participants, “many” when endorsed by > 50% of participants, “some” when endorsed by > 25% of participants, and “few” when endorsed by < 25% of participants. This study was approved by the institutional review board of Columbia University Irving Medical Center with a waiver of written documentation of consent (Protocol # AAAS1044).

RESULTS

Interviews were conducted with a total of 26 NH residents. A description of participant characteristics is provided in Table 1. Participants had a mean age of 75.5 (SD 10.5) years. Among participants, 15 (58%) were female, 22 (85%) were non-Hispanic, 21 (81%) were White, and 9 (35%) had a bachelor’s degree as their highest level of education. Four themes emerged from interview transcripts. We describe these themes below and depict representative quotes in Figure 2.

Table 1.

Participant demographics^*

	No.	%
Age, y†	75.5	10.6
Sex
Female	15	58%
Male	11	42%
Race
Black or African American	4	15%
White	21	81%
Not reported	1	4%
Ethnicity
Hispanic	3	12%
Non-Hispanic	22	85%
Not reported	1	4%
Highest educational level
High school graduate/GED	8	31%
Some college, no degree	5	19%
Associate degree	1	4%
Bachelor’s degree	9	35%
Master’s degree	2	8%
Not reported	1	4%

^*Demographic data collected via resident self-report.

^†Reported as mean and standard deviation.

Fig 2.

Examplars of findings.

Theme 1: Perceived benefits and risks to antibiotics among residents

Most participants conveyed positive attitudes towards antibiotics and described symptom relief and the curing of illness as antibiotic benefits. Participant 11 described, “Whatever I’ve had, they cleared it up, and I think they’re great, seriously. It does help a lot; makes you feel whole again” (68-year-old male). Some participants delineated specific risks to antibiotics, recalling adverse reactions they had experienced in the past while taking antibiotics, including nausea, vomiting and diarrhea. Four participants described antibiotic resistance as a risk to antibiotic use. Participant 10 reflected, “If you have a UTI, you take an antibiotic, but again if you take too much you become, you won’t be able to take it no more” (56-year-old female).

Theme 2: Informational needs regarding antibiotic treatments

Participants articulated information that they and other residents should know regarding their antibiotic treatments, including the name of the antibiotic, the indication for the antibiotic, the duration of antibiotic treatment, how residents will feel when taking the antibiotic, and interactions between the antibiotic and their current medications. Few participants articulated the need-to-know tradeoffs between the benefits and risks to antibiotic use. Participant 4 highlighted the importance of knowing these tradeoffs at the end-of life: “The risk...now, I would assume that I’d want to be around longer so sure...But...if I’m going to go, I’m going to go. I know that people go to hospice. I know people who have been to hospice. It depends upon how much time”(87-year-old female).

Medication administration procedures and suboptimal staffing patterns were noted to pose barriers to residents’ obtaining information regarding their antibiotic treatments, in which information sharing was scant and limited by time constraints. Some participants recalled that descriptions of their antibiotic and reason for antibiotic were offered by nurses during the medication administration process, whereas others recalled the provision of little to no information. Participant 19 described, “They don’t usually volunteer [information]. A lot of times these nurses here are almost always short of staff, almost always, and, you know, they have like a few minutes at the most” (71-year-old female).

Participants emphasized the importance of residents’ asking questions about antibiotics but recognized various factors hindered residents’ ability to ask questions. Participant 14 described, “People should discuss more about, you know, with their physician or nurse practitioner or whatever, about what the side effects might be, but then there are those here who cannot speak for themselves” (70-year-old female) while Participant 10 remarked, “I should have asked [about side effects] but I didn’t...I wasn’t really thinking about, I only cared about that thing [skin infection] getting away from my back” (56-year-old female).

Theme 3: Approaches to address informational needs

Participants described information-seeking behaviors to improve their awareness of antibiotic treatments, emphasizing the importance of being “aware of what’s happening” and their desire to track their medications to “make sure they got it.” Participants described approaches used by them or others to obtain desired information regarding their antibiotic treatments. These approaches included posing questions to nurses and/or prescribers, asking family members to research their antibiotic treatments, and residents’ themselves researching their antibiotic treatments online.

Yet, participants described that memory impairments challenged their recall of gathered information. Participant 9 described, “I remember them at the time they tell them to me, but then later I forget them, you know” (71-year-old female). Participants commented on approaches to improve residents’ initial gathering and recall of information regarding antibiotic treatments, in which initial conversations between NH staff and residents were highly encouraged. Residents also perceived an informational handout that was specific to their course of antibiotic treatment as helpful as it could be referenced later.

Theme 4: Resident involvement in antibiotic treatment decisions

Participants described varying levels of involvement in their antibiotic treatment plans in the NH setting, ranging from seeking antibiotics from their prescriber to leaving antibiotic treatment decisions entirely to the discretion of their prescriber. Participants who sought antibiotics from prescribers felt they knew when antibiotics would be helpful to them. Participants who left antibiotic treatment decisions to prescribers reasoned their prescriber had the skills and knowledge to manage their care. Participant 4 described, “If they are taking care of it and they are giving it to me....I wouldn’t care...I’m not controlling. I mean, they know their job and they are doing their job, you know, I don’t need to know every step of the way” (87-year-old female).

DISCUSSION

In this qualitative descriptive study consisting of interviews with long-term NH residents, study participants described unmet information needs regarding their antibiotic treatment plans and a subset of residents described antibiotic-seeking behaviors. While NH resident desires and wishes form the framework for collaborative decision making among culture change efforts in NHs,^7,8 we found fewer than half of participants described a specific risk to antibiotic use and fewer than one-quarter of respondents offered antibiotic resistance as a risk to antibiotic use. A poor appreciation of the risks to antibiotics may impede NH residents’ ability to engage in collaborative decision making around their antibiotic treatment plans. In an evaluation of the stability of NH resident preferences for medical treatment, Berger and Majerovitz¹⁷ surveyed NH residents regarding their preference for intravenous antibiotic use (requiring hospitalization) across several theoretical scenarios (eg, in a coma, had dementia). Participants’ desire for intravenous antibiotics significantly decreased over the 6-month data collection period, which may be due to changes in NH residents’ evaluation of the benefits and risks of antibiotics overtime.

We found a subset of study participants reported requesting antibiotics from their prescriber, which is consistent with recent studies that report antibiotic seeking behaviors among NH residents and families. A survey of nurses and medical providers in 31 NHs in North Carolina found that residents and their family members were perceived to influence antibiotic prescribing.⁹ Similarly, in a mixed exploratory study of caregivers and residents in NHs across France, researchers found 85% of nurses surveyed and 11% of NH residents reported that residents solicit antibiotics from their prescriber.¹⁸ Despite these findings, residents are largely absent from antimicrobial stewardship efforts in the NH setting. A recent systematic review and meta-analysis found only 2 of 18 studies (11%) that targeted NH residents themselves to improve antibiotic use, with most exclusively targeting physicians and/or nurses.¹⁹ Similarly, a recent systematic review evaluating how residents and families are engaged in medication management identified 40 studies,²⁰ none of which were focused on antibiotic use. Studies of interventions to engage residents and/or their families in NH antibiotic stewardship efforts are needed to evaluate the impact of these approaches on antibiotic use and appropriateness.

Participants readily described the information that NH residents should know regarding their antibiotic treatment plans, including interactions between antibiotics and other medications, and the risks and benefits to the antibiotic. The information desired by participants is consistent with questions suggested by the CDC for NH residents and/or the families to ask to their healthcare provider regarding antibiotics.⁵ We found important factors challenged NH residents’ ability to ask questions and receive answers, including poor staffing patterns at the NH. Innovative approaches that do not rely on resident initiation and are sensitive to NH staffing constraints are needed to improve the informational needs of NH residents regarding their antibiotic treatment plans.

This study has limitations. Study participants were largely non-Hispanic, White women and we did not confirm participants’ antibiotic prescriptions or circumstances around that prescription in the NH. This study was conducted in 1 NH and findings may not be transferable to others. Further, there was a risk of social desirability bias (ie, residents responding in a manner to please the investigator). Further research is needed to explore the perceptions and experiences of NH residents from diverse backgrounds regarding antibiotic use and to develop and test collaborative decision-making tools that effectively engage NH residents in antibiotic treatment decisions.

CONCLUSIONS

NH residents expressed unmet informational needs regarding their antibiotic treatments. Efforts to improve collaborative decision making and antibiotic use in the NH setting may address these information needs.