When people fall ill, it is common for them to request antibiotics (Davis et al, 2017), but it has been reported that there is a lack of understanding among patients of how antibiotics work (Gualano et al, 2015). Lay persons make false assumptions about what antibiotics can treat (e.g. viral infections) and often misuse them when they are prescribed (i.e. not completing the full course once the patients feel better). Patient expectations of antibiotics and time constraints can influence health professionals' decisions to prescribe (Fletcher-Lartey et al, 2016; Lum et al, 2018). Yet, antibiotic stewardship, and nurses' role within this, is deemed important to reduce the risk of antibiotic resistance (Edwards et al, 2011). Many health professionals, including nurses, identify themselves as ‘antibiotic guardians’ (Bhattacharya et al, 2016; Kesten et al, 2018), recognising the importance of not prescribing them in certain situations. However, this needs to be balanced against the fear that not meeting patient expectations will lead to low patient satisfaction (Rowbotham et al, 2012; Lum et al, 2018). Therefore, it has been argued that health professionals should aim to educate their patients on the need and appropriate use of antibiotics (Gualano et al, 2015).
Communication skills are essential to optimise treatment outcomes while maintaining a positive patient-practitioner relationship (Jubraj et al, 2016; Chater, 2018). To communicate effectively, health professionals must use a range of speaking and listening micro-skills to ensure that patient concerns are acknowledged and discussed, misunderstandings are addressed and patient-centred decisions are made. While nurse prescribers have reported that they feel they have some of the communication skills relevant to dealing effectively with patients without the need to prescribe antibiotics, it is acknowledged that training to enhance confidence and skills in this area is needed (Rowbotham et al, 2012; Courtenay et al, 2017b).
Effective communication skills lie at the heart of community nursing (Chater, 2018). Nurses must understand the patient's symptoms and condition, alongside their capability to self-manage, motivation to engage in effective healthcare strategies and opportunities afforded to them by their physical and social environments. To do this, they need to draw on conversation skills that can facilitate optimal treatment and health outcomes (Jubraj et al, 2016). This can be achieved through engaging the patient in the conversation about the best treatment approach for them, focusing on how this may be achieved, evoking ways to reach optimal health and planning a way forward (Rollnick et al, 2008; Chater, 2018). This process is especially important when it comes to antimicrobial stewardship, a term used to describe the combined efforts of health professionals and the public to use antimicrobials responsibly (Dyar et al, 2017).
There are approximately 31 000 nurses in the UK who have the same prescribing capability as doctors, with the numbers increasing steadily (Courtenay et al, 2017a). These prescribers are responsible for around 8% of all primary care antibiotic prescriptions (Courtenay et al, 2017a), and evidence confirms that patient expectations can influence their decision to prescribe an antibiotic (Rowbotham et al, 2012). Research has shown that antimicrobial stewardship is seen as a welcomed extension to the traditional roles in nursing (Carter et al, 2018). However, as with other health professionals, nurses often face the challenge of dealing with a patient who may feel their symptoms would benefit from an antibiotic prescription when clinical judgement would say otherwise (Rowbotham et al, 2012; Lum et al, 2018). In these circumstances, effective communication skills could support nurses to navigate their way through difficult conversations that conclude with a non-antibiotic prescription outcome without causing patient dissatisfaction (Rowbotham et al, 2012, Courtenay et al, 2018). This, in turn, would maintain their antimicrobial stewardship and their identity as ‘antibiotic guardians’, if they are one of the many thousands of health professionals to have made this pledge (Bhattacharya et al, 2016; Kesten et al, 2018).
Multi-drug resistant infections are one of the greatest threats to health worldwide (World Health Organization (WHO), 2017). Antimicrobial resistance is responsible for an estimated 25 000 deaths and €1.5 billion in extra healthcare costs every year in the EU (European Commission, 2017). Antimicrobial resistance can lead to lower protection for surgical patients, extended hospital stay and longer illnesses (WHO, 2017).
The use of antibiotics has increased by over a third in the past decade (Van Boeckel et al, 2014), and this is what has driven the emergence of antimicrobial resistance. Therefore, it is important to develop ways to support appropriate antibiotic prescribing. GPs' prescribing behaviour has been shown to be influenced by their perceptions of patient expectations (Tonkin-Crine et al, 2011), patient pressure (Coenen et al, 2006), clinician characteristics (Brookes-Howell et al, 2012), diagnostic uncertainty and fear of complications (Kumar et al, 2003). Evidence to date suggests that interventions that are complex and multifaceted in addressing barriers to change in specific healthcare settings are effective at reducing inappropriate antibiotic prescribing by GPs (Arnold et al, 2005; Ranji et al, 2008). Although there is less evidence for nurse prescriber behaviour, it seems that similar barriers exist (Courtenay et al, 2019), with lack of knowledge and confidence highlighted as the main barriers to antimicrobial stewardship activities and good communication skills being a core facilitator (Fisher et al, 2018).
Using theory to understand antimicrobial stewardship
Growing evidence supports the use of theoretical frameworks to identify barriers and facilitators to health professional behaviour, and one such approach is the behaviour change wheel (BCW) (Michie et al, 2011). The BCW encompasses three layers that should be considered when supporting behaviour change: (1) the determinants of behaviour (COM-B; Capability, Opportunity, Motivation-Behaviour); (2) intervention functions with which to intervene with these determinants; and (3) policy categories to support change on a more structural level.
The COM-B system forms the hub of the BCW and can lead to a behavioural diagnosis by facilitating understanding of the determinants of behaviour. Using COM-B can help identify the drivers of practitioner behaviour in relation to Capability, both physical (such as skills) and psychological (such as knowledge); Opportunity, both social (norms of practice) and physical (time/space); and Motivation, both reflective (such as confidence and intention) and automatic (driven by identity, emotion or habit). This model is helpful when considering antimicrobial stewardship, as it can be easily mapped to intervention functions (i.e. education, training, enablement) and a selection of behaviour change techniques (BCTs) (instruction on how to perform the behaviour, restructuring the social/physical environment) from the BCT Taxonomy Version 1 (Michie et al, 2013) that can be selected as intervention components to facilitate behaviour change (Michie et al, 2014; Lorencatto et al, 2018). The delivery of these BCTs is also important. Motivational interviewing is an effective behaviour change delivery approach that includes a number of BCTs within it (Miller and Rollnick, 2012; Hardcastle et al, 2017).
Therefore, to reduce global antibiotic resistance, the appropriate use of antibiotics should be improved, starting with prescriber behaviour. As stated before, there is an increasing role for nurse prescribers in antimicrobial stewardship (Courtenay et al, 2018), and it is essential to understand what drives their decisions in terms of capability, opportunity and motivation. Once barriers to appropriate prescribing behaviour are addressed (i.e. lack of knowledge or communication skills (Capability), lack of confidence (Motivation) or lack of a supportive environment (Opportunity)), interventions can be developed. Education, training and enablement can be important intervention functions, equipping nurse practitioners and other health professionals with the knowledge and skills to confidently navigate a consultation to a non-prescribing conclusion, without causing patient dissatisfaction.
Communication skills
It is common for health professionals to find themselves in a consultation where it is clear a non-antibiotic prescribing decision is the best route of action but the patient feels they need an antibiotic. Additionally, patients who are given an antibiotic for a self-limiting condition such as a respiratory tract infection (i.e. when they do not need one) are more likely to return to the surgery when they experience similar symptoms in the future and will expect an antibiotic. These scenarios can lead to frustration, both for the practitioner and patient.
Good communication skills are essential for the success of any consultation, yet there is a paucity of research that evaluates how nurse prescribers can be trained in effective communication skills to enable appropriate antibiotic prescribing behaviour. The ‘Stemming the Tide of Antibiotic Resistance’ (STAR) educational programme (Simpson et al, 2009) highlighted the need for effective communication to enhance antimicrobial stewardship in general practice. The STAR programme was found to effectively reduce the antibiotic prescribing rate among GP clinicians, as compared to a control group that did not receive the training (Butler et al, 2012). Further, there was no difference in the number of hospital admissions between the two groups, indicating that a reduction in antibiotic prescribing did not lead to an increased need for a hospital visit. The training intervention included seminars that allowed learners to reflect on their own prescribing behaviour, online educational components and time to practice and reflect on consultation skills used in routine care. It drew from the core considerations of motivational interviewing in a healthcare setting (Rollnick et al, 2008; Miller and Rollnick, 2012). This selection of practical, instructional and reflective activities can enable an increase in knowledge and confidence to actively engage with consultations, overcoming some of the core COM-B barriers to a non-antibiotic prescribing decision.
Developing training programmes
Training programmes should first consider a learner needs assessment, to create targeted learning outcomes and activities. COM-B can be used to facilitate this process, highlighting the barriers to the target behaviour, which is non-prescribing behaviour in this case. Training can then be developed to target these needs. To enhance consultation knowledge and skills, training programmes should draw from motivational interviewing and reflective practice (Rollnick et al, 2008; Miller and Rollnick, 2012).
Learners should be encouraged to ensure a good PACE: working in Partnership with the patient, showing Acceptance and Compassion for their wants and concerns and making every attempt to have Evocative conversations regarding an acceptable way forward. To do this, as a practitioner, they must engage, focus, evoke and plan. They can use the RULE: Resist the righting reflect, Understand client motivation, Listen and Empower and the micro-skills of the OARS: Open ended questions, Affirmations, Reflective Listening and Summaries to facilitate the consultation. Finally, if an information exchange is needed, the Elicit-Provide-Elicit (EPE) technique can enable this process without causing patient disengagement (Haque and D'Souza, 2019). Below is an example of what training might cover to support antimicrobial stewardship highlighting areas from a COM-B diagnosis and using motivational interviewing techniques to inform clinical practice using a stereotypical consultation of a patient requesting an antibiotic.
Consultation case study
Patient A, a 35-year-old male non-smoker with no obvious comorbidities, is seen by a community nurse, with a common, acute, uncomplicated self-limiting respiratory tract infection. He is concerned his condition will worsen and wants to get better quickly as he cannot afford to take time off work. He is agitated and wants a prescription for antibiotics, as he feels they have helped him get better faster in the past. A clinical assessment suggests his condition would not benefit from an antibiotic prescription.
How to respond
It is important that the whole consultation feels like a partnership, where the patient feels acceptance of their concerns about their condition, giving them the feeling that the practitioner is on their side. Compassion for what they feel is the best course of action is important, even if at this point, it is against clinical judgement. The practitioner's role here is to reach evocation of the best way forward in a patient-centred fashion, by helping the patient to understand how antibiotics work and whether they are required on this occasion. To do this, the practitioner should, through training, build knowledge and skills in the following:
Conclusion
Antimicrobial stewardship in community nursing can be facilitated by the development of effective consultation skills. When training nurse practitioners in communication skills, it is important to acknowledge the drivers of their behaviour in relation to COM-B and to allow them insights into their own behaviour. This can be facilitated through instruction, demonstration, role-play, peer observation and feedback, audits of individual and practice prescribing behaviour and self-reflection. These can all be encouraged on an ongoing basis to develop best practice. Training should therefore be developed to build knowledge, skills and confidence to enable