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Research

Resisting patient demand for antibiotics

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Antibiotics are ineffective in treating many respiratory infections but patients may expect them and try to pressure health professionals into prescribing them

Abstract

Nurse prescribers often see patients with respiratory tract infections (RTIs) who do not need antibiotics, but we know very little about nurses’ experiences of these consultations. To understand the challenges faced by nurse prescribers managing patients with RTIs who do not need antibiotics, we conducted interviews and focus groups with non-medical prescribers (90% of whom were nurse prescribers). We found that participants were unlikely to prescribe antibiotics due to patient pressure and felt they had the skills to manage patients’ conditions without using this type of medication. However, some participants were wary about dealing with patients with RTIs. Training should help build staff’s confidence and skills in this area.

Citation: Rowbotham S, Peters S (2013) Resisting patient demand for antibiotics. Nursing Times; 109: 31/32, 14-15.

Authors: Samantha Rowbotham is a PhD student; Sarah Peters is a senior lecturer in psychology; both at the School of Psychological Sciences, University of Manchester.

Introduction 

Many patients seek medical attention for respiratory tract infections (RTIs) such as coughs, colds and sore throats, most of which are viral and can be managed without antibiotics. Despite this, patients are often given antibiotics for these conditions (Petersen and Hayward, 2007), resulting in the National Institute for Health and Clinical Excellence (now the National Institute for Health and Care Excellence) recommending a “no-prescribing” strategy in 2008 (NICE, 2008).

Research in this area has mainly focused on the experiences of doctors, but has highlighted non-clinical reasons for antibiotics being given, such as:

  • Patient pressure;
  • A feeling that it is quicker and easier to give antibiotics than to try to change patient beliefs;
  • Fear of damaging the doctor-patient relationship by refusing antibiotics (Petursson, 2005).

Changes in prescribing legislation over the past decade mean that many nurses and other health professionals now work as non-medical prescribers (NMPs) in primary care settings and often see patients with RTIs. However, little is known about the experiences of NMPs during these consultations and the challenges they face in employing the “no-prescribing” strategy.

Weiss (2004) found that nurses were less likely than GPs to report feeling patient pressure for antibiotics, suggesting nurses’ experiences of RTI consultations may differ from those of GPs. It is necessary to understand the specific challenges faced by nurses during RTI consultations so that appropriate training and support can be provided.

Method

Fifteen semi-structured interviews and three focus groups (with five, four, and 12 participants) were conducted with NMPs (all but two were nurse prescribers). Participants were recruited by telephoning practices and advertising at training events. Interviews were structured around a topic guide and participants were encouraged to elaborate on their responses. The focus groups took place as part of a training session to improve communication skills and reduce inappropriate prescribing for RTIs. Interviews and focus groups were audio-recorded and transcribed.

Results

Three main themes emerged from the data.

Reasons patients present with RTIs

NMPs regularly saw patients with RTIs and reported that many expected antibiotics, believing they would relieve symptoms such as a sore throat. Patients were thought to lack knowledge about: the causes of symptoms and how to manage them; how antibiotics work; and the difference between viral and bacterial illnesses.

Challenges within the RTI consultation

Difficulty in diagnosing RTIs was a key challenge due to the overlap in symptoms for viral and bacterial infections. NMPs stated they were concerned about missing something important that would indicate the need for antibiotics, particularly when dealing with high-risk groups. Some were worried about a lack of protection for them if they made incorrect decisions. However, NMPs were thorough when dealing with RTIs, and only prescribed antibiotics when there was a strong justification to do so.

Although RTI consultations were often time consuming and complex, NMPs generally felt they had enough time to carry them out and did not see time as a barrier to managing the consultations effectively.

Strategies for managing RTI consultations

A small number of NMPs reported having prescribed antibiotics due to time pressure, patient expectation and diagnostic uncertainty. However, most would not prescribe antibiotics unless a bacterial infection was present and reported various alternative strategies for managing RTI consultations.

In line with the belief that expectations about antibiotics are owing to lack of knowledge, some NMPs used the consultation to do the following:

  • Educate patients on how antibiotics work;
  • Explain the difference between viral and bacterial infections;
  • Explain the negative consequences of overprescribing antibiotics.

They combined this education with advice about symptom relief, such as using paracetamol or steam inhalation, although some were unsure which forms of self-management were evidence based.

NMPs used various strategies to reinforce their “no-prescribing” decision when dealing with challenging patients, such as:

  • Referring to prescribing guidelines and protocols;
  • Asking colleagues to back up their no-prescribing decision;
  • Providing patients with information leaflets to support their explanations.

They recognised the importance of showing empathy towards patients, and the need to avoid dismissing the illness by implying that a viral infection is “less severe” than a bacterial infection.

Overall, NMPs reported that most patients were satisfied with a no-prescribing decision, as they understood why they were not being given a prescription and felt they had been taken seriously. However, there were exceptions as some patients continued to reconsult. In such cases, NMPs persisted with attempts to educate patients and modify their beliefs about antibiotics. Finally, although participants reported using these strategies within RTI consultations, they emphasised the need for more training and the value of finding out what other prescribers are doing.

Discussion

This study revealed that NMPs face similar challenges to those reported by GPs, such as diagnostic uncertainty and patient expectations of receiving antibiotics. However, most NMPs indicated they would not prescribe antibiotics due to non-clinical factors such as patient pressure and would instead use a range of strategies to manage these consultations without antibiotics.

NMPs also highlighted the importance of good communication skills and the use of resources such as peer support, guidelines and patient information aids in guiding and reinforcing decisions. They reported that these strategies were usually accepted by patients.

Given that patient education forms a core part of the nursing curriculum, NMPs’ focus on educating patients is perhaps unsurprising. In the drive to reduce antibiotic prescribing it may be important to support prescribers in providing this type of education within RTI consultations. Future research is needed to investigate how NMPs provide patient education within consultations, and examine which strategies are most successful.

While most NMPs advised patients on self-management, the advice differed between practitioners and some were concerned about the lack of evidence for some types of self-management. Training for NMPs should aim to support self-management advice by covering effective techniques that are supported by evidence. Training should therefore focus on reinforcing the efficacy of self-management strategies and increasing prescribers’ confidence when diagnosing RTIs and making treatment decisions.

Study limitations

As the study involved asking NMPs about their experiences, the results may not be a true reflection of their actual behaviour. An observational study of NMPs’ behaviour during RTI consultations would provide further support for the present findings.

As the focus groups formed part of a training session it is possible that the participants were already motivated to use the no-prescribing strategy - health professionals are more likely to undertake training in subjects they value and in which they feel confident and skilled (Salmon et al, 2007). Nevertheless, even among this group, challenges and lack of confidence were reported, suggesting these aspects may be even greater in the wider population of NMPs.

Key points

  • Nurse prescribers often see patients with viral respiratory tract infections who expect to be given antibiotics
  • A “no-prescribing” strategy was introduced to address the overprescribing of antibiotics for RTIs
  • Patients often do not know the difference between viral and bacterial infections and so don’t realise that antibiotics may not help
  • Strategies used to manage consultations without prescribing antibiotics include educating patients about RTIs and self-management
  • Training for non-medical prescribers should aim to increase their confidence when dealing with such consultations
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