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to an organizational, healthcare provider, or resident/family level to better target the selection of strategies. The mapping process was reviewed by an external implementation scientist (J.M.) for additional validation.
Selection of program strategies
The Rx for Change database was used as a source of information on implementation strategies.26 This database, developed by the Canadian Agency for Drugs and Technologies in Health, sum- marizes evidence-based implementation strategies designed to improve drug prescribing practices and is based on the Cochrane Effective Practice and Organization of Care (EPOC) taxonomy of implementation strategies.27,28 Strategies regarding the use of the Rx for Change database were reviewed in the context of relevance to the desired barriers/facilitators and the feasibility of imple- mentation by LTCFs. Strategies were excluded if they could not be delivered by LTCFs, including financial or regulatory strategies, as well as those requiring external personnel (eg, educational out- reach visits). Each implementation strategy was then mapped to relevant determinants from the TDF, with external review (con- ducted by J.M.) for validation.
Stakeholder consultation
An integrated knowledge translation approach informed 2 stages of program development: (1) validating and contributing addi- tional information on barriers and facilitators and (2) assisting in further development of the program implementation strategies and resources. Staff from 2 LTCFs that had previously expressed interest in making improvements in the overuse of antibiotics participated in 3 separate meetings followed by a focus group. Staff from a large corporate LTCF included a nurse practitioner, the director of care, the infection control lead, a physician, and a registered practical nurse. Staff from a small privately owned LTCF included the director of care, 2 registered nurses, and a staff member responsible for the coordination of data reporting and quality improvement initiatives. Field notes were used to document the discussions and were
uploaded into NVivo 9, a qualitative data management and analysis software (QSR International, Melbourme, Australia). A descriptive coding process was used to summarize contextual information that could be used to better understand the chal- lenges associated with aligning with current practice recommen- dations in addition to perspectives on the acceptability and implementability of the recommended strategies.
Results Identification of barriers and facilitators
In total, 381 responses were captured from the online survey representing multiple different positions in the LTCF: adminis- trators and directors or associate directors of care (50%); regis- tered nurses and registered practical nurses (12.3%); nurse practitioners, physicians and medical directors (3.7%); infection control practitioners (15.2%) (although other roles included infection control responsibilities); and other (18.4%). Moreover, 64 unique excerpts referring specifically to barriers or facilitators to aligning with best practice for the management of UTIs were captured in open-text comments. The most predominant theme (41% of the excerpts) centered around the role of families in
Andrea Chambers et al
influencing decisions to prescribe antibiotics in the absence of clinical signs and symptoms of a UTI. For example, comments included remarks such as “doctors feel their hands are tied as families demand to have loved ones on antibiotics” and “in long- term care, families often push hard for testing and treatment.” Several comments also referred to specific knowledge gaps and the value of additional resources to guide the assessment and management of UTIs. In addition to gaps in awareness and resources, several comments also referred to practices that con- tribute to the contamination of urine specimens, including improper urine collection and storage. An important observation made by stakeholders was how
LTCFs may be receiving conflicting advice across external pro- grams and services. One perception was that current best practice for assessing changes in cognition or behavior in residents involve ruling out a UTI, which prompts the collection of a urine spe- cimen in the absence of urinary symptoms. Ongoing practices that reinforce the treatment of ASB were also highlighted, including the labeling of residents as having “recurrent UTIs” and conflicting practices of other health services. Another observation was that it is common for residents who are sent to the emergency department for assessment to return with a prescription for antibiotics for a UTI. As one respondent stated, “Everyone sent to emergency for whatever reason comes back with a recommen- dation for antibiotics.” The comments also captured staff con- cerns about not treating nonspecific symptoms, including fears that an infection will develop or be missed. For example, one respondent commented, “… the condition in elderly deteriorates really fast if treatment is delayed.” Other comments stressed the importance of focusing on establishing buy-in or acceptance among certain healthcare workers on current practice recommendations and of considering the need for culture change within facilities. During the meetings with the 2 LTCF staff members, all
barriers and facilitators listed were found to be relevant and additional insights were captured. For example, one physician noted that not only families but also healthcare staff influence physicians to prescribe antibiotics. A complete list of the identi- fied barriers and facilitators to following best-practice recom- mendations to minimize treatment of ASB in LTCFs can be found in Table 2. Table 2 also includes results from the process of mapping each barrier or facilitator to the domains from the TDF. Of the 14 domains, the mapping process identified 8 factors relevant to practice change. This process demonstrated that strategies to support practice change should address the following domains: knowledge, skills, environmental context and resources, social or professional role or identity, social influences, beliefs about consequences, emotions, and reinforcement.
Selection of strategies
In total, 9 implementation strategies were selected to address the identified barriers and facilitators: 7 strategies were informed by the Rx for Change database and 2 additional implementation strategies, ‘coaching’ and ‘champions,’ were added to address outstanding barriers. Coaching was added for LTCFs to address challenges in reaching all staff when delivering formal education sessions to provide reassurance and support for more difficult cases (eg, residents with communication difficulties), and to monitor practice improvements. Champions were added to encourage LTCFs to select an individual dedicated to leading the overall implementation of the program and who could strengthen buy-in and overcome challenges as they emerge.
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