Antibiotic resistance is an ongoing problem in healthcare. Many of our institutional quality assurance and performance improvement measures are linked to infection control and different forms of reducing antibiotic resistance. And that's a great place to start. But I can't help thinking we can do more to prevent antibiotic resistance, especially when it comes to patient education.
All too often, the things that seem obvious to us as nurses with all our specialized training, can seem like babble in a foreign language to a patient. We see this all the time if we're paying attention: The patient's eyes glaze over while we're talking to them. They nod knowingly, but the lesson gets lost in mid-air, and the desired outcome never materializes.
A revealing 2018 study published in JAMA Internal Medicine analyzed thousands of telemedicine visits, to show that patients tend to consider their visits successful when they receive prescriptions for antibiotics, whether the medication is medically necessary or not. When you consider the power of patients' expectations paired with heavy institutional emphasis on patient satisfaction scores, prescribers have a strong disincentive for prescribing antibiotics appropriately.
This study made me think about the difference between patient expectations and patient education. Do patients truly understand the problem of antibiotic resistance? My musings seem to be in line with the CDC's public education materials on antibiotic resistance prevention, which suggest that patients do not fully understand what antibiotic resistance is, or how they might be contributing to the problem by expecting, demanding, and taking antibiotics when they don't really need them. Note: The CDC's educational brochure, "Antibiotics Aren't Always the Answer" is free to download here.
Targeted, specific, patient education helps patients and healthcare professionals partner together to reduce antibiotic resistance. Here are some thoughts for nurses at all levels on improving patient education about antibiotic resistance.
Four Key Concepts
Patients must understand at least four key concepts in order to understand antibiotic resistance. First, not all diseases are caused by bacteria. Second, not all bacteria are bad. Third, antibiotic resistance happens in bacterial cells, not in the human body's cells. And fourth, the overuse of antibiotics will render them ineffective over time.
First, patients must understand there are many other types of disease-causing microbes besides bacteria- such as viruses, parasites, and protozoa just to name a few. This distinction matters in the world of antibiotic resistance because antibiotics are specifically designed to target bacteria-not other microbes. So if the patient's illness is being caused by something other than bacteria, an antibiotic won't work, and the patient shouldn't be taking one.
Second, not all bacteria are bad. Help patients understand the human body requires good bacteria to survive and function properly. It's the "bad" or pathogenic bacteria that cause infections and illnesses. Resistant bacteria are like pathogenic or "bad" bacteria with superpowers.
Third, clarify that the resistance part of antibiotic resistance is something that happens in the cells of the bacteria, not the cells of the human body. Patients who have familiarity with the concept of drug tolerance may mistakenly conflate this concept with the idea with antibiotic resistance. Helping the patient understand that antibiotic resistance is all about the bacteria's own drive to survive in the presence of the antibiotic that's trying to kill it can help the patient see the problem in a new light. When patients realize how taking antibiotics makes them a part of the "war on bugs" rather than the "war on drugs," they become more motivated to take the full course of antibiotics as prescribed.
Fourth, the overuse of antibiotics, including using them when they're not necessary, means more bacteria have more time and opportunity to develop resistance. New antibiotics aren't being developed as quickly as bacteria develop resistance, which means the antibiotics we have now could eventually become useless. Using antibiotics judiciously and appropriately is necessary if we want to continue using them.
Managing Patient Expectations
If antibiotics are NOT prescribed, it's important to say the right things to reassure the patient that their needs are being met. A speaker at the American Association of Nurse Practitioners (AANP) conference in 2015, Kim McGinn-Perryman, DNP, shared the acronym, PEARLS, as a strategy for managing patient disappointment when expectations and appropriate antibiotic use practices don't match. While this acronym is especially useful for NPs who find themselves in the position of NOT prescribing antibiotics to someone who is expecting them, all nurses can use aspects of this approach to reinforce their patient education messages throughout the workflow in clinics or any environment where oral antibiotics are prescribed.
Partnership. Acknowledge that you are working in partnership with the patient, toward a goal of resolving the problem. Example: "Part of my job is to help you manage this."
Empathy. Express empathy for the patient's situation. Example: "I understand you're feeling terrible."
Apology. Offer an apology. Example: "I'm very sorry you're not feeling well." If you know the patient is upset about not receiving antibiotics, you might consider taking the conversation a step farther so the patient can sort out their feelings with you instead of taking out their frustration in a rating system or on social media. "I'm sorry you're not getting a prescription for antibiotics today. Do you understand our explanation on why?"
Respect. Show respect for the patient, including their beliefs, intentions, goals, and actions: "You did the right thing coming in to get this checked out today."
Legitimize. Legitimize the patient's thought process: "I can definitely see how you might think an antibiotic would help your symptoms."
Support. Offer actionable support. "I know you want to feel better as soon as possible. Let me give you some treatment suggestions you can use instead of antibiotics."
The bottom line is that nurses at all levels must work with their patients to provide adequate patient education about appropriate antibiotic use. It's not enough to simply direct a patient to take their antibiotics as prescribed. They won't if they don't appreciate why it matters. We must use our patient education skills to ensure they have a clear understanding of antibiotic resistance.
Sources
Antibiotics Aren't Always the Answer
Association Between Antibiotic Prescribing for Respiratory Tract Infections and Patient Satisfaction in Direct-to-Consumer Telemedicine | Infectious Diseases | JAMA Internal Medicine | JAMA Network
Patient Satisfaction Ratings May Be A Factor In Doctors' Prescribing Behavior : Shots - Health News : NPR
Using PEARLS to reduce unnecessary antibiotics - The Clinical Advisor
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