Assignment: Psychosocial Development Throughout The Lifespan

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Select two theoretical perspectives from which to explain psychosocial development throughout the lifespan (i.e. Freud and Erikson, etc.). Describe the major tenets of each theory. Compare and contrast the two approaches to explaining development.

At this stage, 25 papers were excluded, leaving

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nine relevant studies, which were appraised for quality,

using the CASP tool (see ESM Online Resources 1 and 3).

One study was excluded on the basis of this assessment;

therefore, eight studies were included in the analysis.

296 A. Fleming et al.

3.2 Study Characteristics

The details of the included studies are displayed in Table 1.

All studies were conducted in LTCFs. Most studies in-

cluded a mixed health care professional sample of nurses

and doctors. One study included medical directors and

administrators in the sample [14]. The most recently pub-

lished study included nurses, doctors and pharmacists [15].

The focus of the studies was respiratory tract infection

[RTI] (n = 3), urinary tract infection [UTI] (n = 2),

asymptomatic bacteriuria (n = 1) or pneumonia (n = 1),

and another study investigated antibiotic prescribing in

LTCFs in general.

The studies that were included collected their data by

interviews (n = 3) or focus group discussions (n = 2), and

three studies used interviews and focus group discussions.

Three studies were conducted to review the implementa-

tion of an infection management intervention: two re-

viewed an RTI care pathway and one reviewed a UTI care

pathway, implemented during randomized controlled trials

[14, 16, 17].

The quality appraisal of the studies found that all studies

clearly stated their research aims and used qualitative

methods appropriately (see ESM Online Resource 1). The

research design was discussed in detail, and in all studies,

the recruitment of participants was explained and justified.

The method of data collection was presented in sufficient

detail in all studies. One area where nearly all studies were

lacking was that of researcher reflexivity. Two studies did

not state whether they had obtained ethical approval or not

Fig. 1 Flow diagram outlining the identification of papers from

searches. LTCF Long-term care

facility

Antibiotic Prescribing in Long-Term Care Facilities 297

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298 A. Fleming et al.

[17, 18]. One study was excluded on the basis of the quality

assessment, as it was reported as a preliminary qualitative

study, which had a small sample size and did not reach data

saturation [19]. There was no loss of relevant findings on

exclusion of that study. Themes and sub-themes that were

derived from the thematic analysis, with supportive quo-

tations from the studies, are presented in ESM Online

Resource 4. A summary of the presence of the main themes

within each included study is provided in ESM Online

Resource 5.

3.3 Themes

3.3.1 The Long-Term Care Facility Context

The influence of the context of health care delivery in

LTCFs was reported by nurses and doctors in most of

the included studies. In two studies, it was noted that

care of patients in the LTCF setting, rather than in the

acute hospital setting, is better [14, 16]. This is linked to

the relationship between the patient and the nurses and

doctors. When the doctor, nurse or care assistant in the

LTCF knows the patient for many years, it is likely that

they will detect subtle changes in clinical signs and

symptoms that could suggest infection [16, 20, 21].

Doctors providing on-call duty reported difficulty when

managing patients that they did not know well, and they

often prescribed an antibiotic to ‘‘cover themselves’’

[20]. There were many challenges reported by nurses and

doctors in diagnosing patients with infection in LTCFs.

The delay in obtaining microbiology results for urine

samples was perceived as leading to increased empirical

prescribing of antibiotics [15, 17, 18, 22]. Participants

often depend on dipstick test results, interpreting a pa-

tient’s change in behaviour or changes in the urine as a

UTI [18, 20]. The difficulty in collecting urine samples

from these patients was highlighted, as residents are

often bed bound and incontinent [18]. Co-morbidities,

such as cognitive impairment and incontinence, chal-

lenged the nurses’ and doctors’ ability to diagnose in-

fection and conduct the necessary investigations. Not

having a doctor on-site to assess patients as quickly as

possible was also identified as a challenge to fast diag-

nosis and care [16–18, 22]. Prescribing of antibiotics

without assessment by the doctor was referred to in

several studies [17, 18]. The reasons that may have

contributed to this included lack of time on the doctors’

part to visit the LTCF and poor reimbursement for LTCF

patient care, which resulted in reduced visits. Russell and

Gallen [22] reported that many prescriptions were

ordered over the telephone and that nurses were worried

that antibiotic prescribing was conducted as a substitute

for coming to see the patient.

3.3.2 Social Factors Influencing Prescribing

The central role of the LTCF nurse emerged as a very

strong influence on antibiotic prescribing and infection

management, as reported by nurses, doctors, administrators

or pharmacists. It was evident that patient care in the LTCF

is led by nurses, who are primarily responsible for detect-

ing infection, assessing patients, taking microbiology

samples where possible and communicating this informa-

tion to the doctors [15, 20, 22]. Doctors reported that they

depend on and trust the nurses’ judgment in many cases

[15, 20, 22]. In most studies, the doctors reported that nurse

pressure can sometimes lead to increased use of antibiotics

[15].

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