Introduction

In the 1960’s the Advance Nurse Practitioner role was initiated as an action plan initiative to resolve the epidemic of having enough accessible primary care physicians in underserved and rural areas to meet the healthcare needs of the community of people (Woo, Lee & Tam, 2017). Advanced nursing practice’s establishment into primary care’s role has expanded into additional healthcare settings like acute care. Providing acute healthcare needs to patients in a primary care setting from the newly established primary care nurse practitioners, these patients in underserved and rural areas with known acute and chronic health illnesses closed the gaps in care needed to stabilized their health and prevent the potential of decline and exacerbations of their chronic and acute illnesses. If the healthcare needs of these patients weren’t addressed and provided in timely manner, there was a potential need for urgent, emergent and critical care management need that could have caused a global healthcare epidemic. The expansion of the Nurse Practitioner role has grown in the past decade to an autonomous practice on the same level of a primary care physician. The scope of practice of a Nurse Practitioner varies from state to state in the U.S. However, the current Nurse Practitioners scope of practice currently is equal to the practice of a primary care physician. The only variation in a Nurse Practitioners scope of practice is whether they have the autonomy to practice on their own or under the delegation of a collaborating physician. Primary care and acute care facilities have grown in the past decade. Nurse Practitioners  It incorporates both emergency and critical care with emergency and primary care advanced nursing practice sharing similarities since they serve as first-contact access to healthcare (Woo, Lee & Tam, 2017).

The expanded Advance Nurse Practitioner’s autonomy to practice lead to the influx of advanced practice registered nurses (APRNS) in the Nurse Practitioner field in the past 10 years has increased the practice and presence of Advance Nurse Practitioners in acute, ambulatory, emergency, long-term and critically ill care settings. (Woo, Lee & Tam, 2017). Advanced Practice Nurses now serve as first contact when receiving care in the emergency and primary care settings. Acuity of the patient delineates the emergency NP/APNs who are trained to manage patients with critical life- or limb-threatening conditions unlike the primary care NP/APNs (Woo, Lee & Tam, 2017). It’s predicated that in 2020 there will be a 22% shortfall of critical care physicians and another successive shortfall of 35% in 2030 (Woo, Lee & Tam, 2017). “Efforts are underway for measures to enhance productivity through increasing the capacity of the workforce. One potential measure is a greater utilization of nurses in advance practice. The global annual growth of the nurse practitioner (NP) workforce has been estimated to be between three to nine times greater compared to physicians” (Woo, Lee & Tam, 2017, p. 2).

Background of Antimicrobial Resistance

The first commercialized antibiotic, penicillin, was discovered in 1928 by Alexander Fleming. Germs will always look for way to survive and resist new drugs so ever since the discovery of penicillin there has been an active effort to discover and acknowledge resistance along with the discovery of new antibiotics. (CDC, Antibiotic/Antimicrobial resistance, 2018). Antimicrobial resistance microorganisms are difficult and sometimes impossible to treat. (CDC, Antibiotic/Antimicrobial resistance, 2018). There are a growing number of infections like, pneumonia, gonorrhea, tuberculosis, and salmonella that are a list of infections that are becoming difficult to treat due to the resistance of the usual antibiotic drugs used to treat these infections are becoming resistant (Littmann, 2015).  Identified as one of the major threats in the 21

^st

century to the population’s health globally is antibiotic resistance (Littmann, 2015). AMR is antimicrobial resistance and contributing to the manufacture and spread of AMR are numerous biological, behavioral, economic, environment and social factors (Littmann, 2015). The CDC estimates that 23,000 people are killed a year out of 2 million Americans who develop serious infections involving bacteria that resist one or more antibiotics (Manning, 2016).

In the non-traditional practitioner outpatient ambulatory care setting, Nurse Practitioners account for the mass majority of providers (Sanchez et al., 2016). The appropriate selection of antibiotics is critical to an Advanced Practice Nurse Practitioner goal to provide the best quality care that will decrease length of hospital stays, quicker recovery rates, comorbidities and unforeseen outcomes such as death.  This growing global epidemic of antimicrobial resistant will impact the practice of an Advanced Nurse Practitioner.

Literature review

A comprehensive overview of the articles in the literature review provide the ethical challenges that are causing antimicrobial resistant antibiotics to be one of the greatest threats to human health worldwide (Llor & Berrum, 2014). Prescribing the appropriate medication for advanced practice nurse patient’s disease process is critical but antimicrobial resistance in antibiotics can play a role. In the medical practice antimicrobial agents play a huge role to reliably cure infected patients which has saved countless lives over the last century. (Parsonage et all, 2017). Approxiametly 269 million antibiotic prescriptions were dispensed from outpatient pharmacies in 2015 in the United States. That’s “enough for five out of every six people to receive one antibiotic prescription each year. At least 30 percent of these antibiotic prescriptions were unnecessary” (CDC, Antibiotic Use in the United States, 2017, p. 14). Yearly there are approximately 47 million unnecessary antibiotic prescriptions written by doctor offices and emergency departments in the United States. It was identified that most of the unnecessary prescriptions were written for respiratory conditions that are most often caused by viruses (common colds, viral sore throats and bronchitis) that do not respond to antibiotic therapy or for bacterial infections that don’t always require antibiotics (CDC, Antibiotic Use in the United States, 2017).

It’s a combined collaborative effort that includes compliance to not misuse antibiotics from healthcare providers, the agriculture industry and multiple Federal and Government Agencies. The shortcoming centers on the inconclusiveness of the reviews. One review suggested although NP services in the emergency setting did reduce waiting time and provide care comparable to that of a midgrade physician, the cost of NP services was higher than that of resident physicians. In contrast, another review concluded that the use of NPs reduced the cost of emergency and intensive care services.

Who has taken initiatives to act? The CDC has implemented a plan of action to aid in halting the continued epidemic of antimicrobial resistance. “The Targeted Assessment for prevention (TAP) Strategy is a framework for quality improvement developed by the Center for Disease Control and Prevention (CDC) to use dada for action to prevent healthcare-associated infection (HAIS). The Targeted Assessments comprised of three components: 1) running TAP reports in the National Healthcare Safety Network (NHSN) to identify healthcare facilities with an excess burden of HAIS’s 2) Assess infection prevention standards, guidelines and resources of  those facilities and Implement Guides to address any gaps identified 3) Administering TAP  facility assessments tools to identify gaps in infection prevention. The TAP reports will allow ranking for the facility and will to accessible to the public for review (CDC, TAP, 2019).

The U.S. Federal Government has implemented an Action plan: “The National Action Plan was developed by the Interagency Task Force for Combating Atibiotic0 Resistant Bacteria in response to Executive Order 13676. This National Action Plan addresses policy recommendations from the President’s Council of Advisors on Science and Technology. “By February 15, 2015, the Task Force shall submit a 5-year National Action Plan to the President that outlines specifics actions to be taken to implement a Strategy. The Action Plan shall include goals, milestones, and metrics for measuring progress, as well as associated timelines for implementation” (Exec. Order No. 13676, 2014, p. 56932)

The review of this literature expresses the significance of why all health care providers should be ethically and morally obligated to using antibiotics in the appropriate manner. Due to the restrictions of a growing list of antibiotics that have resistance to known microorganisms the Nurse practitioner and other practitioners are constrained to treating their patients. Inappropriate antibiotic prescribing could result in successful management and care contingent on the patient’s diagnosis and the severity of the illness. Due to the reported limitations in the literature delay in care could lead to unanticipated clinical outcomes such as an acute illness developing into a chronic illness or a life-threatening event.

Application of findings

According to (Sanchez et al., 2016) a major problem that’s contributing to antibiotic resistance were identified as Nurse Practitioners and Physician Assistants in outpatient ambulatory care settings.  The research study referenced in this article “Outpatient Antibiotic Prescribing Among United States Nurse Practitioners and Physician Assistants” reports that the most common condition that antibiotics are prescribed for in the ambulatory care settings are for acute respiratory tract infections.

In many circumstances respiratory tract infections do not warrant an antibiotic prescription, yet this remains common (Sanchez et al., 2014). The classification of data being captured limited the research data analysis. There was a smaller number of visits being captured for NP’s and PA’s in comparison to physicians for antibiotic prescribing by condition and provider type for adult ambulatory care visits. This data leaves room to question its validity. Erroneous data can lead to analysis of imprecise commonness, applicability and information that is common or contraindicatory

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Healthcare Providers, patient and families, Health Systems, hospitals, clinics, nursing homes and Federal, State and local health agencies has a role to play in improving antibiotic use. (CDC. Antibiotic Use in the United States, 2017).

Implication for the Nurse Practitioner in Primary Care

There is a large volume of Nurse Practitioners presence in the Primary care settings and antimicrobial resistant antibiotics would significantly affect their practice. They perform a crucial function in regulating access to antibiotics, educating patients about antimicrobial resistance and prescribing antibiotics.  Nurse Practitioners need a general understanding of drug resistance when educating patients about antimicrobial resistant antibiotics. This includes how practitioners play a vital role in guaranteeing antibiotics are being used in a correct manner and an understanding of the causative factors that lead to drug resistance.

Conclusion

This global epidemic is best addressed by promotion of a national educational campaign of intervention that’s tailored to confront all areas of deficits that are contributing to this ethical issue. These educational interventions should be available in designated areas for ease of accessibility and include the publication of practice standards and guidelines for review and compliance, offering education to patients, healthcare professionals and targeted deficient areas. The implemented audits should be completed, and the results are reviewed with the public to guarantee compliance and attain measurable data to assess the outcomes of intervention. Continuous audits should be performed intermittently if warranted once completion of all action plans and baseline assessments are obtained. Warnings should be enforced followed by a consistent course of punitive actions if continued non-compliance is acknowledged.

Numerous cultural characteristics linked to country background, socieo-economic influences, cultural beliefs of the patient and the prescriber, patient demand, and clinical independence influence prescribing antibiotics (Llor & Bjerrum, 2014). Advanced Nurse practiotioners’ local standards and guidelines differ from state to state and country to country and they are held accountable to practice within their scope and remain in compliance. Advanced Nurse Practitioners in the United States are held to a higher practice standard since in other countries antibiotics are readily available for use without a prescription. One of the potentially major contributing factors leading to the significant rise in antimicrobial resistance could be this significant cultural and geographic variations in practice standards. Responsible with providing secure, competent and satisfactory care the Advanced Nurse Practitioners in the United States have numerous of barriers to overcome. Instead of accepting new practice guideline standards that may involve a watch and wait period prior to prescribing antibiotics patients expect to go to the doctor and leave with a prescription.

Nurse Practitioners and their collaborating physicians have to mindful not to adapt to prescribing habits and behaviors they may be comfortable to practicing and/or were trained. Even if they are knowledgeable of evidence-based practice standards most are unwilling to adjust. Nurse Practitioners should practice in a manner that is within the best interest of the patient, the practice standards guidelines and the most recent evidence-based practice standards. The belief that endorsed agents are more likely to cure an infection, fear for the patient or parent satisfaction, and fear of infectious complications are motives for non-adherence (Sanchez et al., 2016). Providers are not taking this wide spread epidemic of antibiotic resistance into consideration when prescribing the correct antibiotic therapy.

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