A pressing public health problem worldwide, antibiotic-resistant bacteria cause more than 2 million illnesses and 22,000 deaths each year in the United States alone.1
At the James Madison University (JMU) University Student Health Center, Kristina Blyer was concerned with student and parent demands for antibiotic therapy as treatment for viral respiratory tract infections. Blyer, the associate director of clinical operations at the Health Center and a doctoral student in the JMU School of Nursing, became intrigued with the use of shared decisionmaking as a method to reduce demands for inappropriate use of antibiotics. For her doctoral research project, Blyer wanted to determine whether engaging students coming into the JMU health center in shared decisionmaking would increase decisional comfort with treatment decisions related to respiratory tract infections while maintaining or reducing current antibiotic prescribing rates. Blyer successfully applied for a JMU internal innovation grant and received approval for her research proposal from leaders in the fields of nursing, medicine, and public health.
- Many respiratory infections are caused by viruses, not bacteria, making antibiotics an ineffective treatment.2
- Widespread use of antibiotics for viral illnesses can promote spread of antibiotic resistant bacteria.2
The SHARE Approach is a five-step process for implementing shared decisionmaking, which offers physicians and other health care professionals the training and tools to help patients compare the potential benefit, harm, and risk of various treatment options for their conditions through meaningful dialogue about what matters most to the patient. The five steps are:
AHRQ's SHARE Approach Workshop Guides Video-Based Training
To prepare for her research project, Blyer participated in one of the Agency for Healthcare Research and Quality's (AHRQ) SHARE Approach train-the-trainer workshops in Baltimore, MD, in May 2015. She earned her certification as a SHARE Approach master trainer at the workshop. As a master trainer, she could then train other health center clinicians and staff to create a team ready to engage students in shared decisionmaking.
To launch shared decisionmaking at the JMU health center, Blyer decided to adapt the SHARE Approach curriculum into a 4-part video training, followed by an interactive in-person session. This combined virtual and in-person training allowed participants to take most of the training at their convenience over the school's winter break. She noted that offering most of the training virtually was critical to securing over 30 participants and kept her research project on track.
The training videos draw on key content from the first four modules of the AHRQ SHARE Approach Workshop:
- Shared Decisionmaking and the SHARE Approach.
- Using Patient-Centered Outcomes Research in Shared Decisionmaking.
- Putting Shared Decisionmaking Into Practice.
The in-person session incorporated some interactive activities from the SHARE Approach Curriculum as well, such as role-playing shared decisionmaking conversations and using a decision aid with student volunteers.
Training Is Well Received
Throughout the training, Blyer received positive comments from providers excited to engage patients in shared decisionmaking. Blyer offered anecdotal feedback about how providers have seen a shift in student interactions: "I've had health care providers report that some students have felt more empowered after reviewing the decision aid with them."
Blyer believes using shared decisionmaking benefits both students and patients; when providers use shared decisionmaking they engage in meaningful conversation to understand their patient's concerns and better explain the risks and benefits associated with antibiotic use.
"I've had health care providers report that some students have felt more empowered after reviewing the decision aid with them."
Blyer noted that successful shared decisionmaking about antibiotic use:
- Incorporates the patient's expectations and preference for antibiotics
- Uses the provider's knowledge about the benefits and risks of antibiotic use
- Guides the patient/provider team in determining a treatment decision that is right for the patient
Since the training, Health Center clinicians and staff are incorporating decision aids and the SHARE Approach in consultations with patients with viral respiratory tract infections. The JMU Health Center staff are using a decision aid developed at the Ottawa Hospital Research Institute on the topic of antibiotics for respiratory infections.3
For her research project, Blyer aims to systematically measure the effects of shared decisionmaking on the Health Center prescribing rates for upper respiratory infections. Blyer has recruited four JMU Health Center providers, including two physicians and two nurse practitioners, to take part in a study. Blyer will measure and compare the Health Center's antibiotic prescribing rates during periods before and after the deployment of the shared decisionmaking and decision aid tool. Blyer will also study the patient experience using the Ottawa Hospital Research Institute's SURE test4 to assess patient decisional certainty.
At the study's intervention mid-point, measures of decisional comfort have increased with relatively more patients reporting no decisional conflict with their treatment decision. Additionally, preliminary data show that prescribing rates for respiratory tract infections have decreased.
Next Steps: Curriculum Development
After completing her study, Blyer hopes to continue her work with shared decisionmaking with studies to determine short- and long-term outcomes of shared decisionmaking-related visits for respiratory tract infections. She also hopes to develop a course on shared decisionmaking for the JMU School of Nursing.
About the Educator
Kristina B. Blyer, M.S.N., R.N., N.E.-B.C., is the associate director of clinical operations at the JMU University Health Center. She is also a candidate for a doctoral of nursing practice degree at the JMU School of Nursing.
Blyer's current position allows her to use creativity and innovation to drive positive change across various areas of health care. One of her most challenging accomplishments was coordinating the move of all clinical operations to two different facilities within 2 years. Past work experience includes her position at Rockingham Memorial Hospital as a registered nurse in the pediatrics unit and as a home health case manager.
Blyer is a member of Sigma Theta Tau International Honor Society of Nursing and is board certified as a nurse executive through the American Nurses Credentialing Center. Her practice interests include public health, shared decisionmaking, promoting self-care, and working with interprofessional teams.
1Centers for Disease Control and Prevention. "Get Smart About Antibiotics Week: Preserve the Power of Antibiotics." http://www.cdc.gov/getsmart/week/downloads/gsw-factsheet-providers.pdf. Accessed March 2016.
2Centers for Disease Control and Prevention. "Antibiotic Resistance Questions and Answers." http://www.cdc.gov/getsmart/community/about/antibiotic-resistance-faqs.html. Accessed March 2016.
3Labrecque, LeBlanc, Legare, Cauchon. "Taking an Antibiotic or Not? Diagnostic Decision Support Tool." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447039/bin/supp_120568v1_train-legare-1-at.pdf. Published 2010. Accessed April 2016.
4O'Connor, Stacy J. Ottawa Hospital Research & Institute of Ottawa. "SURE Test version for clinical practice." https://decisionaid.ohri.ca/docs/develop/Tools/DCS_SURE_English.pdf. Published 2008. Accessed March 2016.