Nurses are underutilised in antimicrobial stewardship – Results of a multisite survey in paediatric and adult hospitals

Overview of the Participation of Nurses in Antimicrobial Stewardship Activities

Antibiotic resistance is a planetary threat demanding maximum attention from health and social care services worldwide due to the clinical, economic, and human costs. Interventions to address resistance-antimicrobial stewardship (AMS) programs-are multipronged and require the close collaboration of all health care workers involved in antimicrobial decisions and use. Nurses have traditionally been absent from such engagement. This Commentary highlights existing evidence of the need for, and impact of, nursing involvement and leadership in AMS. In addition, four barriers (ie, foundational, ownership, education, and leadership) to the increased involvement of nurses in AMS are discussed, with implications and potential solutions.

The application of antimicrobial stewardship knowledge to nursing practice: A national survey of United Kingdom pre-registration nursing students

AIM

To assess student nurses understanding and skills in the application of antimicrobial stewardship knowledge to practice.

DESIGN

Quantitative.

METHODS

Cross-sectional survey.

RESULTS

Five hundred and twenty three student nurses responded across 23 UK universities. Although students felt prepared in competencies in infection prevention and control, patient-centred care and interprofessional collaborative practice, they felt less prepared in competencies in which microbiological knowledge, prescribing and its effect on antimicrobial stewardship is required. Problem-based learning, activities in the clinical setting and face-to-face teaching were identified as the preferred modes of education delivery. Those who had shared antimicrobial stewardship teaching with students from other professions reported the benefits to include a broader understanding of antimicrobial stewardship, an understanding of the roles of others in antimicrobial stewardship and improved interprofessional working.

CONCLUSION

There are gaps in student nurses' knowledge of the basic sciences associated with the antimicrobial stewardship activities in which nurses are involved, and a need to strengthen knowledge in pre-registration nurse education programmes pertaining to antimicrobial management, specifically microbiology and antimicrobial regimes and effects on antimicrobial stewardship. Infection prevention and control, patient-centred care and interprofessional collaborative practice are areas of antimicrobial stewardship in which student nurses feel prepared. Interprofessional education would help nurses and other members of the antimicrobial stewardship team clarify the role nurses can play in antimicrobial stewardship and therefore maximize their contribution to antimicrobial stewardship and antimicrobial management.

IMPLICATIONS FOR THE PROFESSION

There is a need to strengthen knowledge from the basic sciences, specifically pertaining to antimicrobial management, in pre-registration nurse education programmes.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT

What Problem Did the Study Address? Nurses must protect health through understanding and applying antimicrobial stewardship knowledge and skills (Nursing and Midwifery Council 2018); however, there is no research available that has investigated nurses understanding and skills of the basic sciences associated with the antimicrobial stewardship activities in which they are involved. What Were the Main Findings? There are gaps in student nurses' knowledge of the basic sciences (specifically microbiology and prescribing) associated with the antimicrobial stewardship activities in which nurses are involved. Problem-based learning, and activities in the clinical setting, were reported as useful teaching methods, whereas online learning, was seen as less useful. Where and on Whom Will the Research Have an Impact? Pre-registration nurse education programmes.

REPORTING METHOD

The relevant reporting method has been adhered to, that is, STROBE.

Bedside nurses' antimicrobial stewardship practice scope and competencies in acute hospital settings: A scoping review

AIM

To identify and map bedside nurses' practice scope and competencies regarding antimicrobial stewardship in acute hospital settings, and develop a competency framework for them.

BACKGROUND

Antimicrobial stewardship requires multidisciplinary engagement including nursing. However, bedside nurses' antimicrobial stewardship practice scope and competencies in acute hospital settings remain unclear.

DESIGN

Scoping review.

METHODS

Using a five-stage framework proposed by Arksey and O'Malley and following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

A total of 1422 records were retrieved, and 41 studies were included. In addition to the six practices recommended, this review summarized bedside nurses' contributions to five additional fields as well. Correspondingly, the competencies required by bedside nurses were summarized into eight domains: specialized knowledge, safety medication administration, leadership, education, diagnostic stewardship, infection prevention and control, professional development and professional quality.

CONCLUSION

Nurses' practice scope overlaps greatly with routine nursing practice in antimicrobial stewardship, confirming the evidence that nurses are ideal partners in antimicrobial stewardship. This review developed a competency framework at both basic and advanced levels. Among them, professional knowledge is the foundation, while professional quality motivates nurses to participate. In addition to competency assessment, it can also be used for training and human resource deployment based on seniority or professional level. This could bridge the knowledge gap and improve the engagement of nurses in heavy workload situations.

RELEVANCE TO CLINICAL PRACTICE

This practice scope will provide opportunities for nurses to engage in antimicrobial stewardship. Moreover, nursing competencies identified in this field could facilitate the development of competency-based education interventions, talent assessments, training and recruitment programs.

DATA RESOURCES

PubMed, EMBASE, Web of Science, CINHAL, PsycINFO, Cochrane Library, ProQuest and Scopus were searched from inception to November 2022, with an updated search in March 2023.

IMPACT

This scoping review provides evidence for best nursing practice scope and competency in antimicrobial stewardship in hospitals. However, it is also in line with the commitment of all nurses in the global community to combat antimicrobial resistance, which has become a global threat. An antimicrobial stewardship competency framework for bedside nurses was developed at both the basic and advanced levels. It would facilitate talent assessment, training, recruitment and human resource management by guiding the development of competency-based education interventions.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Development of National Antimicrobial Intravenous-to-Oral Switch Criteria and Decision Aid

Introduction: Antimicrobial stewardship (AMS) strategies, such as intravenous-to-oral switch (IVOS), promote optimal antimicrobial use, contributing to safer and more effective patient care and tackling antimicrobial resistance (AMR). Aim: This study aimed to achieve nationwide multidisciplinary expert consensus on antimicrobial IVOS criteria for timely switch in hospitalised adult patients and to design an IVOS decision aid to operationalise agreed IVOS criteria in the hospital setting. Method: A four-step Delphi process was chosen to achieve expert consensus on IVOS criteria and decision aid; it included (Step One) Pilot/1st round questionnaire, (Step Two) Virtual meeting, (Step Three) 2nd round questionnaire and (Step 4) Workshop. This study follows the Appraisal of Guidelines for Research and Evaluation II instrument checklist. Results: The Step One questionnaire of 42 IVOS criteria had 24 respondents, 15 of whom participated in Step Two, in which 37 criteria were accepted for the next step. Step Three had 242 respondents (England n = 195, Northern Ireland n = 18, Scotland n = 18, Wales n = 11); 27 criteria were accepted. Step Four had 48 survey respondents and 33 workshop participants; consensus was achieved for 24 criteria and comments were received on a proposed IVOS decision aid. Research recommendations include the use of evidence-based standardised IVOS criteria. Discussion and Conclusion: This study achieved nationwide expert consensus on antimicrobial IVOS criteria for timely switch in the hospitalised adult population. For criteria operationalisation, an IVOS decision aid was developed. Further research is required to provide clinical validation of the consensus IVOS criteria and to expand this work into the paediatric and international settings.

Nurses' perceptions of their role in antimicrobial stewardship within the hospital environment. An integrative literature review

BACKGROUND

Antimicrobial stewardship (AMS) has traditionally been the domain of doctors and pharmacists but there is a growing recognition that successful stewardship incorporates a multidisciplinary approach that includes nursing staff. This literature review explores nurses' perceptions of their role in antimicrobial stewardship within the hospital environment and provides new insights to inform future practice.

METHODOLOGY

An integrative literature review was undertaken. Five academic databases were searched, which identified six relevant studies. Whittemore and Knafl's method for conducting an integrative review was followed. ENTREQ guidelines have been adhered to.

FINDINGS

Two themes were identified: nurses' working in partnership with other professionals and engagement in education.

DISCUSSION

Antimicrobial stewardship illustrates the role of the nurse within the wider multidisciplinary team regarding wider patient safety issues and the need for education to enhance this role.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a clear role to play in antimicrobial stewardship but need to be fully cognisant of the issues involved. Further clarity on how nurses should enact this role in their complex working environments is required. It is essential that both student and qualified nurses are able to speak up in order to maximise patient safety, fulfil their professional duty and promote the overall effectiveness of AMS if they witness poor antibiotic management practices.

Antibiotic Stewardship Attitudes and Beliefs Among Frontline Staff Nurses: Impact of Virtual Education

Background: Nurses are vital healthcare team members and are often underutilised in antimicrobial stewardship (AS) activities. Several nursing responsibilities, such as taking allergy history and obtaining cultures, already overlap with AS activities. Nurses can play a crucial role in promoting AS in resource-limited settings. This study was conducted to assess frontline staff nurses’ baseline attitudes and beliefs towards AS, and see if a virtual education campaign consisting of newsletters and tip sheets would affect those attitudes and beliefs. Methods: An online survey (pre-survey) was conducted of all in-patient nurses employed in the authors’ hospital on their attitudes and beliefs regarding AS. The survey consisted of 24 questions divided into three domains: demographic and practice information, nursing roles, and beliefs and attitudes towards AS programmes (ASP). After obtaining the results of the pre-survey, the authors started distributing monthly newsletters on various AS topics via email and posting them on a resource page. Topics included how to obtain an accurate allergy history, how to use microbiology results to help guide decisions, and stop therapy in cases of colonisation. The authors also distributed the same survey as a follow-up 6-month survey (post-survey) in March 2021 to gauge the impact of their virtual education efforts. Results: In total, 109 nurses working in the adult in-patient setting of the authors’ institution completed the pre-survey in September 2020, and 64 nurses completed the post-survey in March 2021. Overall, most nurses had a positive attitude towards AS tasks, and over 90% of those who responded in the pre-survey and post-survey agreed with the statement that nurses are antibiotic stewards, thought it was important or very important to obtain appropriate cultures, and understood the relationship between Clostridioides difficile and antibiotics. Most pre-survey respondents listed knowledge gaps in microbiology (47 out of 64 [86%]) and antibiotics (53 out of 64 [84%]) as well as scope of practice concerns (48 out of 64 [75%]) as barriers to nurse participation. The virtual education helped raise the familiarity with the ASP and more nurses in the post-survey said they were familiar with the stewardship programme compared with the pre-survey (48.4% versus 23.2%; p=0.001). Conclusions: This study showed that most nurses consider themselves antibiotic stewards and want to participate in AS activities; however, barriers to nursing involvement, such as lack of knowledge, scope of practice concerns, and time constraints, persist. Virtual education may be an option to increase nursing awareness and participation on ASPs in resource-limited settings.

Influences on nurses' engagement in antimicrobial stewardship behaviours: A multi-country survey using the Theoretical Domains Framework

BACKGROUND

Antimicrobial resistance (AMR) is significantly affected by inappropriate antibiotic use, and is one of the greatest threats to human health. Antimicrobial stewardship (AMS) is a programme of actions promoting responsible antimicrobial use, and is essential for limiting AMR. Nurses have an important role to play in this context.

AIM

This study investigated the determinants of nurse AMS behaviours and the impact of past training.

METHOD

A cross-sectional multi-country survey design with mixed methods was employed. Participants were 262 nurses (223 female; mean age = 44.45; SD = 10.77 years) from ten nationalities, with individual survey links sent via professional networks in 5 countries, alongside Twitter. Nine AMS behaviours and 14 behavioural determinants were quantitatively assessed using the Theoretical Domains Framework (TDF), and mapped to the COM-B (Capability, Opportunity, Motivation - Behaviour) model. Analysis identified differences between nurses with and without AMS training. The influence of COVID-19 on AMS behaviour was qualitatively investigated using free text data.

FINDINGS

Nurses performed all nine AMS behaviours, which were significantly higher (t(238) = -4.14, p < .001), by those who had training (M = 53.15; SD = 7.40) compared to those who had not (M = 48.30; SD = 10.75). Those with AMS training scored significantly higher in all of the TDF domains. The TDF was able to explain 27% of the variance in behaviour, with 'Skills' and 'Behavioural Regulation' (e.g. ability to self-monitor and plan), shown to be the most predictive of AMS actions. Both of these domains are situated in the Capability construct of COM-B, which can be enhanced with the intervention strategies of education and training. An increase in AMS behaviours was reported since COVID-19, regardless of previous training. Six core themes were linked to AMS: 1) Infection prevention and control, 2) Antimicrobials and antimicrobial resistance, 3) The diagnosis of infection and the use of antibiotics, 4) Antimicrobial prescribing practice, 5) Person-centred care, and 6) Interprofessional collaborative practice.

CONCLUSION

This research, has identified the significant benefit of nurse training on AMS behaviour, and its determinants. Those who had training, scored higher in all TDF determinants of behaviour, compared to those who had had no training, resulting in higher Capability, Opportunity and Motivation to perform AMS behaviours. AMS education and training should be offered to nurses to enhance these factors. Future research should consider the optimal level of training to optimise AMS behaviour, with a focus on developing skills and behavioural regulation.

Dismantling antibiotic infrastructures in residential aged care: The invisible work of antimicrobial stewardship (AMS)

Recent social science scholarship has sought to understand the visible and invisible impacts of how antibiotics are entrenched as infrastructures and put to work as a proxy for higher levels of care (clinical or otherwise) within modern healthcare. Using a qualitative research design, in this paper our aim is to draw attention to less visible aspects of antimicrobial stewardship (AMS) in residential aged care and their implications for nurse-led optimization of antibiotic use in these settings. By developing an account of the perceptions, experiences and practices of staff regarding the 'on the ground' work associated with implementing and upholding AMS objectives our study extends research on attempts to dismantle antibiotic infrastructures in Australian residential aged care facilities (RACF). Drawing on a review of relevant policies, empirical data is presented from fifty-six in-depth interviews conducted in 2021 with staff at 8 different RACFs. Interview participants included managers, nurses, and senior and junior personal care assistants. Our results suggest that registered nurses in residential aged care have been tasked with promoting antibiotic optimization and assigned with AMS responsibilities without sufficient authority and resourcing. A host of hidden care work associated with AMS strategies was evident, reinforcing some staff support for empirical antibiotic prescribing as a 'safety net' in uncertain clinical cases. We argue that this hidden work occurs where AMS strategies displace the infrastructural role previously performed by antibiotics, exposing structural gaps and pressures. The inability of organisational accounting systems and the broader AMS policy agenda to capture hidden AMS workflows in RACFs has consequences for future resourcing and organisational learning in ways that mean AMS gaps may remain unaddressed. These results support findings that AMS interventions might not be easily accepted by aged care staff in view of associated burdens which are under recognised and under supported in this domain.

Guideline recommendations for antimicrobial stewardship education for clinical nursing practice in hospitals: A scoping review

Background

Antimicrobial stewardship (AMS) is a proactive healthcare intervention to improve patient outcomes by optimising antimicrobial use. Although nursing involvement is a recognised necessity, bedside nurses may not yet possess competencies to fulfil this role.

Objectives

To identify recommendations for AMS education for the bedside nurse in key global AMS guidelines.

Methods

Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites and websites of professional societies and organisations. Search dates were from 1990 to 2020. Inclusion criteria were English language AMS guidelines for hospitals.

Results

Literature searches retrieved 1 824 articles, with 43 meeting the review inclusion criteria. Reference was made to AMS nursing education in 23 (53.4%) of the articles. Educational opportunities for nurses were recommended: inclusion of AMS concepts/content into undergraduate and postgraduate nursing curricula (n=12; 27.9%), in-hospital training (n=14; 32.5%) and continuing professional development (n=6; 13.9%). Recommendations for nursing education were as follows: role of AMS in preventing antimicrobial resistance (n=7; 16.2%), infection prevention and control (n=3; 6.9%), diagnostics in AMS (n=5; 11.6%), pharmacology (n=11; 25.5%) and collaboration (n=2; 4.6%). Identified nursing educational gaps were: nurses not recognising their role within AMS (n=5; 11.6%), inadequate nursing resources and expertise for dosing, pharmacokinetic/pharmacodynamic strategies and managing possible drug incompatibilities with extended/prolonged infusions (n=3; 6.9%), and inappropriate nurse disposal of antibiotic waste (n=1; 2.3%).

Conclusion

Although recommendations for nursing education were found in many key AMS guidelines, few guidelines provided detailed descriptions of the nursing competencies that were required for this role.

Contributions of the study

This study serves to compile and highlight previously little-known recommendations within key international antimicrobial stewardship (AMS) guidelines for the education of clinical nurses in their AMS role. It provides a summary of expected clinical nurse competencies. It adds to current discussion within the literature on how to improve and support this critical nursing role.

The delivery of antimicrobial stewardship competencies in United Kingdom pre-registration nurse education programmes: A national cross-sectional survey

BACKGROUND

Registered nurses perform numerous functions critical to the success of antimicrobial stewardship but only 63% of pre-registration nursing programmes include any teaching about stewardship. Updated nursing standards highlight nurses require antimicrobial stewardship knowledge and skills.

AIM

To explore the delivery of key antimicrobial stewardship competencies within updated pre-registration nursing programmes.

METHOD

A cross-sectional survey design. Data were collected between March and June 2021.

FINDINGS

Lecturers from 35 UK universities responsible for teaching antimicrobial stewardship participated. The provision of antimicrobial stewardship teaching and learning was inconsistent across programmes with competencies in infection prevention and control, patient centred care, and interprofessional collaborative practice taking precedent over those pertaining to the use, management, and monitoring of antimicrobials. On-line learning and teaching surrounding hand hygiene, personal protective equipment, and immunisation theory was reported to have increased during the pandemic. Only a small number of respondents reported that students shared taught learning with other healthcare professional groups.

CONCLUSION

There is a need to ensure consistency in antimicrobial stewardship across programmes, and greater knowledge pertaining to the use, management and monitoring of antimicrobials should be included. Programmes need to adopt teaching strategies and methods that allow nurses to develop interprofessional skill in order to practice collaboratively.

Navigating sociocultural disparities in relation to infection and antibiotic resistance-the need for an intersectional approach

One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.

Perceived roles and barriers to nurses' engagement in antimicrobial stewardship: A Thai qualitative case study

BACKGROUND

Antimicrobial stewardship is the practice of ensuring the optimal use of antibiotics to prevent antimicrobial resistance. A multidisciplinary approach is considered best practice; however, little is known about nurses' contribution.

OBJECTIVES

To explore how organisational multidisciplinary leaders and clinical nurses perceive nurses' roles in AMS in a single organisational site case study based in Thailand, within the current governance, educational and practice context, and the barriers to nurses' engagement in AMS.

METHODS

A qualitative descriptive study using thematic analysis approach was conducted in a 1000-bed university hospital in Bangkok, Thailand. The combined number of organisational leaders and nurses was 33 including 15 individual organisational leader interviews and three focus groups involving 18 nurses.

RESULTS

Nurses currently participate in AMS by supporting system processes, monitoring safety and optimal antibiotic use and patient education. A lack of clear articulation of nurses' role and traditional professional hierarchies limits active participation. Inconsistent engagement was perceived as due to a failure to prioritise AMS activities, a lack of formal policies and a need for further education.

CONCLUSION

Nurses do engage in AMS but there are significant governance, hierarchical and educational impediments. These gaps need to be addressed before clearly defined nurse roles in AMS can be developed and embedded into clinical practice.

Paediatric nurses', children's and parents' adherence to infection prevention and control and knowledge of antimicrobial stewardship: A systematic review

INTRODUCTION

Infection prevention and control precautions help to decrease microbial transmission, and through the appropriate use of antibiotics, Antimicrobial Stewardship programs aim to decrease the prevalence and emergence of Antimicrobial Resistance.

METHODS

A systematic review was undertaken to critically appraise and synthesise evidence for nurses', children's and parents' knowledge and understanding of antimicrobial stewardship, and of infection prevention and control in acute paediatric care settings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guided the review. Studies were included if they examined the factors that contributed to nurses' adherence to, or consumers' practice in relation to, antimicrobial stewardship and infection prevention and control.

RESULTS

Of the 16,957 papers identified, 50 studies conducted in acute paediatric settings met the eligibility criteria, and were included. Most studies were of low methodological quality. Fourteen studies evaluated nurses' knowledge and self-reported adherence to Infection Prevention and Control principles and identified consistent practice gaps by nurses. Six studies evaluating the effectiveness of education programs reported modest improvements in nurses' knowledge and adherence to infection prevention and control. There were 15 studies, that investigated consumers' involvement in infection prevention and control that identified the following themes: Consumer knowledge and attitudes to infection prevention and control and transmission-based precautions, and parents' willingness to take an active role in infection prevention. Six studies focused on paediatric nurses' role in antimicrobial stewardship, exploring the following themes: (1) nurses' understanding and beliefs of antimicrobial stewardship roles, and (2) barriers to nurses taking a greater role in antimicrobial stewardship. Nine studies explored the role of consumers in antimicrobial stewardship and identified consumers' misconceptions about the benefits and downplayed concerns regarding antibiotic use.

DISCUSSION

Although consumers articulated a willingness to be actively involved in infection prevention, observed practice remained lower than that required to consistently prevent infection transmission.

CONCLUSION

These findings highlight a critically important gap in current practice. In relation to optimal use of antimicrobials, although paediatric nurses were involved in supporting antimicrobial stewardship processes and educating consumers, they identified limited antimicrobial stewardship knowledge. Consumers appeared to lack understanding about the benefits of antibiotics and negated concerns regarding antibiotic use.

Nursing students' awareness and perceptions of nurses' role in antimicrobial stewardship

Antimicrobial resistance is a major threat to public health worldwide. Antimicrobial stewardship programs and interventions aiming to optimise the use of antibiotics, are increasingly used to ensure judicious use of antibiotics and limit the emergence of antimicrobial resistance. Nurses are pivotal in antimicrobial stewardship however nursing students' awareness of such programs has not been investigated. This study aimed to elicit nursing students' perspectives and perceptions of the nurse's role in antimicrobial stewardship. A cross-sectional design was utilised to survey pre-registration nursing students. A total of 321 nursing students enrolled in an Australian university participated. The survey comprised questions on knowledge and opinions regarding the nurse's role in AMS and on a range of topics relating to antimicrobial stewardship and antimicrobial resistance, through closed and open-ended questions. While 44.5% of participants indicated they were familiar with the term Antimicrobial Stewardship, 70.7% believed they had very little or no knowledge of the principles. Completion of subjects with a focus on quality and safety in nursing practice and quality use of medications was associated with greater awareness. Findings underscore the need to engage nursing students in discussions exploring the problem of antimicrobial resistance and the important role nurses play in Antimicrobial Stewardship programs.

Evaluating knowledge and perception of antimicrobial stewardship among nurses in an acute care hospital

BACKGROUND

Antimicrobial stewardship programs are essential to reduce the risks of antimicrobial resistance.

METHODS

A cross sectional survey was used to evaluate nurses' knowledge and perceptions of antimicrobial stewardship.

RESULTS

Of 241 nurses recruited, 22.9% reported good knowledge of antimicrobial stewardship. Nurses agreed that ensuring appropriate antimicrobial use, hygiene for preparation, administration and disposal of antibiotics, as well as educating colleagues, patients and public were vital. Many felt that to reduce the impact of antimicrobial resistance, AMS should be included in the undergraduate nursing curriculum.

CONCLUSIONS

Improving the awareness of and education on AMS and AMR among nurses is an essential element in infection and prevention control.

Knowledge, perceptions and experiences of nurses in antimicrobial optimization or stewardship in the intensive care unit

There is an urgent and recognized need for an interprofessional collaborative approach to support global action in addressing antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) refers to systematic approaches for antimicrobial optimization within healthcare organizations. In areas with high antimicrobial utilization such as intensive care units (ICUs), specific roles for nurses in AMS are not clearly defined. This review aimed to identify and to critically evaluate primary studies that examined knowledge, perspectives and experiences of nurses associated with antimicrobial use and optimization in ICUs. A systematic search of Medline, CINAHL, PsychINFO, EMBASE, PubMed, SCOPUS, Cochrane Library and Web of Science databases for primary studies published from 1^st January 2000 to 20^th March 2020 was performed. A convergent synthesis design was used to synthesize quantitative and qualitative data. Of the 898 studies initially screened, 26 were included. Most (18/26) studies were quantitative. All qualitative studies (6/26) were of high methodological quality. Studies where interventions were used (10/26) identified significant potential for ICU nurses to reduce antimicrobial use, time-to-antibiotic administration, and error rates. Barriers to nursing engagement included knowledge deficits in antimicrobial use, interprofessional dissonance and the culture of deference to physicians. Enhancing education, technology utilization, strong nursing leadership and robust organizational structures that support nurses were perceived as enablers to strengthen their roles in optimizing antimicrobial use. This review showed that nursing initiatives have significant potential to strengthen antimicrobial optimization in ICUs. Barriers and enablers to active engagement were identified.

Reconsidering the nursing role in antimicrobial stewardship: a multisite qualitative interview study

OBJECTIVES

This study responds to calls for greater focus on nursing roles, and the need for nursing integration within the antimicrobial optimisation agenda. The objective of this study was to explore Australian hospital nurses' views on antimicrobial resistance and antimicrobial stewardship (AMS) in a hospital setting, in order to better understand the opportunities for and challenges to integration of nursing staff in antimicrobial optimisation within hospital settings.

DESIGN

Qualitative one-on-one, semistructured interviews. Interview transcripts were digitally audio-recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory.

SETTING

Four hospitals (three public and one private), across metropolitan, regional and remote areas, in two Australian states.

PARTICIPANTS

86 nurses (77 females, 9 males), from a range of hospital departments, at a range of career stages.

RESULTS

Findings were organised into three thematic domains: (1) the current peripheral role of nurses in AMS; (2) the importance of AMS as a collaborative effort, and current tensions around interprofessional roles and (3) how nurses can bolster antimicrobial optimisation within AMS and beyond.

CONCLUSION

Nursing staff are central to infection management within the hospital and are thus ideally located to enhance antibiotic optimisation and contribute to AMS governance. However, without increased interprofessional cooperation, education and integration in the AMS agenda, as well as addressing organisational/resource constraints in the hospital, the nursing role in stewardship will remain limited.

Nurse role and contribution to antimicrobial stewardship: An integrative review

AIM

To examine existing published literature regarding nurses and antimicrobial stewardship, and their potential role and contribution, to identify what is known, to evaluate methodologies used in published research, and to review and integrate findings to inform practice and future priorities for research.

DESIGN

Integrative review.

METHODOLOGY

The approach to this review was informed by Whittemore and Knafl's integrative review methodology. Electronic databases were searched for papers published since the start of the database to November 2019, with abstracts available, related to humans and published in English. Papers were included regardless of practice setting (acute, aged, and primary care) and if they were research based, included nurses as participants and reported specifically on results from nurses or that had implications for nursing practice. Excluded were conference abstracts, and papers focussed solely on nurse prescriber, nurse practitioner, or nurse manager roles.

RESULTS

Fifty-two papers were included in the review. Identified themes were: i) nursing knowledge, learning needs and education; ii) nurse perceptions of the nursing role and motivations for involvement; iii) nursing brokerage and influence on information flow to and from patients; iv) nursing workflow, workload and workarounds; and v) nurse leadership. Methodological quality of the included papers varied, limiting transferability and applicability of findings for some of the included studies.

CONCLUSION

Formal inclusion of nurses in antimicrobial stewardship activities has been associated with improved nurse knowledge, nurse confidence, and in some cases improved clinical outcomes for patients. The review reinforces nursing values as a motivator of nursing actions, and reveals the complex yet significant influence of nurses on antimicrobial prescribing. Potential opportunities to enhance nurses' participation and contribution to antimicrobial stewardship include; formal acknowledgement of the nurse role, educating nurses so that they are aware of how they can contribute, collaborating with nurses in planning and implementing local stewardship activities, and ensuring nurse leaders are involved. However, evidence on this topic remains limited. Research is needed to facilitate greater understanding about the nature, scope and influence of the nurse role in antimicrobial stewardship, how nurses enact and carry out their role, and nurses' support needs. Tweetable abstract: Integrative review explores #nurse role in #antimicrobialstewardship. Nurse contribution, influence significant, but not well understood.

The nurses' role in antimicrobial stewardship: A scoping review

BACKGROUND

The role of nurses in antimicrobial stewardship is understated and not well understood. Nurses can have a significant impact on the development of antimicrobial resistant bacteria in hospitals and the wider community through their management of intravenous antibiotics.

OBJECTIVE

To investigate the nurse's role in antimicrobial stewardship and examine best practice for preparing, administering and disposing of intravenous antibiotics.

METHODS

A systematically conducted scoping review was used. Seven databases were searched for published articles. Retrieved articles were screened for eligibility against pre-set inclusion and exclusion criteria with eligible full-text articles included in the synthesis. Reference lists of eligible articles and social media were reviewed to identify further sources of literature.

RESULTS

Forty-three sources of evidence were included. The extracted data indicate that a part of the nurse's role in antimicrobial stewardship is to monitor judicious antibiotic prescribing practices. Other than literature related to medication errors, there was limited research describing best practice when preparing, administering and disposing of intravenous antibiotics. There was also little evidence of consistent policy, guidelines and education for nurses' practice related to antimicrobial stewardship.

CONCLUSIONS

The evidence for best practice when nurses prepare, administer and dispose of intravenous antibiotics in hospitals is scarce. When nurses use best practice to manage intravenous antibiotics, the risk of antimicrobial resistant bacteria developing is minimised. The role of nurses in antimicrobial stewardship needs to be supported through education and evidence-based guidelines. Tweetable abstract: Nurse work practices may prevent the development and spread of antimicrobial resistant bacteria.

Fostering nursing innovation to prevent and control antimicrobial resistance using approaches from the arts and humanities

BACKGROUND

Efforts to address the complex global problem of antimicrobial resistance (AMR) highlight the need for imagination and innovation. However, nursing has not yet leveraged its potential to innovate to prevent AMR advancing.

AIMS

This paper focuses on the initial phase of an ongoing research and development study that seeks to foster nursing imagination and innovation by enhancing the meaningfulness of AMR for practising nurses and by facilitating their creative ideas.

METHODS

This aim is addressed through application of arts and humanities approaches, in particular the use of visualisation, co-design and historical methods, underpinned by the Design Council Double Diamond process model. The first phase with 20 UK participants explored how hospital and community-based nurses understand and respond to the priorities and consequences of AMR within their everyday working lives.

RESULTS

Nurses varied in their conceptualisations of AMR and in their depictions and explanations of its meaning and priority within everyday practices. Some saw infection prevention and control as bound up with AMR, whereas others differentiated in the context of specific work activities. Insights into related reasoning and practice tactics were also generated.

CONCLUSIONS

The initial project phase provides a basis for fostering nursing innovation in this important field.

Antimicrobial stewardship and pre-registration student nurses: Evaluation of teaching

Background

Antimicrobial resistance (AMR) is a global health concern. It is therefore imperative that healthcare professionals receive ongoing and relevant education and training to ensure they are competent in contributing to antimicrobial stewardship (AMS). At present, few undergraduate nursing programmes include AMS within their curriculum.

Objective

The aim of the evaluation was to determine the relevancy of AMS within the undergraduate nursing programme through the perceptions of student nurses.

Methods

A survey questionnaire was used to obtain undergraduate perceptions of AMS and the relevance to them and their clinical practice.

Results

Our evaluation of this educational programme demonstrated that providing AMS education to undergraduate student nurses raises awareness of current challenges around AMR and reinforces the vital role nurses play in enhancing AMS and infection prevention and control.

Discussion

This evaluation and current literature demonstrate a necessity for AMS to be embedded throughout undergraduate nursing education. Additionally, there is also a requirement to develop clear educational pathways in AMS to ensure continued professional development and contribute towards the advancement of the nursing role in AMS. By doing so, we will continue to build capacity and capability for the future delivery of healthcare.