Bedside Nurses: Champions of Antimicrobial Stewardship

A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses' activities in daily practice regarding antibiotic use

Background

Antimicrobial stewardship (AMS), the set of actions to ensure antibiotics are used appropriately, is increasingly targeted at all those involved in the antimicrobial pathway, including nurses. Several healthcare organizations have issued position statements on how bedside nurses can be involved in AMS. However, it remains unclear how nurses, in reality, contribute to appropriate antibiotic use.

Objectives

To systematically search the literature to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, in relation to the activities proposed by the aforementioned position statements.

Methods

We searched MEDLINE, Embase, CINAHL and grey literature until March 2021. Studies were included if they described activities regarding antibiotic use performed by bedside nurses. Methodological rigour was assessed by applying the Mixed Method Appraisal Tool.

Results

A total of 118 studies were included. The majority of the proposed nurses' activities were found in daily practice, categorized into assessment of clinical status, collection of specimens, management of antimicrobial medication, prompting review and educating patient and relatives. Nurses may take the lead in these clinical processes and are communicators in all aspects of the antimicrobial pathway. Patient advocacy appears to be a strong driver of bedside nurses' activities.

Conclusions

Nurses' activities are already integrated in the day-to-day nursing practice and are grounded in the essence of nursing, being a patient advocate and showing nursing leadership in safeguarding the antimicrobial treatment process. An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial pathway. Educating, engaging and empowering nurses in this already integrated role, could lead to a solid, impactful nursing contribution to AMS.

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.

Effect of educational intervention on nurses' perception and practice of antimicrobial stewardship programs

BACKGROUND

Nurse involvement in antimicrobial stewardship programs is insufficient, which limits the programs' effectiveness. To evaluate the effect of the training programs on nurses' perception and practice of antimicrobial stewardship to embed it in practice.

METHODS

A quasi-experimental study without a control group was conducted on 115 nurses. A specifically validated and designed instrument was utilized to evaluate perception and practice before, after, and 2 months follow-up the training sessions.

RESULTS

The difference between the pre, post, and 2 months follow-up tests was highly significant for the dimensions of knowledge, perception, and practice (P < .01). Also, nurses reported a lack of knowledge, lack of training, high workload as barriers of AMS. Nurses suggested ways to overcome barriers such as physician and manager support, in-service training every 6 months, and saving time for training and education.

CONCLUSIONS

An educational intervention improved perception and practice among nurses related to antimicrobial stewardship and easily embedded it in practice.

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.