Antibiotic Stewardship and the Nurse's Role
The increase in bacterial antibiotic resistance is considered to be one of the major problems facing healthcare. Another significant problem is hospital-associated infections. Antibiotic-resistant hospital-associated pathogens cause more than 2 million cases of infection annually, and approximately 23,000 of those infected patients die (Monsees, Goldman, & Popejoy, 2017). Thus, it is highly important to decrease the rate of hospital-associated infections. Antimicrobial stewardship programs (ASPs) play a significant role in reducing hospital-associated infections. The main purpose of ASP is to reduce the misuse of antibiotics (Wilson et al., 2017). The typical ASP team consists of a physician, microbiologist, and pharmacist.
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However, the inclusion of a nurse in this team might increase the efficiency of the program (Gillespie, Rodrigues, Wright, Williams, & Stuart, 2013). Moreover, the lack of ASP program implementation in nursing homes is observed (Wilson et al., 2017). Based on the information above, it is possible to state that the purpose of this literature review was to explore the nurses’ involvement in antimicrobial stewardship programs in different healthcare facilities and their role in the reduction of antibiotic misuse.
The literature review is dedicated to the problem of nurses' involvement in antimicrobial stewardship programs in healthcare settings. The search was conducted in the following two databases: PubMed and CINAHL. The search was limited to the articles published within the last five years (from 2013 to 2018).
In the PubMed database, 16 search results were found; however, none of them could be accessed for free. CINAHL found 10,580 results. Among them, five articles with free access were chosen for the analysis. Only research peer-reviewed articles in English were included in the review. Qualitative and quantitative studies were included in the analysis. The chosen articles presented particular data on the role of nurses in the ASPs in different healthcare settings. All chosen articles were focused on the participation of nurses in the programs.
- Purpose. The study aimed to explore antibiotic use optimization in pulmonary medicine and the barriers to best practice optimization.
- Design. A qualitative study was conducted.
- Sampling/sample. 28 doctors and nurses and nurses from the pulmonary wards of two teaching hospitals were included. Participants were invited by formal letter via e-mail. Inclusion criteria were working in pulmonary wards and the use of antibiotics. No exclusion criteria were stated. Convenience sampling was used.
- Data collection. Data were collected from medical personnel of the pulmonary ward from two hospitals where ASP was implemented during two periods (2014-2015 and 2016).
- Measurement (instruments). Semi-structured qualitative interviews were used. They were focused on the healthcare workers' experiences the antibiotics use in the treatment of pulmonary infections, knowledge of antibiotics resistance and its significance for clinical practice, professional dynamics, and team collaboration.
- Intervention. No interventions were applied.
- Data analysis. No statistical tools were used. Two investigators analyzed the scripts and coded the data. All research team members performed further discussion and data interpretation.
- Results. The study allowed identifying barriers to the optimization of antibiotics use. Barriers were distinguished into two groups. Clinical barriers included differentiation between pneumonia and chronic obstructive pulmonary disease, bacterial and viral infections, and sputum colonization and pathogens development. Social barriers included underestimating the significance of antibiotic resistance, low trust in the antibiotics use guideline, and the impact of hospital hierarchy.
- Limitations. The authors stated several limitations. In particular, personnel from only two hospitals were involved. It is necessary to extend the study to other cultural environments and settings and include other specialists.
The study by Gillespie et al. (2013) was dedicated to the influence of nursing education on the effectiveness of antimicrobial management.
- Purpose. The purpose of the research was to estimate the impact of nursing education on clinical practice and antimicrobial medications use.
- Design. The cohort study was conducted.
- Sampling/sample. 100 nurses with 3 – 43 years of experience who were responsible for intravenous antibiotics injections were included in the study. Less experienced nurses were excluded. All participants worked at 2 campuses: Monash Medical Centre-Clayton and Dandenong Hospital. Among the included participants, 79 were interviewed after the medication intervention. The decline in the number of participants was related to the hospital's staff changes.
- Data collection. Pre- and post-intervention face-to-face interviews were performed with participants for data collection. The information about the rate of intravenous use of antibiotics before, during, and after the education was collected from hospitals.
- Measurement (instruments). The same open-ended questionnaire was used for pre-and post-intervention data collection. The questionnaire aimed to assess the nurses’ knowledge and attitudes toward antibiotic treatment. Second, the IV-line use before, during, and after the educational intervention was assessed. Finally, the number of IV-line-related Staphylococcus aureus bacteremia in six hospital wards before and after the intervention was compared.
- Intervention. The educational intervention was applied. It continued for four weeks at Monash Medical Centre-Clayton and three weeks at Dandenong. The infection control consultant provided the education. Sessions were conducted for small groups of nurses or face-to-face with participants. Educational interventions were performed by consultants for infection control. The intervention aimed to improve the role of nurses in antibiotics management. The possibility to switch from intravenous to oral antibiotics administration was discussed. Participants were provided with session materials and references. Two waves of educational intervention were applied.
- Data analysis. Descriptive statistics (percentage and 95% confidence interval) were used for presenting the data. To analyze obtained data, statistical tests were used. However, the authors did not state which exact test was applied.
- Results. A significant increase in the percentage of nurses who would consider whether the use of antibiotics was necessary before administrating them was observed after the intervention. The nurses’ awareness regarding the risk of antibiotic resistance development and the relation between IV-line antibiotics administration and associated bacteraemias was also increased. There was a significant enhancement of knowledge among nurses who were aware of the possibility to switch antibiotics administration from intravenous to oral. Three of six wards reduced the number of IV-line days. However, the general rate of IV-lines use did not change. Finally, the number of Staphylococcus aureus bacteremia decreased from three line-related infections before the intervention to two infections after the intervention.
- Limitations. The author did not state any limitations of the study.
The qualitative study by Jeffs et al. (2018) was dedicated to assessing the experience of ASP teams to improve the antibiotics used by nurses in intensive care units (ICU).
- Purpose. The study aimed to identify strategies that lead to the nurse's involvement in ASPs and improvement of the antibiotic use.
- Design. Qualitative research was conducted.
- Sampling/sample. Six focus groups from four hospitals participated in the study. In total, 25 participants were included in the research. All hospitals have previously implemented the ASP in the ICU. Inclusion criteria: participants have engaged the members of the ASP-SUSTAIN project aimed to enhance the quality and safety of antibiotics management. No exclusion criteria were stated.
- Data collection. Semi-structural interviews with focus-group participants were conducted.
- Measurement (instruments). The interviews were dedicated to three main topics: effective use of nurses’ interest and desire to improve healthcare quality, making nurse involvement a routine practice, and encouraging nursing leaders to spread the ideas of the ASP. The participants’ views on these three topics were collected and analyzed through the interview.
- Intervention. No interventions were conducted.
- Data analysis. A directed content analysis approach was applied for the interview data analysis. Interviews transcripts were reviewed by three investigators to identify the codes of the interview. Next, investigators met and developed categories of main themes.
- Results. The first theme was leveraging the interest and passion of nurses. Participants of the ASP-SUSTAIN project described how they engaged nurses to participate in ICU ASPs. The low level of nurse engagement and the need to enhance nurse participation were reported. However, respondents reported the interest and desire of nurses to participate in the program.
The second topic was making nurse participation a routine practice. Among the six teams, only one reported that they initially involved a nurse and a nurse manager in their ASP team. Other engaging strategies include sharing the results of ASP with nurses, assessment of their learning needs, including learning interventions into the existing process and decreasing the tasks for nurses to avoid their workload.
The third topic was dedicated to encouraging nurse leaders to promote ASP ideas. Nursing staff considers nurse leaders to be credible sources of information. It was reported that engaging leaders in the program made it easier to implement ASP principles into the practice. Participants of the study considered involving nurse leaders in the ASP as important.
- Limitations. Several limitations were reported. First, only nurses who were members of the ASP team were involved in the study. Second, possible desirability bias might be present because only ASP team participants who voluntarily wished to participate were involved. Third, the study was performed in four settings in one geographical region, which decreased the transferability of the results.
The research of Trautner et al. (2017) assessed nursing home personnel’s knowledge about hospital-acquired infections and ASPs.
- Purpose. The study aimed to estimate nursing home personnel’s knowledge about infection prevention and to identify gaps, which can be addressed by collaborative quality improvement.
- Design. A baseline knowledge assessment of the target population was applied.
- Sampling/sample. Licensed (RNs, LPNs, APRNs, MDs) and unlicensed (clinical nursing assistants) healthcare personnel participated in the study. 236 nursing homes provided answers from at least ten participants (five licensed and five unlicensed). Sampling was non-random because the facilities chose participants voluntarily. Inclusion and exclusion criteria were not stated.
- Data collection. A baseline knowledge assessment of personnel from 236 nursing homes was conducted to determine the educational needs of participants for healthcare quality improvement and hospital-acquired infection prevention.
- Measurement (instruments). The following knowledge was assessed: team building, catheter-associated urinary tract infections definition, surveillance, and reporting, patient safety culture, hand hygiene, precaution measures, and antibiotics stewardship. For the data collection, tailoring questions were developed for licensed and unlicensed personnel.
- Intervention. No interventions were conducted.
- Data analysis. Descriptive statistics (percentage of correct answers) was used for data presentation.
- Results. The study detected multiple gaps in knowledge related to hospital-acquired infection prevention and antibiotics stewardship. In particular, a significant part of the personnel could not distinguish urinary tract infection from asymptomatic bacteriuria. Also, personnel did not know that cloudy and smelly urine should not be cultured. Finally, the personnel was not aware of how to conduct proper hand hygiene procedures. These results indicated the significant need for improved education.
- Limitations. The authors stated several limitations. First, demographic information from respondents was not collected. Thus, it was not possible to estimate the effect of these variables on the level of knowledge. Second, a non-randomized sampling method was used. In addition, healthcare facilities were selected non-randomly. Finally, the knowledge assessment procedure was not validated.
The study by Wilson et al. (2017) estimated the effect of educational intervention on nurses’ knowledge and attitude toward ASP in long-term healthcare facilities.
- Purpose. The study aimed to compare the knowledge, beliefs, and attitudes of nurses from long-term healthcare facilities regarding antimicrobial stewardship before and after online education.
- Design. The paired survey was applied.
- Sampling/sample. 103 registered nurses or licensed practical nurses who worked at nursing homes and other long-term healthcare facilities participated in the study. The sampling method was not specified nor were the exclusion and inclusion criteria.
- Data collection. Data were collected before and after nurses passed the online educational course. A survey for data collection was developed.
- Measurement (instruments). The survey consisted of demographics-related questions, items about attitudes and beliefs, and multiple-choice questions for the level of knowledge estimation. The survey was anonymous. It was completed online.
- Intervention. The online educational intervention was applied. The online course was free for participants. It consisted of six modules addressing the following topics: signs and symptoms of infection in elderly patients, the difference between urinary tract infection and asymptomatic bacteriuria, detection of different infections of the respiratory tract, the use of measures for transmission-based infections prevention, rules for sample collection, and the use of Situation, Background, Assessment, and Recommendation (SBAR) communication style in practice.
- Data analysis. Descriptive statistics (mean, percentage, and 95% confidence interval) were used for presenting quantitative data. Differences between pre-and post-intervention surveys were assessed using paired t-test with a Bonferroni correction.
- Results. The study demonstrated the increase in nurse knowledge of the learning objects. A significant increase in the score of nurses’ role in ASP was demonstrated. Also, nurses' beliefs about their influence on residents’ baseline status and needs for antibiotics prescription increased. Finally, the intervention resulted in a significant increase in nurse knowledge of the appropriate use of antibiotics.
- Limitations. The authors stated several limitations. In particular, the sample size was small. Second, the role of respondents’ educational background and the type of healthcare facility was not assessed. Third, some of the survey items were not validated. Fourth, the social desirability bias is possible. Fifth, the sampling was not randomized. Finally, the effect of the educational course on the practice was not assessed.
Similarities and Differences
Nurses as healthcare professionals who most closely interact with patients and administrate antibiotics to them are important team members. All of the studies underlined the importance of ASP implementation and nurses' involvement in addressing the issue of antibiotic resistance development. Some similarities and differences regarding the role of nurses in ASPs can be detected.
The research by Broom et al. (2017) identified the barriers to ASP implementation. The authors did not state the differences between the nurses’ and physicians’ points of view on the problem. However, they postulated such barriers as hospital hierarchy. Nurses may depend on the physicians’ orders and are afraid to question them because of their lower hierarchy status. These results are in line with the results of Gillespie et al. (2013) who found that at the baseline of the investigation, only 14% of the participants would consider whether the use of antibiotics was needed before drugs administration while 71% of participants had questioned the order of physician to administrate antibiotics. Other studies did not focus their attention on this significant problem.
Studies by Gillespie et al. (2013) and Wilson et al. (2017) discussed the effectiveness of educational interventions for the increase of nursing competence in appropriate antibiotic use and their participation in ASPs. Both studies demonstrated similar results. It was shown that the level of nursing knowledge about the appropriate use of antibiotics and antibiotic resistance development significantly increased after the intervention. Second, the level of nursing confidence and awareness of their role in ASPs also increased. However, Wilson et al. (2017) did not assess the effect of education on practice, while Gillespie et al. (2013) did not detect significant changes in both intravenous antibiotics administration and the number of IV-related bacteremias. Thus, further research focusing on the practical effects of nurses’ education is needed.
At the same time, the study by Trautner et al. (2017) estimated the baseline level of participants before providing the educational intervention. The results of the estimation demonstrated the low level of personnel knowledge corresponds to the results of the study by Broom et al. (2017). In both cases, nurses had difficulties in detecting the infectious process and distinguishing this process from less severe diseases that did not require antibiotics use. These results are in line with the results of Wilson et al. (2017) and Gillespie et al. (2013) who also detected a lack of nursing knowledge on antibiotics appropriate use of. Thus, four of five studies underlined the lack of nursing knowledge and experience and underlined the need for education.
By contrast, the study of Jeffs et al. (2017) did not focus on the lack of nurse knowledge and experience. Instead, the study was dedicated to the problem of nurse involvement in the ASPs. The authors underlined the nurses’ passion and interest in participating in programs. The possible difference between this study and other research can be explained by the different topics of research. All five studies postulated the importance of nurse involvement in the program. However, the study of Jeffs et al. (2017) focused more on strategies of involvement instead of the level of nurse readiness. In addition, the authors conducted the study before the educational intervention implementation. In all likelihood, they will present the results of nursing knowledge estimation before and after education in further studies.
Even though none of the investigators presented the effects of their research on the clinical procedures, all of the results are important and can be translated into practice. In particular, the results of Broom et al. (2017) can be used for addressing barriers to the best practices. Educational sessions can be used to overcome the lack of knowledge and understanding among personnel. Also, the hospital hierarchy barrier can be addressed by changing the staff policy and segregation of duties among nurses and physicians. The studies of Gillespie et al. (2013) and Wilson et al. (2017) underlined the importance of educational interventions for nurses. It is possible to make educational sessions for nursing staff regarding antimicrobial stewardship and antibiotics resistance development routines and obligations. This practice will help to increase the nurses’ awareness of the problem as well as their involvement in ASPs. The study of Trautner et al. (2017) detected existing gaps in knowledge regarding catheter-associated urinary tract infections that need to be addressed. Educational interventions for nurses in these wards might be useful. Finally, the research of Jeffs et al. (2017) proposed some efficient strategies for increasing nurse involvement. In particular, it is possible to engage nursing leaders for spreading the information among nurses and encouraging them to participate. Thus, it is possible to state that all of the research has potential practical implementations for nurses, which can increase the quality of healthcare and address the problem of inappropriate use of antibiotics and resistance development.
Five studies dedicated to the role of nurses in antimicrobial stewardship programs were analyzed in the review. All of the research underlined the importance of nurse involvement in the programs. At the same time, studies demonstrated the low level of nurse participation in ASP teams and lack of appropriate knowledge, and low attitude toward participation. Educational interventions might improve the situation and increase the role of nurses in ASPs.