Leading role for nurses in antimicrobial stewardship

Reflecting on nurses’ leadership role in antimicrobial stewardship: what does it look like, how does it work?*

Antimicrobial stewardship (AMS) is an important element of a comprehensive infection prevention and control program. AMS aims to ensure that antimicrobials are used safely, so that people who require these medicines have the best possible outcomes. In hospital settings, AMS has been shown to improve appropriateness of antimicrobial prescribing, reduce unnecessary antimicrobial use and to positively impact rates of AMR.¹ AMS is multidisciplinary, which means it involves all health professionals who are involved in prescribing, dispensing or administering antimicrobials. This includes nurses.

Nurses may contribute to AMS in different ways; for example, by ensuring specimens for culture are taken, stored and transported correctly, by ensuring compliance with infection prevention and control measures, or by educating patients about safe antimicrobial use. Nurses may also have a leadership role in AMS. Nurses lead a range of programs and services in both acute and non-acute settings; however, the term “nurse-led” may mean different things.² Similarly, the concept of nurse leadership in relation to AMS is not well defined.

Anecdotally, there are examples of nurse-led AMS activities and programs in Australian hospitals, which appear to have been developed mostly in settings where specialist medical or pharmacist advice is limited or not available onsite, for example in small hospitals.¹ An unpublished survey by the Guidance Group in 2016 found that, of 254 respondent hospitals, 22 (9%) funded an infection control professional or nurse to manage AMS activities. However, leadership roles are not restricted to smaller hospitals; for example, at the Peter MacCallum Cancer Centre in Melbourne, a nurse practitioner candidate leads coordination of AMS.

Although few published studies have specifically explored nurses’ leadership role in hospital-based AMS, there are some interesting findings. Considering nurses perceptions about their potential involvement in AMS, nurses see that their role in antimicrobial management is linked to patient advocacy,³, ⁴ but also see that they require education, and look to nurse managers and educators as important sources of support.^{4, 5} Regarding nurse-led AMS interventions, in Australian research, a nurse-led education intervention significantly improved nurse knowledge about AMS, and increased the number of nurses who agreed they would question, or had questioned, an antimicrobial order.⁶ Finally, regarding nurse leadership of AMS programs, the role of nurses in advocating for patients, and applying their organisational and collaboration skills, were highlighted as important to the success of a nurse-driven AMS program which had been implemented in a South African hospital intensive care unit.⁷

These studies point to the potential for nurses to have a leadership role in AMS. But, detail about what enables nurses to fulfil such a role remains unexplored, despite that nurse-led programs appear to be well established in some settings. This lack of evidence limits understanding of how best to design, implement and sustain an AMS program that is nurse led. Unanswered questions are: What are the features of nurse-led AMS? How do nurses establish and enact their leadership role? What are the facilitators of a nurse-led AMS program? How are nurse-led AMS programs best evaluated? What are the outcomes?

Education about AMS principles and practice is undoubtedly an important enabler for nurses in an AMS leadership role. However, education and training alone are unlikely to be enough to support nurses who hold AMS leadership responsibilities. Context is also important. Nurse engagement in AMS may be influenced by workplace culture, interprofessional hierarchies or by perceptions nurses or other health professionals have about their role.^{3, 4, 8} Findings from studies exploring nurse led programs in other fields show that these same factors can determine the extent to which nurses exercise their leadership abilities.² Moreover, although there are established measures for monitoring the impact of AMS programs, these do not take into account the specific components of the nurse contribution, such as the communication, coordination and collaboration components of the nurse role, which have been identified as important concepts for measuring nursing practice.⁹

What nurse leadership in relation to AMS looks like, then, and how it works in practice, will very likely depend on the local context, resources that are available, and the nature and quality of professional support. Potential benefits of having nurses lead AMS interventions are apt to be similar to those associated with nurse-led initiatives in other areas, and may include improved clinical outcomes, a more patient centred approach to care and an engaged nursing workforce, enabled to more fully use and apply their nursing knowledge and skills.² However, research is needed to enable a better understanding about nursing leadership of AMS, so that these benefits can be realised.

Current research at The National Centre for Antimicrobial Stewardship (NCAS) focuses on exploring nurse-led AMS programs in Australia, to understand how they work, what supports nurses to effectively lead a program and any challenges that are to be addressed. To learn more about this research, contact NCAS.

Footnote: Chapter 12 of the Australian Commission on Safety and Quality in Health Care’s publication, Antimicrobial Stewardship in Australian Health Care,¹ discusses suggested approaches and considerations in the engagement of nurses in AMS, and to implementing nurse-led AMS activities. The publication includes links to many useful resources.

Fiona Gotterson is a registered nurse and a PhD candidate at the National Centre for Antimicrobial Stewardship (NCAS) at the University of Melbourne. NCAS and its research is funded by the Australian NHMRC (APP1079625).

*This article is based on a presentation given by Fiona Gotterson at the 2018 ACIPC conference.

References

1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Antimicrobial Stewardship in Australian Health Care. Sydney: ACSQHC, 2018
2. Douglas C, Schmalkuche D, Nizette D, Yates P and Bonner A. Nurse-led services in Queensland: A scoping study. Collegian. 2018; 25: 363-70.
3. Broom A, Broom J, Kirby E and Scambler G. Nurses as Antibiotic Brokers: Institutionalized Praxis in the Hospital. Qualitative Health Research. 2016; 30: 30.
4. Carter EJ, Greendyke WG, Furuya EY, et al. Exploring the nurses' role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists. American Journal of Infection Control. 2018; 46: 492-7.
5. Mostaghim M, Snelling T, McMullan B, et al. Nurses are underutilised in antimicrobial stewardship - Results of a multisite survey in paediatric and adult hospitals. Infection, Disease and Health. 2017; 22: 57-64.
6. Gillespie E, Rodrigues A, Wright L, Williams N and Stuart RL. Improving antibiotic stewardship by involving nurses. American Journal of Infection Control. 2013; 41: 365-7.
7. Rout J and Brysiewicz P. Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa. Southern African Journal of Critical Care. 2017; 33: 46-50.
8. Edwards R, Drumright LN, Kiernan M and Holmes A. Covering more Territory to Fight Resistance: Considering Nurses’ Role in Antimicrobial Stewardship. Journal of infection prevention. 2011; 12: 6-10.
9. Sim J, Crookes P, Walsh K and Halcomb E. Measuring the outcomes of nursing practice: A Delphi study. Journal of Clinical Nursing. 2018; 27: e368-e78.

Image credit: ©stock.adobe.com/au/Horacio Selva