Nurses Want to Participate in Antimicrobial Stewardship Programs but Often Don’t Feel Welcome

Nurses think they should play a professional role in antimicrobial stewardship (AS) programs, but a culture of safety at hospitals that focuses on other kinds of providers often hinders nurse involvement. Investigators with Children’s Mercy Hospital in Kansas City, Missouri, and the University of Missouri in Columbia, Missouri, used a cross-sectional survey to gather data at 9 hospitals, ranging in size from 42 to 562 beds serving both pediatric and adult patients in 2 different metropolitan areas. 

The study, in the American Journal of Infection Control, draws on data collected from 558 nurses and includes comments from 91 nurses with 50 statements saying that the primary barrier to AS programs are organizational factors that included a perceived lack of a safety culture. 

When they were asked about what support they received to participate in AS programs, 43% and 27.3% of respondents said that they received encouragement from nursing leaders and physician prescribers respectively. 

“Nurses identified the top engagement strategies as formal educational offerings, empowerment techniques to enhance communication, and soliciting nurse input in antibiotic use discussions,” the study states. “Whereas nurses expressed a desire to participate in stewardship processes, a lack of knowledge, safety culture, and poorly defined roles limited their ability to steward. Ninety percent of nurses reported at least one barrier to stewardship, although 95% perceived that they functioned as stewards.” 

The study reflects interest in, and bolstering of, AS programs. The number of hospitals in the United States with antibiotic stewardship programs nearly doubled in 4 years, from 52% in 2013 to 95% in 2017, in part because the US Centers for Disease Control and Prevention (CDC) and the Joint Commission have both recommended the installation of such programs, with the Joint Commission going so far as to make them a condition for accreditation. The CDC wants the programs to include a pharmacist and physician leader. And the Agency for Healthcare Research and Quality (AHRQ) encourages the use of integrated team-based approaches to modify clinician behavior. 

Nurses play a pivotal role in AS safety because they work in teams, interact with other healthcare professionals and patients, and know how the healthcare system works, the study notes. Nursing, the investigators add, is also the largest healthcare discipline. 

“As part of their daily work, nurses perform practices that influence antibiotic decisions, thus are integral to the collective process of therapy optimization,” according to the study. “Yet, little is known about how organizational safety culture influences the stewardship perspectives of bedside nurses, as there is a dearth of literature on the nursing role in antibiotic stewardship.”

The survey contained 48 questions that were scored on a 5-point Likert scale. Respondents were asked to provide written free text responses meant to gauge how participants perceived their participation, knowledge and role in AS programs. They were also asked to how their roles might be enhanced.

Investigators “grouped free text comments by content then categories were developed using similar words or concepts that represented facilitators or barriers to stewardship,” the study states. 

Investigators say that they found that most nurses believe that they have a professional role to play in AS programs and want to participate. When nurses thought that their duties contributed to AS programs, they grew more confident in their performance. “Finally, subtle changes in organizational systems where specialty services are responsible for antibiotic management and the interactions between teams may influence nurse participation or limit the overarching message that everyone is a steward,” the study concludes.