Survey-Guided Initiatives in Improving Nurses’ Attitudes, Perceptions and Practices of Antimicrobial Stewardship

Antimicrobial resistance is now considered a global health threat by the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) [1-2]. This global phenomenon has been accelerated by overuse and misuse of antibiotics [3]. Up to 60% of hospitalized patients receive antibiotics, and 30% of these antibiotics are deemed unnecessary [4,5]. In order to combat this growing threat, acute care hospitals are required to form Antimicrobial Stewardship Programs (ASP). ASPs have been shown to improve antimicrobial utilization, patient outcomes, cost, and antimicrobial resistance [6-10]. The CDC recommends that all ASPs should meet the seven core elements in a multidisciplinary approach, and this has been enforced by The Joint Commission and Centers for Medicare and Medicaid Services [11-13]. Previous guidelines did not include roles of nursing in antimicrobial stewardship (AS). However, increasing nursing contributions to AS have been published in the literature [14-16]. In July 2016, the CDC in partnership with the American Nurses Association (ANA) held a joint conference in Maryland to discuss nurses’ roles in AS, and to specifically identify nursing-focused antimicrobial stewardship activities. A report of the conference was published detailing these activities in a white paper [17]. The nurses’ perspective and active engagement are critical to the success of AS. Nurses make up the largest segment of healthcare workers. They are directly involved in patient care providing consistency, continuity, and coordination of care for patients. Several publications have described nursing-driven AS activities [14,15,18]. Nurses perform AS-related activities from patients’ admission through discharge (Figure 1).

Figure 1:Nurses perform several AS-related activities from the patient’s admission through discharge.

Loyola University Medical Center (LUMC) is a quaternary caresystem in Maywood, IL, USA, with an existing multidisciplinary ASP that includes representation from the nursing department. LUMC has received Magnet® designation from the American Nurses Credentialing Center. This designation is given to facilities that provide an optimal environment for nurses to deliver the highest standard of care to their patients. Since there are now increasing efforts towards engaging nurses in AS, more information is warranted regarding gaps in nurses’ knowledge and perceptions of AS. Our team sought to assess RNs’ knowledge and perceptions of AS and AR, as well as their current engagement in AS-related activities. In the United States, a RN is an individual with a nursing diploma who has passed the National Council Licensure Examination (NCLEX-RN) examination.

In February 2018, a voluntary anonymous online survey was developed using an online tool, Survey Monkey® (SurveyMonkey Inc.® Palo Alto, California, USA), and disseminated electronically to all RNs at LUMC. The first survey was composed of 20 questions categorized into 3 components: service type, knowledge and perception of AS and AR, and nurse engagement in AS. Likert-type questions were utilized for the second and third components. The instrument was developed by infectious diseases physicians and infectious diseases pharmacists. The questions were reviewed by the antimicrobial stewardship committee at LUMC. The goal of the first survey was to assess RNs’ knowledge and perception in AS and AR, as well as their practices in AS at LUMC. After approval of the study by the institutional review board, an electronic message was disseminated to all employed RNs at LUMC with an invitation to participate and a link to the survey. Participation was voluntary and no incentive was provided for participation. Paper surveys were also available and were distributed to RNs during a hospital-wide meeting. The answers of the paper survey were manually entered by the investigators. Based on the outcomes of the survey, our team implemented multi-faceted strategies focused on education that included PowerPoint slides that were electronically disseminated to all RNs, as well as live sessions during nurses’ huddles in Intensive Care and floor units discussing different roles of RNs in AS. In March 2019, a second survey was sent to all RNs with the primary focus of evaluating any changes in their knowledge and perception of AS and AR post implementation of our educational strategies. The questions on the second survey were identical to the first survey but with the addition of a fourth component in order to obtain feedback regarding our educational methods. Figure 2 describes the components of the surveys. Responses to questions on knowledge and learning preferences were presented as counts and percentages (Figure 2).

Figure 2:Components of Survey 1 and Survey 2.

There were 179 RNs who completed the first survey, and 117 RNs who completed the second survey (Figure 3). The majority of respondents were from general medical and medical subspecialties.

Figure 3:Distribution of respondents for each survey.

RNs’ knowledge and perception of AS and AR

Both surveys showed that majority of RNs agreed that they play important roles in AS, AS can lead to reduction in AR and adverse effects of antimicrobials, AR can be caused by inappropriate use of antimicrobials that can lead to harm for patients. Only 65% of RNs strongly agree/agree that AR is a problem at LUMC, which further decreased to 59% in the second survey. A majority of RNs were not familiar with AS practices in both surveys (Figure 4).

Figure 4:Nurses’ Knowledge and Perception of AS and AR.

RNs’ engagement in AS

Overall, nurse related AS activities are encouraging in both surveys. More than 75% of the respondents for both surveys indicated that culture collection was ensured prior to administration of antimicrobials, while more than 80% indicated that they verify antimicrobial indication/dose/route/duration of therapy and antimicrobial allergies prior to administering antimicrobials, and that they monitor for side effects and toxicities while patients are receiving antimicrobials. In both surveys, more than 80% of respondents discuss the antimicrobial plan including side effects with patients upon discharge. Approximately 60-70% of the RNs include an antimicrobial report on shift changes and perform antimicrobial reconciliation when patients are transferred from units. RNs’ perception of their involvement in the antimicrobial plan appears to be subdued. Fifty-seven percent of RNs question the antimicrobial plan when patients develop Clostridioides difficile Infection (CDI), however, this slightly improved to 61% in the second survey. Fifty-nine percent of RNs indicate that they advocate for IV to PO switch in stable patients, and this rate slightly increased to 62% in the second survey. Only 44% of respondents affirmed their involvement in the patient’s antimicrobial plan, which decreased to 40% in the second survey. Finally, only 38% of the respondents evaluate the need for continuing antimicrobials, but this increased to 43% in the second survey (Figure 5).

Figure 5:Nurses’ Engagement in AS.

RNs’ feedback on education

More than half of respondents read the PowerPoint education slides, but only 38% recollected being educated during nursing huddles by our AS team. Majority of the RNs prefer live over electronic education (Figure 6).

Figure 6:RN’s Feedback on Education.

Several surveys on knowledge and perceptions on AS and AR have been utilized to understand the drivers of antibiotic prescription and to further AS efforts [19-22]. It has been widely accepted that infectious diseases physicians and pharmacists are the leaders of ASPs. However, there is an urgent call to include other members of the healthcare workforce in AS involvement [23,24]. Nurses are integral members of the healthcare team and their engagement in AS is critical. Nurses are known to be involved in infection control measures and prevention [25-28]. Moreover, nurses have played essential roles in quality improvement initiatives in infection prevention [29-31]. However, much is unknown about nurses’ optimal roles in AS. Understanding the knowledge and perceptions of nurses is a fundamental initial step in delineating their roles in AS. Similar surveys have also aimed to evaluate nurses’ knowledge and perception on AS and AR [32-36].

Our study demonstrated that the respondents had a favorable understanding of AS and AR, however, most are not familiar with our institution’s AS activities which is also reflected in surveys at other institutions [33-35]. A study by Merrill et al. evaluated nurses’ knowledge of antimicrobial utilization and resistance, as well as assessed their attitudes in AS involvement. This survey demonstrated that 52% of the respondents were not familiar with AS, however, 95% agreed that they should be involved in AS [33]. Similarly, the majority in our study’s RNs did not believe that AR is a problem at our institution. This discrepancy was also observed in a recent study by Perez et al. where 92% of their surveyed nurses agreed that antimicrobial resistance is a significant problem nationally, but only 35% agreed that this was a problem in their institution [35]. This gap can likely be overcome by sharing facility antibiograms and rates of resistant organisms [33]. Currently, our RNs are familiar with their unit’s infection control-related metrics, such as Catheter-Associated Urinary Tract Infection (CAUTI) and Central Line-Associated Blood Stream Infection (CLABSI) rates as shared by our Infection Control Committee. However, current reporting of AS-related metrics is only limited to medical staff and the pharmacy department. This challenge has also been demonstrated by Abera et al. where a larger proportion of RNs reported they have not received information on antimicrobial resistance compared to physicians [36,37].

Our surveys showed that the most common AS-related activities RNs are engaged in are monitoring for side effects and toxicities of antimicrobials, verifying allergies, discharge education on antimicrobial plan, verifying antimicrobial details prior to administration, and obtaining cultures prior to administration of antimicrobials. Assessment of the need to continue antimicrobials and discussion with the treating team is an area RNs report they rarely perform. This has also been demonstrated in other studies and may be attributed to a lack of understanding of their roles in AS [36,38,39]. Moreover, nurses perceive that physicians are solely responsible for antimicrobial de-escalation, and that questioning the doctors’ medical decisions may lead to conflict and disregard of their authority [36,40]. This area of concern provides an opportunity to implement strategies that can empower nurses in their roles in AS and patient safety. Gillespie et al. evaluated nurses’ knowledge and attitudes on AS with pre-and post-education involvement, focusing on questioning medical staff about the antibiotic plan. Post intervention, the percentage of nurses questioning the medical staff regarding antibiotic order increased from 71% to 91% [41]. Involving nurses during ward rounds can also improve their involvement in the patient’s antibiotic plan [18]. Several studies have demonstrated that multidisciplinary rounding involving nurses led to improved patient satisfaction and outcomes [42-44].

Education on AS is critical not only for physicians but for every member of the healthcare team, including nurses. Our survey showed that less than 50% of the respondents indicated they need more education on AS, reflecting increased confidence in their knowledge of AS. In contrast, other surveys revealed that nurses identified lack of education as a barrier in AS [34,36,39]. Most nurses in a survey by Padigos et al, indicated that lectures and continuing education modules are the preferred tool of education [34]. In comparison, RNs in our survey preferred PowerPoint slides and emails.

We have identified several limitations in our study. Aside from having a small sample size, our surveys were answered anonymously and voluntarily which did not allow for direct comparisons of pre- to post-test change nor assessment of survey OF non-responders. Moreover, since the PowerPoint slides were disseminated electronically, we lacked reliable ways of measuring compliance. Finally, since we were not able to attend all nursing huddles, a significant portion of nursing staff may not have been captured with this educational strategy.

The nurses’ perspective and active engagement are critical in the success of AS, as they make up the largest segment of healthcare workers and are directly involved in patient care. Roles of nurses in AS is not well defined. Our ASP at LUMC implemented multi-faceted interventions to expand nursing education and engagement in AS. We then evaluated this strategy by utilizing pre and post surveys. Our surveys show that LUMC RNs have a superior understanding of AS and AR, however, most are not familiar with our AS activities. Our surveys also demonstrated notable AS engagement among LUMC RNs. However, more education is needed to re-enforce their engagement. Surveys will continue to be utilized in assessing AS interventions and educational efforts at LUMC.

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