Nurses play an increasingly important role in the administration of antimicrobials so it is vital that they understand how to achieve best outcomes and reduce harm
The Scottish Antimicrobial Prescribing Group (SAPG) is a national clinical multidisciplinary forum that coordinates and delivers antimicrobial stewardship (AS). This work includes ensuring health professionals have the necessary knowledge to contribute to improving the use of antimicrobials and to develop and implement education resources if required. The SAPG undertook a survey to scope the current understanding and learning needs among nurses and midwives in a range of care settings across Scotland. This article reports on the results, which have been used to help develop a dedicated AS education programme for this group of health professionals.
Citation: McGregor W et al (2015) Assessing knowledge of antimicrobial stewardship. Nursing Times; 111: 21, 15-17.
Authors: Willie McGregor is senior charge nurse, NHS Lothian, and project manager, Stewardship Nurse Education Resource; Arlene Brailey is assistant director of pharmacy; Gill Walker is programme lead - healthcare associated infection; all at NHS Education for Scotland; Gwen Bayne is information analyst and Jacqueline Sneddon is project lead for the Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland; Jo McEwen is advanced nurse practitioner, antimicrobial stewardship, NHS Tayside.
- This article has been double-blind peer reviewed
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Antimicrobials are among the most commonly used medicines in hospital practice, with one in three patients receiving an antibiotic during their inpatient stay. Antimicrobial use in primary care is also common: GPs see several patients each day presenting with infection. Antimicrobial medicines include antibiotics, antivirals and antifungals.
The Scottish Antimicrobial Prescribing Group (SAPG) was established in March 2008 to deliver a national framework for antimicrobial stewardship (AS) in Scotland as described in the Scottish Management of Antimicrobial Resistance Action Plan 2008 (ScotMARAP) (NHS Scotland, 2008) and, subsequently, ScotMARAP 2 (NHS Scotland, 2014).
The SAPG defines AS as “making the best use of antimicrobials to manage infection so as to ensure optimal outcomes and minimal harm to patients and the wider society”.
One of the key issues for action within ScotMARAP was the development of education and training frameworks, programmes and competencies to promote prudent prescribing.
Since its inception, the SAPG has worked closely with NHS Education for Scotland (NES) to develop and implement educational resources to meet the training needs of various health professionals and support the multiprofessional team approach to AS across hospital and primary care settings. However, training has been primarily targeted at medical staff and pharmacists.
With the increasing acknowledgement of the critical role of nurses and midwives in antimicrobial administration, management and monitoring (Gillespie et al, 2013; Edwards et al, 2011), the SAPG and NES were keen to develop education to support this role and to align with existing initiatives for other health professions to promote a consistent approach across the team. It is recognised that the contribution of nurses and midwives is paramount to effective AS, but that appropriate education and training support is required.
To inform the development of an education tool the SAPG undertook a survey to:
- Scope the current understanding of AS in nursing and midwifery;
- Identify learning needs and support required for effective engagement.
Survey development and dissemination
A questionnaire was developed from a paper-based survey used previously in NHS Lothian. It comprised 13 questions: four to establish background information and nine to scope understanding of AS and learning needs. Many of the scoping questions required a free-text response and respondents were given the opportunity to expand on answers and supply comments.
The survey was disseminated to nursing and midwifery staff in all 14 NHS board regions in Scotland via the Scottish Executive Nurse Directors group. Nurses at all grades, and with various levels of experience across all care settings, were encouraged to participate. In addition, a small sample of nursing and midwifery staff was asked to complete the survey in person to respond to questions from the advanced nurse practitioner for AS.
The survey started in mid-July 2014 and closed at the beginning of September 2014.
The NHS Scotland workforce includes 67,400 nurses and midwives. The survey was sent to all nurses and midwives in all boards; there were 901 respondents, although not all answered every question. Of the 901 respondents, 855 completed an online survey and 46 face-to-face questions from the ANP in NHS Tayside.
The NHS board of employment was not stated by all respondents but as responses showed results were obtained from at least 12 of the 14 NHS Scotland health boards, the sample was representative. More than two-thirds of respondents worked in two health board areas: NHS Tayside and NHS Greater Glasgow and Clyde. At least 171 separate work sites were identified, with the highest number of respondents from any single site being 137 - these were from Ninewells Hospital in Dundee, NHS Tayside, where the face-to-face survey took place.
The work setting could be derived for most (n = 896) of the respondents: 54.8% worked in an acute (including paediatric) setting, with the remainder working in community or primary care.
There was a relatively even split among grades of staff, with approximately a third each at grades 5, 6 and 7. Of the respondents, 79.2% had been qualified for more than 10 years.
The results (Table 1, attached) showed that 36.1% of respondents rated their knowledge of antibiotics as “good” or “very good”. Only 21.5% had heard of the term “antimicrobial stewardship” however, indicating there was a gap in knowledge for many practitioners. A larger proportion of respondents on the higher-grade bands had heard of the term (band 7, 33.1% and band 8a, 100%).
A personal interpretation of the term was provided by 21% of respondents; this low response rate may explain why many staff did not answer all of the subsequent questions about AS. Most of these personal interpretations included the idea of “appropriate use of antimicrobials”, with mention often also being made of duration of treatment, best outcomes for patients and antimicrobial resistance. Mention of the consequences of antimicrobial misuse and resistance to the wider society was minimal but implicit in some replies.
Training and education
A large majority of responses (74.4%) indicated that education on AS should begin at pre-registration, supporting the need to review nursing undergraduate programmes. This is something the SAPG and NES are already discussing with university colleagues, although the education resource currently being considered would be aimed at nurses and midwives who are already practising. However, it may also be used to inform undergraduate curricula. Various programmes may be beneficial in training nursing and midwifery staff:
- NES Flying Start: this would be an opportunity to introduce training at an early stage of practice to make up for nursing and midwifery staff not having gained the required knowledge during the degree programme, and provides support during the first year of practice (www.flyingstart.scot.nhs.uk);
- NES Effective Practitioner: this may also be a useful vehicle for making education available to those with many years’ experience who will also have missed out on education in this area;
- NES Advanced Practitioner: this may be used for more in-depth education on stewardship for those with prescribing or specialist clinical roles.
Six comments indicated that nurses and midwives have little control over GPs who make prescribing decisions, and/or that GPs also required training on AS because nurses making suggestions about prescribing was unlikely to be well received by GPs. These results suggest a specific need for training on how to effectively engage with medical staff to influence antibiotic prescribing practice.
Of the respondents, 54.4% preferred education to be a “blend of styles” including a combination of lectures, online learning, tutorials, ward-based teaching and other face-to-face teaching.
The nurse’s role
Of the respondents, 36.8% thought the nurse/midwife role in AS should involve “ensuring appropriate antimicrobial use”, with some explicitly referencing being able to ensure correct duration and prevent overuse. In total, 29.0% thought the role should be about good knowledge of antimicrobials/antimicrobial guidelines and keeping this knowledge up to date.
An education role was also seen to be important: 21.6% thought this should involve educating colleagues and/or patients about antimicrobial use, while 11.1% thought it should include challenging prescribing decisions that would support the team approach to stewardship. Each of these responses indicated that the respondents recognised their own importance in the stewardship role.
The main challenge forseen in accepting and embedding AS was “time constraints/workload”. This indicated that opportunities to give nurses time to study and keep their knowledge up to date with appropriate ward cover must be explored.
Another perceived major challenge was “changing practice/habits/attitude” so antimicrobial use is not seen as the “doctor’s job” - this provided evidence supporting a professional team approach.
Respondents recognised that evidence around AS was continually evolving and 24.5% of those who expressed a view thought they would require regular “updates of information” to take forward an AS role. This suggests a process to allow the dissemination of up-to-date information must be put in place so nurses, midwives and other staff are confident they are working to current standards.
Of the respondents, 42.0% thought they would need support to take forward an AS role on the ward. The development of a network of support among colleagues and in a mentoring programme to provide specialist input could be considered.
The University of Dundee has recently added stewardship to its nursing degree programme and Edinburgh Napier University is reviewing its content in this area. NES and the SAPG, meanwhile, are working together to develop an AS education programme to meet the learning needs identified. The resource will be tested with frontline staff to ensure it is fit for purpose and supports improvements at the point of care.
Nurses and midwives play a key role in antimicrobial administration and monitoring and, as the providers of the majority of care, are well placed to ensure patients receive safe and effective antibiotic therapy. This survey of nurses and midwives in Scotland suggests there is a need for education and training on AS starting at undergraduate level to support this role. An interactive education resource based on the survey findings has now been developed and work is ongoing to disseminate and implement it across Scotland.
- The full report on this survey (NHS Education for Scotland, 2014) is available on the NHS Education for Scotland website. The educational resource informed by the survey (NHS Education for Scotland, 2015) is also available.
- Antimicrobial stewardship (AS) aims at the best use of these medicines to ensure optimal outcomes and minimal harm
- Training in AS is primarily targeted at medical staff and pharmacists
- Nurses’ and midwives’ contribution is paramount to effective AS
- A survey shows that only one in five nursing and midwifery staff had heard of AS
- The same survey showed the main challenge to nurses and midwives becoming more involved with AS to be lack of time due to workload pressures
Edwards R et al (2011) Covering more territory to fight resistance: considering nurses’ role in antimicrobial stewardship. Journal of Infection Prevention; 12: 1, 6-10.
Gillespie E et al (2013) Improving antibiotic stewardship by involving nurses. American Journal of Infection Control; 41: 4, 365-367.
NHS Scotland (2014) Scottish Management of Antimicrobial Resistance Action Plan 2014-18 (ScotMARAP 2).
NHS Scotland (2008) Scottish Management of Antimicrobial Resistance Action Plan 2008.
NHS Education for Scotland (2015) Antimicrobial Stewardship Educational Workbook.
NHS Education for Scotland (2014) Exploring the Role of Nurses and Midwives in Antimicrobial Stewardship.