EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
ANTIMICROBIAL STEWARDSHIP
EXECUTIVE SUMMARY
Antimicrobial stewardship in its simplest term means ‘taking care of antibiotics’. By
this we mean ensuring appropriate use of antimicrobials to preserve the
effectiveness of these important medicines for future generations. It is widely
acknowledged that a multiprofessional approach to antimicrobial stewardship is
required involving all healthcare staff who prescribe, administer or monitor
antimicrobial treatment. The Scottish Antimicrobial Prescribing Group (SAPG)
identified the benefits of involving front line nursing staff in stewardship but also
identified a possible lack of knowledge and understanding of antimicrobial
stewardship amongst nurses and midwives. In order to find out if this were the case
a survey was designed to scope current understanding of antimicrobial stewardship
in nursing and midwifery to inform development of an education resource to meet the
learning needs of this staff group.
The survey was based on a previous paper based survey that had been carried out
in NHS Lothian. A Survey Monkey© on-line tool was developed which allowed
nurses and midwives to input data. The tool was disseminated to nursing and
midwifery staff in all NHS boards via the Scottish Executive Nurse Directors group.
In addition to the on-line survey a small sample of nursing and midwifery staff was
asked to complete the survey through oral discussion with a Senior Charge Nurse or
an Infection Control Nurse during a ‘walk about’.
In total 901 responses to the survey were obtained with 46 of these being from the
‘walk about’ in NHS Tayside. The largest number of respondents (36.8%) came from
NHS Tayside. The greatest proportion of respondents described their specialism as
community care (40%).There was an even split amongst seniority with AFC bands 5,
6 and 7 being relatively equally represented. 80% had been qualified more than 10
years.
There was a relatively low level of understanding of the term ‘antimicrobial
stewardship’ by nurses and midwives (only 22% of respondents had heard of the
term) although this improved with increased seniority (11% of band 5s vs. 33% of
band 7s). The majority (74%), of respondents thought that education about
antimicrobial stewardship should begin prior to registration.
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When asked about the format education for a role in anti-microbial stewardship on
the ward should take, most respondents (54%) favoured a blend of styles.
Encouragingly 58% thought that everyone on the ward should play a role in
antimicrobial stewardship. When asked about the specific role of nurses and
midwives, 37% of those that answered said they should ensure appropriate
antimicrobial use with specific references to overuse and duration being made. Upto-date knowledge of antimicrobials and education of colleagues and patients were
also mentioned by a number of respondents (29% and 22%).
The perceived personal barriers to accepting and embedding antimicrobial
stewardships were mainly ‘time constraints and workload’ (26%) with the next most
common being ‘changing practice/habits/attitudes’(16%).
When asked about ongoing support to take forward antimicrobial stewardship on the
ward support from colleagues was mentioned most often (37/183) with the next two
most commonly reported areas being ‘management / senior staff’ (36/183) and
‘pharmacy’ (29/183). 25% mentioned that updates in information were important and
19% thought that a specific expert contact or mentor would help.
The results of the survey showed that the term “antimicrobial stewardship” is not
widely known by practicing nurses and midwives in Scotland. Therefore there is
scope for education to improve knowledge in this area at undergraduate level and
beyond. Those who did understand the term recognised that it was a continually
evolving area and the need to keep up-to-date. This suggests that some sort of
mechanism for continually updating nurse’s antimicrobial knowledge should be put in
place. Many also felt they needed support to implement their stewardship role
particularly from colleagues. Therefore thought should be given on how to develop a
network of colleague support/expert mentors that would provide this. The main
perceived barriers to embedding anti-microbial stewardship were ‘time constraints
and workload’.
The other main perceived barrier of ‘changing
practice/habits/attitudes’ is more cultural and may need a whole system/organisation
approach.
The survey results are being used by SAPG and NHS Education for Scotland (NES)
to develop and implement an education resource utilising existing education delivery
systems in NHS boards.
Jacqueline Sneddon, Project Lead for SAPG
Gill Walker, Programme Director HAI, NES
SAPG/NES/2014
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REPORT ON SURVEY TO SCOPE LEARNING NEEDS OF
NURSES AND MIDWIVES TO SUPPORT THEIR ROLE
IN ANTIMICROBIAL STEWARDSHIP
BACKGROUND
As part of the multi-professional team approach to antimicrobial stewardship there is
increasing recognition of the critical role of nurses and midwives in antimicrobial
administration, management and monitoring. The Scottish Patient Safety
Programme sepsis collaborative is also recognising the key role of nurses and
midwives in the effective implementation of the Sepsis bundle. This demonstrates
the important role of nurses and midwifes in providing advocacy for patients to
ensure medicines are used safely.
The Scottish Antimicrobial Prescribing Group (SAPG) and NHS Education for
Scotland (NES) have also been promoting the contribution that nursing and
midwifery staff can make to antimicrobial stewardship through education initiatives
and quality improvement work and have been engaged with the Scottish Executive
Nurse Directors (SENDs) group regarding the benefits of developing the nurses’ role
in stewardship.
SAPG and NES have received funding from the HAI Task Force to progress with a
project to develop an education resource for nurses and midwives and a Senior
Charge Nurse has been seconded from NHS Lothian as Project Manager. An
Advisory Group comprising stakeholders from Scottish Government HAI Policy Unit,
Associate Nurse Director (representing SEND), NES HAI and Pharmacy
directorates, SAPG, Non-medical Prescribing Lead and an Antimicrobial Advanced
Nurse Practitioner has been established and their primary objective will be to define
the scope of education required and oversee the development of the resource
content and delivery. As a first step in this process the Advisory Group
commissioned a survey to scope the learning needs of nurses and midwives to
support them in this emerging role.
AIMS AND OBJECTIVES



To scope the current understanding of antimicrobial stewardship amongst
nurses and midwives.
To identify the learning needs of nurses and midwives at various grades and
levels of experience across all NHS care settings.
To identify preferred methods of education delivery and support mechanisms
required.
METHOD
A survey was developed based on a paper –based survey used previously in NHS
Lothian. A Survey Monkey© on-line tool was created to allow nurses and midwives
to input data and SAPG to create a summary report. The tool was disseminated to
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nursing and midwifery staff in all NHS boards via the Scottish Executive Nurse
Directors group. In addition to the on-line survey a small sample of nursing and
midwifery staff was asked to complete the survey through oral discussion during a
‘walk about’ by an Antimicrobial advanced Nurse Practitioner. Results from the online survey were analysed to create a report which will inform development of the
education resource.
RESULTS
Which Hospital do you work in?
848 of the total 901 (94%) respondents specified a work area. Unfortunately the
wording of the question mentioning ‘Hospital’ was not relevant to many respondents
who indicated that they worked in a community setting. At least 171 separate work
places were specified although a difficulty with interpreting responses means that
this is only an approximate figure. The highest number of respondents from any
single site was 137 from Ninewells Hospital in Dundee.
The Board worked in could be derived for 647 respondents. Over one third of
respondents (238, 37%) worked in NHS Tayside with the next largest number (194,
30%) working in NHS Greater Glasgow and Clyde.
EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
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Board Worked In
- Percentage of 647 Respondents
100%
80%
60%
40%
20%
1.2%
% ofRre sponde nts
36.8%
30.0%
0%
Source: SAPG Survey
2.9%
5.7%
2.3%
0.6%
5.6%
10.0%
0.2%
2.8%
1.9%
Board
The Setting worked in could be derived for 896 respondents. Around 55% worked in
an acute (including paediatric) setting with the remainder working in community or
primary care.
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EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
ANTIMICROBIAL STEWARDSHIP | SEPTEMBER 2014
Setting Worked In - Percentage of 896 Respondents
100%
% ofRrespondents
80%
60%
48.7%
45.2%
40%
20%
6.1%
0%
Acute Hospital
Community/Primary Care
Setting
Source: SAPG Survey
Paediatric Hospital
Which specialty do you currently work in?
848 of the total 901 (94%) respondents specified the specialty that they worked in.
337 (40%) answers indicated that the respondents worked in Community Care, with
Surgical (15%) and Medical (13%) being the only other specialties where more than
10% of respondents worked.
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Specialty Worked In - Percentage of 848 Respondents
% ofRrespondents
100%
80%
60%
39.7%
40%
20%
4.5%
1.3%
6.3%
1.3%
1.7%
8.5%
15.2%
13.3%
1.4%
5.3%
1.5%
0%
Source: SAPG Survey
Specialty
What AFC band are you?
880 of the total 901 (98%) respondents specified their AFC band. Respondents
were relatively evenly split across the three AFC bands 5, 6 and 7 with
approximately one third of respondents falling into each category.
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EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
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AFC Band - Percentage of 880 Respondents
100%
% ofRrespondents
80%
60%
40%
36.3%
33.2%
30.5%
20%
0.1%
0%
Band 5
Band 6
Band 7
Band 8a
AFC Band
Source: SAPG Survey
How long have you been qualified?
The majority (79%) of the 890 respondents to this question had been qualified for
over 10 years.
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Number of Years Qualified - Percentage of 890 Respondents
100%
79.2%
% ofRrespondents
80%
60%
40%
20%
3.6%
7.9%
9.3%
0%
< 2 years,
Source: SAPG Survey
2 – 5 years
6 – 10 years
Number of Years Qualified
> 10 years
How would you rate your knowledge of antibiotics?
Approximately half (49%) of the 887 respondents rated their knowledge of antibiotics
as average; 15% rated their knowledge lower than average (‘minimal’ or ‘limited’)
and the remainder (36%) rated their knowledge as ‘good’ or ‘very good’.
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Knowledge of Antibiotics - Percentage of 887 Respondents
100%
% ofRrespondents
80%
60%
48.5%
40%
30.4%
20%
11.6%
5.7%
3.7%
0%
Minimal
Limited
Source: SAPG Survey
Average
Knowledge of Antibiotics
Good
Very good
The responses to the ‘How would you rate your knowledge of antibiotics?’ were
broken down by AFC band to examine how responses changed with increasing
seniority. As expected, improved knowledge was reported as seniority increased;
with the % responding in the top two knowledge categories for Band 7s being double
that of Band 5s.
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Knowledge of Antibiotics by AFC Band - Percentages of 871 Respondents
100%
% ofRrespondents
80%
Good
22.9%
60%
Good
30.1%
Good
40.2%
Very good
Good
100.0%
40%
Good
Average
Limited
Minimal
20%
0%
Band 5
Source: SAPG Survey
SAPG/NES/2014
Band 6
Band 7
Knowledge of Antibiotics by AFC Band
Band 8a
7
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Knowledge of Antibiotics by AFC Band - Percentages of 825 Respondents
100%
Good
23.4%
% ofRrespondents
80%
Good
28.9%
60%
Good
40.2%
Very good
Good
100.0%
40%
Good
Average
Limited
20%
Minimal
0%
Band 5
Source: SAPG Survey
Band 6
Band 7
Knowledge of Antibiotics by AFC Band
Band 8a
Have you heard of the term “Antimicrobial Stewardship”?
191 out of 887 (22%) respondents indicated that they had heard of the term
‘Antimicrobial Stewardship’.
EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
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Heard of the Term 'Antimicrobial Stewardship' - Percentage of 887 Respondents
Yes
21.5%
No
78.5%
Source: SAPG Survey
When these responses were broken down by AFC band, we again see that
knowledge increases with seniority.
SAPG/NES/2014
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Heard of the Term 'Antimicrobial Stewardship' by AFC Band - Percentages of
870 Respondents
100%
Yes
11.2%
Yes
21.0%
% ofRrespondents
80%
Yes
33.1%
60%
Yes
100.0%
40%
20%
0%
Band 5
Source: SAPG Survey
Band 6
Band 7
Heard of the term 'Antimicrobial Stewardship' by AFC Band
Band 8a
Similarly, when the relationship between the responses to the question on
knowledge of antibiotics and the term stewardship were graphed, the term
‘Antimicrobial Stewardship’ had been heard of more often by respondents with a
better knowledge of antibiotics. However, less than one third (31%) of those who felt
they had ‘good’ knowledge of antibiotics and just over one half (55%) of those with
‘very good’ knowledge had heard of the term ‘Antimicrobial Stewardship’. This
suggests that there is scope for some education around this area and that
‘knowledge of antibiotics’ may not extend to areas such as antimicrobial resistance
and the implications for the wider society.
EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
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Knowledge of Antibiotics v whether heard of the Term 'Antimicrobial
Stewardship' - Percentages of 880 Respondents
100%
Yes
9.4%
% ofRrespondents
80%
Yes
12.6%
Yes
15.0%
Yes
30.5%
Yes
54.9%
60%
40%
20%
0%
Minimal
Limited
Average
Good
Very good
Knowledge of Antibiotics v whether heard of the term 'Antimicrobial Stewardship'
Source: SAPG Survey
SAPG/NES/2014
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If you have heard the term “Antimicrobial Stewardship”, in your own words,
what do you understand by the term?
A personal interpretation of the term ‘Antimicrobial Stewardship’ was provided by
191 (21%) of respondents. Note that the definition subsequently provided in the
survey was: ‘Making the best use of antimicrobials to manage infection so as to
ensure optimal outcomes and minimal harm to patients and the wider society’.
Most of the 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. There was minimal mention of
consequences to wider society but this was implicit in many replies.
The responses ranged from the very short e.g. ’appropriate use’ to the very detailed
e.g. ‘Although antibiotic stewardship is traditionally associated with pharmacists and
medical teams, it is also the role of nurses to promote proficient assessment of
potential infections to rule out colonisation, other inflammatory and viral causes and
to ensure antibiotics, if required, are prescribed following the available prescribing
guidelines to reduce unnecessary use of antibiotics specifically associated with
reduction of gut flora and higher risks of colonisation with C Diff / precipitation of C
Diff tox A&B in some genotypes. Nurses can question prescriptions of second line
antibiotics in patients without known allergies and with basic infections and
prescribe/ remind prescribers to change IV to oral ASAP, chase up results and
ensure review of antibiotics and ensure review dates are written on prescriptions by
medical staff to reduce the risk of unnecessarily prolonged use of antibiotics. Nurses
and medical staff should complete the available modules to increase their knowledge
and improve compliance with evidence based practice.’
When within the career pathway do you think nurse and midwife education on
antimicrobial stewardship should commence?
628 (70%) of respondents responded to this question with the lower response rate
perhaps indicating a lack of confidence in the area of Antimicrobial Stewardship. Of
the 628, most people (74%) thought that education on Antimicrobial Stewardship
should commence at pre-registration.
SAPG/NES/2014
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EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
ANTIMICROBIAL STEWARDSHIP | SEPTEMBER 2014
When in Career Pathway nurse and midwife education on Antimicrobial
Stewardship should commence - Percentage of 628 Respondents
Induction (Flying Start)
18.9%
Effective Practitioner,
Advanced Practitioner
6.7%
Pre-registration
74.4%
Source: SAPG Survey
Who would you expect to be involved in antimicrobial stewardship in your area
on the ward?
There were 507 (59%) on-line responses to the question ‘Who would you expect to
be involved in antimicrobial stewardship in your area on the ward?’ Most
respondents (32%) expected the ‘Doctor’ to be involved. The next most common
choice was ‘Nurse’ at 20% with all other possible responses from a closed list
(pharmacist, infection control team, microbiologist, infection control nurse and
midwife) being lower as shown below.
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Who Expected to be Involved in Antimicrobial Stewardship in Respondents
Area on the Ward - Percentage of 507 Respondents
% ofRrespondents
100%
80%
60%
40%
31.6%
19.7%
16.6%
20%
3.4%
7.7%
17.8%
3.4%
0%
Doctor
Source: SAPG Survey
Infection
Infection Microbiologist Midwife
Nurse
Pharmacist
control nurse control team
Who Expected to be Involved in Antimicrobial Stewardship in Respondents Area
However, there was space for comment after this question and over half of
respondents 299 (58%) made comment. This question only allowed for one
response to be chosen and many (at least 58%) used the comment space to express
SAPG/NES/2014
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the view that everyone should be involved in Antimicrobial Stewardship. This was an
error in the survey set up as respondents should have been able to select more than
one answer. Note that the ‘walk about’ results have not been included here because
all these responses included several options and over half chose all relevant options.
Again this was due to an error in the survey instructions.
What do you think the nurse/midwife role in antimicrobial stewardship should
involve?
There were 513 (57%) responses to this question. A wide variety of views were
expressed from ‘none’ to ‘all aspects’ with several indicating a range of ideas. 37%
of responses included the view that the role should be about ‘ensuring appropriate
antimicrobial use’ with some of these explicitly referencing duration and overuse.
29% 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 with 22% thinking the role should
involve educating colleagues and/or patients about antimicrobial use. Only 2
respondents indicated that they did not think that antimicrobial stewardship should
be part of a nurse’s role.
Nurse/Midwife Role in Antimicrobial Stewardship
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What the Nurse/Midwife Role in Antimicrobial Stewardship should Involve Percentage of 513 Respondents
Ensuring appropriate antimicrobial use
Knowledge of antimicrobials
Educating colleagues / patients / public
Challenging prescribing decisions
Role model / Raising awareness
Don't know
Communication / Staff discussions
Hygiene
Patient advocate
Monitoring and Evaluation
Other (2 comments or fewer each)
Source: SAPG AMT Survey
36.8%
29.0%
21.6%
11.1%
6.2%
6.2%
3.5%
3.7%
3.3%
2.5%
5.1%
0%
5%
10%
15%
20%
25%
% of Respondents
30%
35%
40%
Note that some responses included more than one category so results do not sum to 100%
What challenges would you anticipate personally in accepting and embedding
the practice of antimicrobial stewardship?
415 (46%) respondents expressed a view on the personal challenges they
anticipated in accepting and embedding the practice of antimicrobial stewardship.
Several anticipated more than challenge. One quarter (26%) noted the challenge of
‘Time constraints / workload’ with the next two biggest challenges being ‘Changing
practice/habits/attitude’ and ‘Lack of knowledge/keeping knowledge up to date’. The
top eight personal challenges are shown below.
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EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
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Top 8 Personal Challenges to Accepting and Embedding the Practice of
Antimicrobial Stewardship - Percentage of 415 Respondents
Top 8 Personal Challenges
Time constraints / workload
26.3%
Changing practice / habits / attitudes
15.7%
Lack of knowledge / keeping knowledge up to date
15.4%
Patient / family expectations and attitudes
10.8%
Challenging medical staff / prescribing decisions
10.6%
None
9.2%
Staff education / training
8.7%
Staff communication
2.4%
0%
5%
Source: SAPG AMT Survey
10%
15%
20%
% of Respondents
25%
30%
Note that some responses included more than one category so results do not sum to 100%
What type of introductory education would you need to take forward an
antimicrobial stewardship role on the ward?
There were 423 (47%) responses to this question with a very wide variety of views
on the type of introductory education needed. Examples are posters, on-line
learning and Learn pro courses, study days, workshops, basic training, anything,
everything.
What format of education do you prefer?
The preferred format of education was reported in 594 (66%) cases. Just over one
half (54%) preferred a ‘Blend of styles’ to include some combination of lectures, online learning, tutorials, ward based teaching and other face-to-face teaching.
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Preferred Format of Education - Percentage of 594 Respondents
100%
% ofRrespondents
80%
60%
54.4%
40%
18.5%
20%
5.7%
15.8%
5.6%
0%
Blend of styles
Source: SAPG Survey
SAPG/NES/2014
Lectures
On-line learning
Tutorials
Ward-based
teaching
Preferred Format of Education
13
What ongoing support would you need to take forward an antimicrobial
stewardship role on the ward?
There were 436 (48%) responses indicating the types of support that would be
needed to take forward an antimicrobial stewardship role on the ward. Many of
these indicated that a range of support mechanisms would be needed with 183
(42%) needing ‘Support’ of some type. 25% of responses were for ‘Updates of
information’ and 19% commented that an ‘Expert contact’ or ‘Mentor’ would be a
useful support mechanism e.g. ’ Someone designated for advice and support’. 6%
needed ongoing support in the form of ‘Continued education’.
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Ongoing Support Needed to take Forward an Antimicrobial Stewardship Role
on the Ward - Percentage of 436 Respondents
Ongoing Support Needed
Support from various sources
42.0%
Updates of information
24.5%
Expert contact / Mentor
18.8%
Protected time for teaching / learning
15.8%
Continued education
6.2%
0%
Source: SAPG AMT Survey
5%
10%
15%
20% 25% 30%
% of Respondents
35%
40%
45%
Note that some responses included more than one category so results do not sum to 100%
Of the 183 responses indicating ‘Support’ was needed, most expressed the source
this support was required from. The main source was ‘colleagues’, with the next two
most commonly reported areas being ‘management / senior staff’ and ‘pharmacy’.
Support was also needed from ‘ICT’ and ‘clinicians’. These results are reported
below.
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EXPLORING THE ROLE OF NURSES AND MIDWIVES IN
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Detail on Support Needed to take Forward an Antimicrobial Stewardship Role
on the Ward - Number out of 183 Respondents
Detail on Support Needed
Support from colleagues
37
Support from management / senior staff
36
Support from pharmacy
29
Support (no detail provided)
24
Support from Infection Control Team
22
Support from clinicians
17
Support from microbiology
7
Support from nurse specialist / advanced practitioner
4
Support from other (2 responses or fewer each)
7
0
Source: SAPG AMT Survey
5
10
15
20
25
30
Number of Respondents
35
40
Additional comments
Finally, there was space to supply final comments and 55 respondents took the
opportunity to comment. These comments are summarised below with some
examples also included.







7 comments on Antimicrobial Stewardship being everybody’s responsibility and
that commitment and training were required by entire team.
5 comments highlighting agreement with importance of Antimicrobial
Stewardship.
10 comments on the survey being mainly aimed at hospital setting – or indicating
that the survey didn’t seem aimed at them e.g. ‘We have a lot of non medical
prescribers so very important to target community - looking at trends and costs.’
3 other comments pointing out shortfalls in the survey, for example missing
categories in the drop down boxes (‘other’ category was sometimes needed).
6 comments on how nurses feel they have little control over GPs who make
prescribing decisions and/or GPs requiring prescribing training e.g. ‘Suggestions
about prescribing from us would not go down well with a number of our GPs!’
8 comments on time/staffing constraints and issues with being taken away from
ward e.g. ‘Yet again nursing staff are being taken away from the bedside. Where
are our senior nurse managers/leaders of our field to support the role of the nurse
with direct patient care, instead of leading us down the route of 'policing' what our
medical colleagues do? I feel so let down by my own profession. This will allow
the organisation to have the 'buck' stop with nurses. I know this sounds very
negative and I make no apology for telling the truth, as I see this happening all
the time.’
16 other general comments
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