Discussion

This nursing KAP survey highlighted the discrepancy between nursing confidence versus demonstrable knowledge in clinical decision-making relevant to four potential antimicrobial stewardship initiative topic areas. Further, differences were seen in the national versus local perceptions of antimicrobial resistance and the threat it may pose. Additionally, we found that nursing staff were largely unfamiliar with the suite of ASP resources available at our facility. We found these results deeply informative to the design of future stewardship interventions targeted at bedside nurses who serve as our most important patient advocates and educators.

Previous KAP surveys of nurses describe nurses’ overall familiarity with antimicrobial stewardship, attitudes toward AR on the national level, and understanding of antimicrobials. ^{Reference Merrill, Hanson, Sumner, Vento, Veillette and Webb5–Reference Srinivasan, Song, Richards, Sinkowitz-Cochran, Cardo and Rand7} Our study builds on this experience and demonstrates results can change substantially when framed on the local level. We designed our study with specific ideas for future nurse-driven stewardship interventions in mind, allowing us to shed light on potential challenges and opportunities to their implementation. Finally, while other studies have asked about general educational resources our survey highlighted the challenges of disseminating ASP educational materials to bedside nurses.

For our ASP, the finding of greatest relevance was the discrepancy between nursing confidence and knowledge in our four topic areas for proposed interventions. For a nursing-based IV to PO initiative, our data suggested we focus on empowering nurses to feel confident in their assessments and in prompting a switch to oral medications. In contrast, for a urine culture diagnostic stewardship intervention our data suggested a need to focus on education to overcome misconceptions about indications for urinalysis and culture. Further, this educational initiative would need to be communicated in a novel manner given nursing unfamiliarity with our existing ASP resources. Nursing-based stewardship interventions proposed at the national level are better informed by adaptation to local environments. For this purpose, KAP surveys remain a helpful method to anticipate implementation challenges in a specific setting. We believe ASP personnel aiming to engage multidisciplinary groups in stewardship should prioritize gathering KAP data when designing inclusive initiatives.

Our study has limitations. The survey was conducted at a single large academic center with a well-supported ASP and magnet level nursing staff; thus, results may not be reflected in other, more diverse institutions such as of smaller community hospitals. Additionally, our knowledge assessment for stewardship topics was not a previously validated tool and may be an imperfect measure of clinical decision-making in real-world scenarios. Finally, the survey was voluntary with a low response rate and may not be representative of nurses as a whole with insufficient power to evaluate differences which could exist in nurses from distinct work areas.

Nearly all patient care flows through bedside nurses, who represent critical partners and a valuable resource to expand the reach of antibiotic stewardship initiatives and promote the principles of judicious antibiotic use. The success of these multidisciplinary interventions will depend on improving ASP communication with bedside nurses and an understanding of stewardship knowledge, attitudes and practices at the local level. ASPs should consider the use of KAP surveys to guide their development of nursing-based stewardship initiatives.