Canadian nurses’ perspectives on challenges to antimicrobial stewardship in long-term care homes

Abstract

Background: The World Health Organization recognizes antimicrobial resistance (AMR) as a top global health threat. Antimicrobial resistance-related deaths in Canada are projected to exceed 13,500 annually by 2050. In long-term care homes (LTCH), 40% to 75% of antimicrobial prescriptions are inappropriate or unnecessary. Nurses are well-positioned to lead in antimicrobial stewardship (AMS) initiatives; however, it is unclear what challenges LTCH nurses face in participating in AMS activities. This study aims to provide insights into barriers and facilitators influencing nurses’ engagement in AMS within Canadian LTCHs.

Methods: A survey was developed using literature and an AMS working group assessing AMS knowledge (10 questions), confidence, barriers and facilitators. The survey targeted nurses working in Canadian LTCHs and was administered through Qualtrics online from January 20, 2023 to April 10, 2023 by distribution partners to obtain a convenience sample. Open-coding thematic analysis was used to describe quantitative data and analyze qualitative responses.

Results: A total of 346 complete responses were recorded. The mean knowledge score was 71% (standard deviation [SD]=15%). Most respondents perceived infection prevention and control measures, and monitoring changes in the health of residents to be part of the duties of nurses within AMS. However, making recommendations about antimicrobials was the least cited nursing responsibility. This suggests a lack of clarity around the role of nurses in AMS. Barriers to AMS activities included pressure to treat and lack of meaningful interprofessional communication, while AMS education and senior management support were drivers for AMS engagement.

Conclusion: Education, senior-level support, and formal recognition of nurses in AMS programming represent key facilitators to effectively engage LTCH nurses in AMS best practices.

Introduction

Antimicrobial resistance (AMR) is recognized as a public health risk globally ^{Footnote 1} and in Canada ^{Footnote 2}. According to the Council of Canadian Academies by 2050, deaths in Canada attributable to AMR is predicted to reach over 13,500 per year ^{Footnote 3}. In long-term care home (LTCH) settings, 40% to 75% of antimicrobial prescriptions are inappropriate or unnecessary ^{Footnote 4Footnote 5Footnote 6Footnote 7}. Antimicrobial stewardship (AMS) programs use a systematic approach to improve judicious antimicrobial use (AMU) and promote behavioural changes, commonly focusing on the beliefs and motivations of prescribers ^{Footnote 8Footnote 9}.

Long-term care home physicians often oversee over 50 residents ^{Footnote 10} and, in turn, rely on nurses, who interact frequently with residents and their caregivers, to monitor and contribute to residents’ care plans ^{Footnote 11}. Recognizing the potential for nurses to lead AMS, the Canadian Nurses Association (CNA) Antimicrobial Stewardship Competencies: A Pan-Canadian Framework for Nurses identified seven AMS domains to effectively promote and participate in AMS in nurse practice settings ^{Footnote 12}. While nurses have been identified as important and successful AMS stewards, and some research focuses on the roles, perspectives, and challenges for nurses around AMR and AMS ^{Footnote 13Footnote 14Footnote 15}, there is no clear literature focusing on the Canadian LTCH context specifically targeting nurses working in these settings. This study aims to describe the current landscape, based on the perspectives of nurses in Canadian LTCH settings, to identify the barriers and facilitators that influence their engagement in AMS, thereby informing future initiatives and enhancing their contributions to AMS activities.

Methods

Survey design

Survey development involved an informal literature review on AMS initiatives that include nursing staff and was overseen by a working group of infectious disease physicians, behavioural scientists and infection prevention and control (IPC) experts. For face validity, appropriate length and clarity, the survey was piloted by four LTCH nurses.

The anonymous 15 minute online survey (Appendix, Table S1) ran from January 20, 2023 to April 10, 2023, targeting Canadian LTCH nurses via convenience sampling through distribution partners (Appendix, Table S2). Informed consent was obtained, with no incentives, and data privacy followed the Canadian Privacy Act.

The survey consisted of four sections: participant demographics, knowledge, perspectives, and barriers and facilitators. Two open-ended questions were included for additional comments.

Demographics

Demographics included educational background, work experience, certifications and previous AMS/AMR training.

Knowledge

Eighteen knowledge questions were adapted from the literature to determine each respondent’s knowledge of AMS practices ^{Footnote 16Footnote 17Footnote 18Footnote 19Footnote 20}. Topics included defining relevant concepts (AMR, AMS, IPC, judicious AMU), and identification and testing for respiratory tract infections (RTIs), and urinary tract infections (UTIs) ^{Footnote 16Footnote 17Footnote 18Footnote 19Footnote 20Footnote 21Footnote 22Footnote 23Footnote 24Footnote 25} (Appendix, Table S1). Ten of 18 questions were randomly displayed to respondents.

Perspectives

Respondents were asked about their perspectives on AMU ^{Footnote 8}, influence on prescribing antimicrobials, responsibilities related to AMS, and their self-reported behaviours around AMR ^{Footnote 22Footnote 24}. Confidence related to performing AMS-related tasks was assessed using Likert scales ^{Footnote 25} (Appendix, Table S1).

Barriers and facilitators

Twelve barrier indicators and ten facilitator indicators for AMS activities were identified through literature ^{Footnote 26} and examined using Likert scales.

Descriptive analysis was conducted using R software ^{Footnote 27} and Microsoft Excel ^{Footnote 28}, as well as open-ended thematic coding to analyze qualitative responses. Due to a low response rate, no sub-group analyses were conducted.

Results

The survey was completed by 346 LTCH nurses (326 female, 94%), and 106 (31%) of the respondents were 45–54 years old) (Table 1). One quarter (92/346, 27%) of respondents were from Alberta, followed by Manitoba (79/346, 23%), New Brunswick (66/346, 19%), and Ontario (61/346, 18%). Over half (195/346, 56%) of respondents had more than 10 years of experience working in LTCHs, 57% worked full-time, and most were registered nurses (64%). Respondents also included eleven (3%) nurses who were directors of care or in manager positions.

Antimicrobial stewardship knowledge

The mean score for the knowledge questions was 71% (7/10) (standard deviation [SD]=15%) with a range of 1/10 to 10/10 (Figure 1). The highest scores were reported for IPC questions (86%, SD=28%), followed by AMS knowledge questions (75%, SD=24%). The lowest scores were for RTI-related questions (62%, SD=43%). Forty-two percent (146/346) of respondents indicated awareness of an AMR or AMS policy at their LTCH. Thirty-three percent (114/346) of respondents reported not receiving AMR training in the past twelve months.

Figure 1: Descriptive text

Knowledge questions listed:

1. Purulent (pus containing) nasal discharge, with the presence of a prolonged (3+ weeks) cough is an indication of a lower respiratory tract infection

2. It is good practice when collecting a nasal aspirate to try and get a sample after a meal, as it will suggest if the patient is aspirating or not

3. If a fever is present, foul smelling or discoloured urine is sufficient cause to test for a urinary tract infection

4. For elderly individuals, positive results of a urinalysis test (bacteria and blood is present in the urine) indicate that antibiotics are necessary

5. If no fever is present, dysuria (painful urination) is sufficient cause to test for a urinary tract infection

6. If a resident presents with a new onset of delirium and foul-smelling urine, the correct course of action would be to encourage greater intake of fluids and a complete delirium assessment

7. Newly admitted residents should be tested for urinary tract infections

8. To prevent infections, one should irrigate catheters on a regular schedule with antibiotics or put antibiotics in the drainage bag

9. It is recommended in some cases to wait until symptoms worsen before prescribing antibiotics

10. An accurate definition of antimicrobial stewardship is ‘Reducing the use of inappropriate or unnecessary antibiotics’

11. An accurate definition of antimicrobial resistance is ‘Medicine becomes less effective at killing bacteria and viruses. Fungi and parasites cannot mutate to become more resistant’

12. Prescribing broad-spectrum antibiotics when equally effective narrower spectrum antibiotics are available increases the chance for antibiotic resistance to occur

13. Appropriate use of antibiotics can cause antimicrobial resistance

14. Once symptoms have stopped occurring within a resident, it can be safe to stop the use of antibiotics, even if the prescription has not yet been completed

15. Broad spectrum antibiotics only destroy bacteria that is harmful to humans

16. It is good practice to take regular urine cultures on residents with indwelling catheters

17. An acute onset of confusion alone in a resident with an indwelling catheter is reason to suspect a urinary tract infection

18. Residents who are colonized with antimicrobial resistant bacteria (e.g., MRSA), should be treated with antibiotics to prevent infections

Type	Question number	Number of respondents	Percent (%) of correct responses
Urinary tract infection (UTI)	16	187	87
UTI	6	204	82
UTI	5	189	66
UTI	4	189	65
UTI	17	200	54
UTI	3	184	22
Respiratory tract infection (RTI)	2	203	84
RTI	1	187	38
Infection prevention and control (IPC)	8	194	99
IPC	7	198	94
IPC	9	199	66
Antimicrobial stewardship (AMS)	14	178	99
AMS	10	187	96
AMS	15	186	89
AMS	12	174	87
AMS	18	180	84
AMS	11	200	48
AMS	13	201	33

Perspectives

Eighty-one percent (281/346) of respondents reported that AMU is a problem in Canada, however, only 41% (143/346) indicated that antimicrobial overuse is a problem at their LTCH. Most respondents felt physicians (335/346, 97%) and pharmacists (308/346, 89%) were highly responsible for AMS, while 87% felt nurses were highly responsible for AMS activities.

Most respondents perceived the following stewardship activities to be part of their responsibilities: IPC measures (340/346, 98%), monitoring changes in resident health status, with certain signs and symptoms that would indicate the need for testing and potential treatment (337/346, 97%), and monitoring side effects of medication (318/346, 92%). Providing recommendations on appropriate dosage and duration (148/346, 43%), discontinuation of antimicrobials (134/346, 39%), and use of narrow-spectrum antimicrobials (127/346, 37%) were activities least identified to be responsibilities of nurses. Over half of respondents (199/346, 58%) reported that when testing for UTIs, they always or often consider AMR. In practice, 53% (184/346) report administering or overseeing two or fewer urine cultures per month. Most respondents (282/346, 82%) felt at least somewhat comfortable raising concerns about antimicrobials to physicians, and 75% of respondents believe their interdisciplinary communication with physicians and pharmacists can influence antimicrobial prescribing. However, 46% (159/346) of respondents believed that they sometimes or often gave antimicrobials that they thought were inappropriate.

Respondents had high overall confidence in performing AMS tasks (average 4.1/5, SD=0.6). Respondents felt least confident identifying an incorrectly prescribed antimicrobial class (3.3/5) and felt most confident recognizing signs and symptoms of UTI in residents (4.5/5). High confidence was not statistically significantly correlated with knowledge score.

Barrier and facilitator indicators

Responses ranged widely on how each barrier affected nurses’ ability to practice AMS at their LTCH (Figure 2). The most prevalent barriers were pressure from a resident’s family and friends to treat or test (269/346, 78%), lack of meaningful communication with prescribers (268/346, 77%), lack of time or energy (264/346, 76%), and lack of guidelines for AMS in the LTCH setting (261/346, 76%). The least cited barrier was having to conduct a full assessment, making antibiotics the easiest course of action (176/346, 51%).

Figure 2: Descriptive text

Impact	Type	Impact percent (%)
Barrier	Pressure from family/friends to treat or test	Negative impact: 78
Barrier	Lack of meaningful communication with prescribers	Negative impact: 77
Barrier	Lacking in time or energy	Negative impact: 76
Barrier	Lack of guidelines for AMS	Negative impact: 76
Barrier	Unaware of best practices	Negative impact: 70
Barrier	Lack of interest in AMS	Negative impact: 69
Barrier	Diagnostic uncertainty	Negative impact: 65
Barrier	Concern that residents health will worsen	Negative impact: 62
Barrier	Lack of feedback	Negative impact: 62
Barrier	Inability to deviate from a routine	Negative impact: 57
Barrier	Concern for legal repercussions due to lack of testing	Negative impact: 56
Barrier	Additional effort required to conduct a full assessment	Negative impact: 51
Facilitator	UTI/RTI assessment and treatment guidelines	Positive impact: 94
Facilitator	Training on infection prevention and control	Positive impact: 92
Facilitator	Support from colleagues	Positive impact: 91
Facilitator	Policies and procedures for culture testing	Positive impact: 91
Facilitator	Training on antimicrobials	Positive impact: 91
Facilitator	Support from supervisors/management	Positive impact: 90
Facilitator	Communication techniques with prescribers	Positive impact: 88
Facilitator	Public awareness campaigns	Positive impact: 85
Facilitator	Feedback on stewardship	Positive impact: 82
Facilitator	Stewardship reminders	Positive impact: 81

 

For facilitators, UTI or RTI assessment and treatment guidelines (324/346, 94%) were perceived to positively influence the practice of AMS among nurses, followed by IPC training (320/346, 92%), policies and procedures for specimen testing (315/346, 91%), and support from colleagues (315/346, 91%). The lowest response was for stewardship reminders, such as AMR posters in the halls (280/346, 81%). It was unknown whether respondents had access to all facilitators, however, all facilitators were perceived to be beneficial in promoting AMS practices. There were no significant differences in facilitators or barrier ranking when comparing nurses with over 10 years and less than 10 years of experience in LTCHs.

Qualitative analysis

Of the 346 respondents, 159 (46%) provided open-ended responses. Key facilitators included education, workplace guidelines, advocacy, and provincial/national AMS guidelines. Responses highlighted successful implementation, adequate staffing, and management endorsement and participation. One noted the influence of culture and collaboration: “It is an antibiotic first culture. We need to focus on other non-pharmaceutical interventions to... maintain health and prevent infection are the key, the challenge is to have adequate staffing to achieve this. This is a systemic problem and requires the financial support of the government and the local leadership team.”

Respondents noted that everyone had a role in AMS and desired accessible training and inclusion of other healthcare staff and residents and their caregivers in AMS education. Improved interdisciplinary communication, collaboration and building a preventive culture were needed. Workload, staff shortages, and staff burnout were persistent barriers.

Discussion

There is growing international interest in implementing and evaluating AMS in community settings ^{Footnote 29}. Internationally, the focus has been on nursing home staff (which often includes less clinically complex residents), however, LTCH nurses have not been well-studied in the context of AMS. It is necessary to understand the perspectives and knowledge of LTCH nurses to understand barriers and facilitators to AMS engagement.

Respondents felt highly responsible for many AMS activities. Nearly all respondents identified AMR as an issue and believe they can contribute positively to AMS at their workplace. Respondents performed best on IPC and AMS knowledge questions, suggesting familiarity with AMS practices. The widely ranging overall scores suggest variations in knowledge of AMS, including lack of AMS guidelines, lack of awareness of best practices, insufficient training, and low awareness of existing AMS policies. Furthermore, qualitative responses supported tailored education, AMS-specific training and specific guidelines to promote the involvement of nurses.

Respondents were confident in their abilities to perform AMS tasks, specifically those related to education on AMU, recognizing signs of infection, and performing tests in line with IPC practices. However, confidence did not correlate with better knowledge scores as noted among other healthcare professionals ^{Footnote 30}. High confidence reinforced the suggestion that many nurses are familiar with AMS tasks and frequently perform them. Formally recognizing their roles and supplying the appropriate training and support can address gaps in stewardship knowledge ^{Footnote 9Footnote 15Footnote 29}.

Interprofessional communication is critical for combatting AMR in LTCHs ^{Footnote 29Footnote 31Footnote 32Footnote 33}. While most nurses felt comfortable raising concerns to physicians about antimicrobial therapy, almost half felt they may be administering inappropriate antimicrobials. A lack of meaningful communication suggests nurses’ concerns are not taken into consideration by other health professionals. The framework (published after survey distribution) identifies timely communication and discussion on antimicrobial therapy as core competencies ^{Footnote 12}, however, survey findings suggest current lines of communication may not be sufficient for effective interprofessional collaboration and thus should be prioritized.

Over three quarters of respondents identified seven of the eleven stewardship activities to be part of a nurse’s responsibility in LTCHs, confirming that nurses already take on stewardship roles ^{Footnote 34Footnote 35Footnote 36Footnote 37}. However, less than half perceived recommendations on antimicrobial therapy as their responsibility, highlighting a discrepancy in AMS involvement for these activities. While most LTCH physicians are the prescribers, LTCH nurses are the most present regulated healthcare professionals and significantly influence residents’ care plans, including decision-support for antimicrobial therapy ^{Footnote 11Footnote 13}. Notably, the framework and AMS best practices highlight two competencies: appropriate use of antimicrobial agents and interprofessional collaborative practice, which can involve recommendations from nurses on antimicrobial therapy ^{Footnote 12Footnote 13}. Potential reasoning for the gap in nurses’ perspectives include unclear AMS responsibilities, a lack of confidence in their AMS knowledge, and a lack of interprofessional relationships that foster collaborative AMS discussions. The framework also promotes clear role definition, interprofessional collaboration, and ongoing education ^{Footnote 12}. Formal inclusion of nurses in AMS activities acknowledges their significant contributions, strengthens their role in antimicrobial decision-making, and empowers them to actively participate and lead in AMS initiatives within their organizations ^{Footnote 38}.

All listed facilitators were well-received by respondents, indicating implementing any of them could be beneficial (Figure 2). Respondents specifically mentioned buy in from senior management and other healthcare professionals would be extremely beneficial to their AMS activities, partly because they perceive that they are working in an “antimicrobials-first culture” with little senior leadership that encourages AMS. The listed facilitators can be used to identify optimal strategies for incorporating nurses in AMS activities in their local context. The listed barriers had greater variability in perceived negative effect, suggesting they may be more context specific.

Limitations

This first national AMS survey of Canadian LTCH nurses was timely amid growing interest in disease prevention and AMS. Use of open-ended responses enabled respondents to provide clarity and voice concerns. The results relied on convenience sampling, introducing selection bias. Survey distribution in a post-COVID-19 pandemic context may have reduced response rate, representativeness and generalizability, as only those with strong interest in AMS may have participated.

Conclusion

Canadian nurses in LTCHs perceive AMS as an important part of their responsibilities, and many already include AMS activities in their routines. The AMS knowledge and responsibilities of nurses vary. Key challenges include interprofessional communication, inconsistent AMS roles, and an antimicrobials-first culture. Leading facilitators include having AMS guidelines, tailored education, senior-level endorsement, and formalized AMS roles. Future representative sample studies should identify core AMS competencies relevant to LTCH nurses. Local nuances can be identified through replicating this study locally in consideration of local or province-specific AMS policies and guidelines.

Authors' statement

AV — Conceptualization, methodology, investigation, data curation & analysis, project administration
KQ — Data analysis, writing–original draft, writing–review & editing
JC — Conceptualization, methodology, writing–review & editing
GB — Conceptualization, methodology, writing–review & editing
KP — Conceptualization, methodology, writing–review & editing
TG — Conceptualization, methodology, writing–review & editing
BC — Methodology, writing–review & editing
SR — Methodology, writing–review & editing, project administration
AM — Methodology, writing–review & editing, project administration
DGT — Conceptualization, methodology, writing–review & editing

Competing interests

Authors have no conflict of interest to disclose.

ORCID numbers

Jorida Cila — 0000-0001-8741-0683
Gabrielle Brankston — 0000-0001-8601-1111
Klajdi Puka — 0000-0001-7763-988X
Tyler Good — 0000-0002-4153-3917

Acknowledgements

The authors extend their appreciation to Infection Prevention and Control (IPAC) Canada and the Canadian Nurses Association (CNA) for their assistance with data collection. The authors thank the working group supporting the Public Health Agency of Canada’s Office of Behavioural Science and Antimicrobial Resistance Task Force for their input and guidance on survey development. The authors also thank both the members of the Behavioural Science Office: Rhiannon Mosher and Mark Mossier, and members of the Antimicrobial Resistance Task Force: Robyn Mitchell, Kanchana Amaratunga, and Dhurata Ikonomi, for their expertise, guidance, and support.

Funding

This work was supported by the Public Health Agency of Canada.

Appendix

Supplemental material is available upon request to the author: amrtf-gtram@phac-aspc.gc.ca

Table S1: Survey questions

Table S2: Survey recruitment and distribution process

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