Nurses’ Perceptions, Involvement, Confidence and Perceived Barriers Towards Antimicrobial Stewardship Program in Pakistan: Findings from a Multi-Center, Cross-Sectional Study

Figures & data

Table 1 Participant Characteristics (N = 583)

Characteristics		N (%)
Age class	< 30 years	257 (44.1)
	> 30 years	326 (55.9)
Gender	Female	583 (100)
	Male	0 (0.0)
Designation	Head nurse	15 (2.6)
	Staff nurse	568 (97.4)
Degree	Bachelor	565 (96.9)
	Master degree	18 (3.1)
Marital Status	Single	145 (24.9)
	Married	438 (75.1)
Residence	Rural	215 (37.1)
	Urban	365 (62.9)
Years of Experience	1–2 years	80 (13.7)
	3–5 years	250 (42.9)
	6–10 years	173 (29.7)
	11 or more years	80 (13.7)

Table 2 Perception of Nurses Towards Antimicrobial Stewardship Programs (ASPs) (N = 583)

Perception Towards ASPs (5 Items)	N (%)
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. Antimicrobial stewardship programs promote reasonable prescription of antimicrobials	–	–	20 (3.4)	234 (40.1)	329 (56.4)
2. Antimicrobial stewardship programs help control antimicrobial resistance	–	–	15 (2.6)	230 (39.5)	338 (58)
3. Antimicrobial stewardship programs reduce the overuse of antimicrobials	–	–	71 (12.2)	186 (31.9)	326 (55.9)
4. Antimicrobial stewardship programs reduce the cost of treatment.	–	–	62 (10.6)	246 (42.2)	275 (47.2)
5. Antimicrobial stewardship programs Improves medical quality.	–	1 (0.2)	19 (3.3)	228 (39.2)	333 (57.3)

Table 3 Median (Interquartile Range) Score for Each Domain Score in Overall and by Years of Experience and Age

		Perception Towards ASPs (0–20 Scale)	Involvement in ASPs (0–64 Scale)	Confidence to Perform ASP Activities (0–28 Scale)	Barriers Towards ASP Activities (0–32 Scale)
Overall		18 (16, 19)	18 (15, 37)	22 (14, 24)	19 (17, 24)
Years of Experience
	1–2 years	18 (17, 19)	17 (13.5, 19)	22 (15, 24)	18 (17, 23)
	3–5 years	18 (17, 19)	18 (15, 37)	23 (21, 24)	18 (17, 23)
	6–10 years	17 (16, 18)	23 (15, 39)	21 (14, 23)	21 (17, 24)
	11 or more years	17 (16, 19)	20 (8, 36.5)	16 (9, 22)	21.5 (17, 24)
	p-value	< 0.001	0.012	< 0.001	0.049
Age class
	<30 years	18 (17, 19)	17 (15, 28)	23 (21, 24)	18 (17, 22)
	>30 years	17 (16, 19)	20 (15, 39)	21 (12, 23)	21 (17, 24)
	p-value	< 0.001	< 0.001	< 0.001	< 0.001

Table 4 Involvement of Nurses Towards Antimicrobial Stewardship Programs (ASPs) (N = 583)

Involvement in ASPs (16 Items)	N (%)
	Never	Seldom	Sometimes	Often	Always
1. I review prescription of antimicrobials.	52 (8.9)	48 (8.2)	53 (9.1)	145 (24.9)	285 (48.9)
2. I proactively intervene in problematic prescriptions of antimicrobials	292 (50.1)	65 (11.1)	38 (6.5)	100 (17.2)	88 (15.1)
3. I comment on antimicrobial prescriptions and medical orders.	328 (56.3)	51 (8.7)	39 (6.7)	92 (15.8)	73 (12.5)
4. I provide feedback on antimicrobial prescriptions and medical orders	300 (51.5)	69 (11.8)	44 (7.5)	67 (11.5)	103 (17.7)
5. I participate in decision-making of antimicrobial treatment for critically ill patients.	344 (59)	59 (10.1)	32 (5.5)	104 (17.8)	44 (7.5)
6. I participate in antimicrobial stewardship committee meetings and decision making	372 (63.8)	36 (6.2)	53 (9.1)	81 (13.9)	41 (7)
7. I provide advice to doctors regarding the intravenous-to-oral conversion of antimicrobials	389 (66.7)	32 (5.5)	20 (3.4)	97 (16.6)	45 (7.7)
8. I provide advice to doctors about the adverse drug effects of antimicrobials	155 (26.6)	94 (16.1)	197 (33.8)	87 (14.9)	50 (8.6)
9. I provide advice to doctors about drug interactions related to antimicrobials	251 (43.1)	93 (16)	119 (20.4)	78 (13.4)	42 (7.2)
10. I monitor the duration of antimicrobial treatment and recommend appropriate cessation.	148 (25.4)	49 (8.4)	95 (16.3)	145 (24.9)	146 (25)
11. I participate in developing hospital antimicrobial treatment guidelines.	398 (68.3)	21 (3.6)	45 (7.7)	58 (9.9)	61 (10.5)
12. I provide feedback to doctors on bacterial resistance.	141 (24.2)	31 (5.3)	123 (21.1)	161 (27.6)	127 (21.8)
13. I participate in the management and evaluation of antimicrobial types in hospital.	345 (59.2)	20 (3.4)	41 (7)	92 (15.8)	85 (14.6)
14. I monitor and evaluate antimicrobial consumption in hospital.	353 (60.5)	14 (2.4)	32 (5.5)	106 (18.2)	78 (13.4)
15. I communicate with doctors on anti-infective treatment.	352 (60.4)	13 (2.2)	21 (3.6)	106 (18.2)	91 (15.6)
16. I communicate with patients and family members on antimicrobial treatment	97 (16.6)	28 (4.8)	42 (7.2)	216 (37)	200 (34.3)

Table 5 Confidence of Nurses to Perform Antimicrobial Stewardship Program (ASP) (N = 583)

Confidence to Perform ASP Activities (7 Items)	N (%)
	Very Unconfident	Unconfident	Neutral	Confident	Very Confident
1. To review the appropriateness of antimicrobials use	57 (9.8)	71 (12.2)	35 (6)	172 (29.5)	248 (42.5)
2. To determine the antimicrobial type to treat common infections such as pneumonia, urinary	14 (2.4)	30 (5.1)	85 (14.6)	206 (35.3)	248 (42.5)
3. To adjust the dose and frequency of antimicrobials based on patient and infections	27 (4.6)	60 (10.3)	93 (16)	293 (50.3)	110 (18.9)
4. To optimize antimicrobial treatment based on pharmacodynamic and pharmacokinetic parameters	122 (20.9)	38 (6.5)	157 (26.9)	153 (26.2)	113 (19.4)
5. To provide reasonable advice on the course of antimicrobial treatment	32 (5.5)	54 (9.3)	78 (13.4)	283 (48.6)	135 (23.2)
6. To identify unnecessary antimicrobial treatment and suggest stopping treatment	21 (3.6)	52 (8.9)	100 (17.2)	259 (44.4)	151 (25.9)
7. To participate in consultation and case discussion on antimicrobial treatment	35 (6)	42 (7.2)	88 (15.1)	364 (62.4)	54 (9.3)

Table 6 Barriers Faced by Nurses Towards ASP Activities (N = 583)

Barriers Towards ASP Activities (8 items)	N (%)
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. Have limited knowledge of antimicrobial treatment indications, dosage, duration, combination and adverse reactions	221 (37.9)	64 (11)	23 (3.9)	161 (27.6)	114 (19.6)
2. Attention from the hospital administration about ASPs is not enough	21 (3.6)	96 (16.5)	169 (29)	169 (29)	128 (22)
3. Participation in ASPs will make no difference	142 (24.4)	204 (35)	68 (11.7)	131 (22.5)	38 (6.5)
4. Have limited time to participate in ASPs due to other daily work	21 (3.6)	50 (8.6)	53 (9.1)	203 (34.9)	255 (43.8)
5. There is a lack of efficient communication between nurses and doctors	15 (2.6)	63 (10.8)	83 (14.3)	202 (34.8)	218 (37.5)
6. Nurses’ advice on antimicrobials has not been widely accepted by doctors	14 (2.4)	43 (7.4)	102 (17.5)	213 (36.5)	211 (36.2)
7. Lack of adequate number of trained nurses	179 (30.7)	144 (24.7)	84 (14.4)	138 (23.7)	38 (6.5)
8. Lack of training about antimicrobial stewardship programs	19 (3.3)	26 (4.5)	21 (3.6)	312 (53.5)	205 (35.2)