Influences on nurses’ engagement in antimicrobial stewardship behaviours: a multi-country survey using the Theoretical Domains Framework

Background: Antimicrobial resistance (AMR) is significantly affected by inappropriate antibiotic use, and is one of the greatest threats to human health. Antimicrobial stewardship (AMS) is a programme of actions promoting responsible antimicrobial use, and is essential for limiting AMR. Nurses have an important role to play in this context. Aim: This study investigated the determinants of nurse AMS behaviours and the impact of past training. Method: A cross-sectional multi-country survey design with mixed methods was employed. Participants were 262 nurses (223 female; mean age = 44.45; SD = 10.77) from ten nationalities, with individual survey links sent via professional networks in 5 countries. Nine AMS behaviours and 14 behavioural determinants were quantitatively assessed using the Theoretical Domains Framework (TDF), and mapped to the COM-B (Capability, Opportunity, Motivation – Behaviour) model. Analysis identified differences between nurses with and without AMS training. The influence of COVID-19 on AMS behaviour was qualitatively investigated using free text data. Findings: Nurses performed all nine AMS behaviours, which were significantly higher (t(238) = -4.14, p < .001), by those who had training (M = 53.15; SD = 7.40) compared to those who had not (M = 48.30; SD = 10.75). Those with AMS training scored significantly higher in all of the TDF domains, with ‘Skills’ and ‘Behavioural Regulation’ (e.g. ability to self-monitor and plan), being the most predictive of AMS behaviour (R2 = .27). Both of these domains are situated in the Capability construct of COM-B, which can be enhanced with the intervention strategies of education and training. An increase in AMS behaviours was reported since COVID-19, regardless of previous training. Six core themes were linked to AMS: 1) Infection prevention and control, 2) Antimicrobials and antimicrobial resistance, 3) The diagnosis of infection and the use of antibiotics, 4) Antimicrobial prescribing practice, 5) Person-centred care, and 6) Interprofessional collaborative practice. Conclusion: This research, has identified the significant benefit of nurse training on AMS behaviour, and its determinants. AMS education and training should be offered to nurses to enhance Knowledge, Skills, Social/Professional role and identity, Beliefs about capabilities, Optimism, Beliefs about consequences, Reinforcement, Intentions, Goals, Memory, attention and decision making, Environmental context and resources, Social influences, Emotion, and Behavioural regulation. Future research should consider the optimal level of training to optimise AMS behaviour, with a focus on developing skills and behavioural regulation