Building Nursing Capacity In Antimicrobial Stewardship: Learning From Low- And Middle-Income Countries
Antimicrobial resistance presents a global threat to human health and societies. A variety of measures including increased education for prescribers, prescribing audits and feedback, drug restrictions and input from specialist clinicians in advisory roles have been proposed to arrest the progress of resistance, under the umbrella term of ‘antibiotic stewardship’. The participation of nurses in such initiatives has been arguably limited and without much independence. Such modest contribution is surprising, in view of emerging nursing roles that include autonomous management and use of complex medication regimens, as well as decision-making within difficult clinical scenarios.
In other settings and healthcare systems, however, nurses have been encouraged to lead the implementation and delivery of primary and secondary care services. Often, such services will involve the management and use of complex medication regimens with potential for resistance akin to antibiotics.
The travel fellowship aimed to enable the learning from the experiences and expertise of the overseas partners setting up new and advanced roles for nurses managing complex antibiotic regimens, with a view to “reverse innovate” those experiences and apply them in the United Kingdom. The visit intended to make explicit the predisposing conditions and facilitating factors for the involvement of nurses in stewardship, as well as metrics of success. Factors such as the context of practice and environmental characteristics, including the influence of the health care system, education and training tools at local, regional, and national level, or feedback and auditing mechanisms would be discussed with key leaders. Finally, the direct observation and contact with nurses would enable an understanding of their motivations and benefits to assume new roles and skills related to antimicrobial decisions and stewardship.
In South Africa, nurses manage infections such as HIV and tuberculosis with comparable quality to doctors with the help of evidence-informed decision-making algorithms developed by the University of Cape Town. The success of such approach is not solely related to the quality of the guidelines, but to the surrounding implementation and evaluation mechanisms as well as the optimal support for the nurses involved in expanding their competencies.
In Rwanda, a novel model of public-private partnership in primary care between the government of Rwanda and One Family Health encourages and enables nurses to provide and lead services, aided by mobile health tools for logistic and evaluation purposes. Their involvement in appropriate use of antibiotics activities is supported by policies, guidelines and financial incentives that discourage substandard clinical decision-making. In addition, such model helps retain experienced clinicians and provides nurses with business skills beneficial to their wider communities. On the other hand, hospital nurses struggle to increase their contribution towards antibiotic stewardship due to staff shortages and limited training opportunities.
In both countries clear identification of factors encouraging nurses to adopt expanded roles, sustained implementation efforts and robust evaluation mechanisms have been instrumental to introduce novel roles that resolve the challenges of local socioeconomic contexts.
The travel fellowship has permitted a close examination of successful initiatives and a deeper understanding of such local contexts. It has also allowed the fostering of professional relations and collaborations that will facilitate the expansion of antimicrobial stewardship roles for nurses in the United Kingdom.