Promoting nurse participation in hospital antimicrobial stewardship: A realist review
Abstract
Background Antimicrobial stewardship is a collaborative intervention strategy aimed at promoting the selection of optimal antimicrobial regimens to improve and measure the appropriate use of antimicrobials, thereby fostering rational use of these agents, enhancing patient outcomes effectively, and curbing the wide dissemination of antimicrobial resistance. Recently, nurses' pivotal contribution in multidisciplinary antimicrobial stewardship teams is increasingly recognized. However, the contexts and mechanisms able to facilitate nurses' participation in the complex dynamics of antimicrobial stewardship remain unclear. Objective This review aims to identify and analyze the mechanisms, contextual factors, and outcomes that promote nurses' participation in antimicrobial stewardship interventions. Methods This study adheres to the methods of realist review based on the Normalization Process Theory. Preliminary programme theories were generated through an extensive literature review and thematic analysis. A systematic search was conducted in PubMed, EMBASE, CINAHL, Web of Science, CNKI, and Wangfang databases. The final Context-Mechanism-Outcome configurations were determined to validate the final programme theory. Results A total of 5635 articles were retrieved; ultimately, 35 studies were included for a comprehensive analysis. The review identified five key configurations clarifying the interactions among contextual factors, mechanisms, and outcomes: (1) Contextual factors: multidisciplinary team collaboration and hospital organizational support. (2) Strategies and mechanisms: articulating nurses' contributions and impact (Coherence-Building), promoting awareness and positive perceptions (Cognitive Participation), enhancing nurses' competencies (Collective Action), fostering collaborative and motivating frameworks, and emphasizing continuous quality improvement (Reflexive Monitoring). (3) Outcomes: improvements in patient outcomes (e.g., faster antibiotic initiation, shorter hospital stays, and lower mortality) and staff outcomes (e.g., enhanced knowledge, confidence, and adherence to antimicrobial stewardship practices). Conclusion This realist review has developed a theoretical framework to promote nurses' participation in antimicrobial stewardship practices. This framework emphasizes the complex dynamic mechanisms that facilitate or hinder nurses' involvement in antimicrobial stewardship and aims to implement evidence-based strategies to encourage nurses' participation in antimicrobial stewardship practices. This, in turn, is expected to enhance the effectiveness of hospital antimicrobial stewardship initiatives and improve the quality of patient care within the hospital environment. Significance This realist review highlights that, at both individual and organizational levels, supporting nurses' professional roles and responsibilities through targeted education, expanded prescribing authority, collaborative frameworks, and continuous quality improvement empowers nurses to integrate antimicrobial stewardship into their daily practice. By delineating the relevant mechanisms, contextual factors, and outcomes, the findings inform the design of complex interventions to sustain nurses' engagement in hospital antimicrobial stewardship programs, and advance the evolution of advanced nursing practice.
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Cites
Using thematic analysis in psychology
Braun, V., & Clarke, V. (2006) · Qualitative Research in Psychology · doi:10.1191/1478088706qp063oa · Cited by 194,414 · see citing works
Reflecting on reflexive thematic analysis
Braun, V., & Clarke, V. (2019) · Qualitative Research in Sport, Exercise and Health · doi:10.1080/2159676x.2019.1628806 · Cited by 19,677 · see citing works
Realist review - a new method of systematic review designed for complex policy interventions
Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2005) · Journal of Health Services Research & Policy · doi:10.1258/1355819054308530 · Cited by 3,190 · see citing works
Development of a theory of implementation and integration: Normalization Process Theory
May, C. R., Mair, F., Finch, T., MacFarlane, A., Dowrick, C., Treweek, S., Rapley, T., Ballini, L., Ong, B. N., Rogers, A., et al. (2009) · Implementation Science · doi:10.1186/1748-5908-4-29 · Cited by 1,409 · see citing works
What is antimicrobial stewardship?
Dyar, O. J., Huttner, B., Schouten, J., & Pulcini, C. (2017) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2017.08.026 · Cited by 870 · see citing works
Schuts, E. C., Hulscher, M., Mouton, J. W., Verduin, C. M., Stuart, J. W. T. C., Overdiek, H. W. P. M., van der Linden, P. D., Natsch, S., Hertogh, C. M. P. M., Wolfs, T. F. W., et al. (2016) · The Lancet Infectious Diseases · doi:10.1016/s1473-3099(16)00065-7 · Cited by 772 · see citing works
Realist synthesis: illustrating the method for implementation research
Rycroft-Malone, J., McCormack, B., Hutchinson, A. M., DeCorby, K., Bucknall, T. K., Kent, B., Schultz, A., Snelgrove-Clarke, E., Stetler, C. B., Titler, M., et al. (2012) · Implementation Science · doi:10.1186/1748-5908-7-33 · Cited by 742 · see citing works
Realist synthesis - an introduction
Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2004) · UCL Discovery (University College London) · Cited by 570 · see citing works
Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review
Nathwani, D., Varghese, D., Stephens, J., Ansari, W., Martin, S., & Charbonneau, C. (2019) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0471-0 · Cited by 457 · see citing works
RAMESES publication standards: realist syntheses
Wong, G., Greenhalgh, T., Westhorp, G., Buckingham, J., & Pawson, R. (2013) · Journal of Advanced Nursing · doi:10.1111/jan.12095 · Cited by 385 · see citing works
Jagosh, J. (2019) · Annual Review of Public Health · doi:10.1146/annurev-publhealth-031816-044451 · Cited by 346 · see citing works
Association Between Antimicrobial Stewardship Programs and Antibiotic Use Globally
Ya, K. Z., Win, P. T. N., Bielicki, J. A., Lambiris, M. J., & Fink, G. (2023) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.53806 · Cited by 211 · see citing works
Dada, S., Dalkin, S. M., Gilmore, B., Hunter, R. L., & Mukumbang, F. C. (2023) · Research Synthesis Methods · doi:10.1002/jrsm.1630 · Cited by 211 · see citing works
Olans, R. N., Olans, R. D., & DeMaria, A. (2015) · Clinical Infectious Diseases · doi:10.1093/cid/civ697 · Cited by 190 · see citing works
Competency in nursing practice: a concept analysis
Mrayyan, M. T., Abunab, H. Y., Abu Khait, A., Rababa, M. J., Al-Rawashdeh, S., Algunmeeyn, A., & Abu Saraya, A. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-067352 · Cited by 114 · see citing works
Maillard, J., Bloomfield, S. F., Courvalin, P. M., Essack, S. Y., Gandra, S., Gerba, C. P., Rubino, J. R., & Scott, E. A. (2020) · American Journal of Infection Control · doi:10.1016/j.ajic.2020.04.011 · Cited by 106 · see citing works
Nurse role and contribution to antimicrobial stewardship: An integrative review
Gotterson, F., Buising, K. L., & Manias, E. (2020) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2020.103787 · Cited by 84 · see citing works
Tromp, M., Hulscher, M., Bleeker‐Rovers, C. P., Peters, L., van den Berg, D. T. N. A., Borm, G. F., Kullberg, B. J., van Achterberg, T., & Pickkers, P. (2010) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2010.04.007 · Cited by 77 · see citing works
Integrating staff nurses in antibiotic stewardship: Opportunities and barriers
Monsees, E., Popejoy, L., Jackson, M. A., Lee, B. R., & Goldman, J. L. (2018) · American Journal of Infection Control · doi:10.1016/j.ajic.2018.03.028 · Cited by 74 · see citing works
Integrating bedside nurses into antibiotic stewardship: A practical approach
Monsees, E., Tamma, P. D., Cosgrove, S. E., Miller, M. A., & Fabre, V. (2019) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2018.362 · Cited by 73 · see citing works
Haunch, K. J., Thompson, C. A., Arthur, A. J., Edwards, P. W., Goodman, C. M., Hanratty, B., Meyer, J. E., Charlwood, A., Valizade, D., Backhaus, R., et al. (2021) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2021.103905 · Cited by 57 · see citing works
The nurses’ role in antimicrobial stewardship: A scoping review
van Huizen, P., Kühn, L., Russo, P. L., & Connell, C. J. (2020) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2020.103772 · Cited by 53 · see citing works
(2019) · JAC-Antimicrobial Resistance · doi:10.1093/jacamr/dlz037 · Cited by 50 · see citing works
Dalkin, S. M., Hardwick, R., Haighton, C., & Finch, T. L. (2021) · Implementation Science Communications · doi:10.1186/s43058-021-00172-3 · Cited by 49 · see citing works
Antimicrobial stewardship: Staff nurse knowledge and attitudes
Merrill, K. C., Hanson, S. F., Sumner, S., Vento, T. J., Veillette, J. J., & Webb, B. J. (2019) · American Journal of Infection Control · doi:10.1016/j.ajic.2019.03.022 · Cited by 47 · see citing works
Chater, A., Family, H. E., Abraão, L. M., Burnett, E., Castro‐Sánchez, E., Toit, B. D., Gallagher, R., Gotterson, F., Manias, E., McEwen, J., et al. (2022) · Journal of Hospital Infection · doi:10.1016/j.jhin.2022.07.010 · Cited by 46 · see citing works
Courtenay, M., Castro‐Sánchez, E., Gallagher, R., McEwen, J., Bulabula, A. N. H., Carré, Y., Toit, B. D., de Figueiredo, R. M., Gjerde, M. E., Hamilton, N., et al. (2019) · Journal of Hospital Infection · doi:10.1016/j.jhin.2019.08.001 · Cited by 42 · see citing works
Castro‐Sánchez, E., Gilchrist, M. J., Ahmad, R., Courtenay, M., Bosanquet, J., & Holmes, A. H. (2019) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0621-4 · Cited by 40 · see citing works
Bonaconsa, C., Mbamalu, O. N., Mendelson, M., Boutall, A., Warden, C., Rayamajhi, S., Pennel, T. C., Hampton, M. I., Joubert, I., Tarrant, C., et al. (2021) · BMJ Quality & Safety · doi:10.1136/bmjqs-2020-012372 · Cited by 39 · see citing works
Mattison, G., Bilney, M., Haji-Michael, P. G., & Cooksley, T. (2016) · Supportive Care in Cancer · doi:10.1007/s00520-016-3362-4 · Cited by 38 · see citing works
Antibiotic stewardship: The role of clinical nurses and nurse educators
Sumner, S., Forsyth, S., Merrill, K. C., Taylor, C., Vento, T. J., Veillette, J. J., & Webb, B. J. (2017) · Nurse Education Today · doi:10.1016/j.nedt.2017.10.011 · Cited by 36 · see citing works
What Is an Antibiotic? Revisited
Bentley, R., & Bennett, J. W. (2003) · Advances in applied microbiology · doi:10.1016/s0065-2164(03)01012-8 · Cited by 34 · see citing works
Padigos, J., Reid, S. A., Kirby, E. R., & Broom, J. K. (2020) · Journal of Hospital Infection · doi:10.1016/j.jhin.2020.12.003 · Cited by 33 · see citing works
Bos, M., Schouten, J. A., de Bot, C., Vermeulen, H., & Hulscher, M. (2023) · JAC-Antimicrobial Resistance · doi:10.1093/jacamr/dlad123 · Cited by 32 · see citing works
Kim, J., Craft, D. W., & Katzman, M. (2015) · Laboratory Medicine · doi:10.1309/lmc0shrjby0onhi9 · Cited by 26 · see citing works
Ness, V., Price, L., Currie, K., & Reilly, J. (2016) · Journal of Clinical Nursing · doi:10.1111/jocn.13249 · Cited by 25 · see citing works
A novel framework to guide antibiotic stewardship nursing practice
Manning, M. L., Pogorzelska‐Maziarz, M., Hou, C. M., Vyas, N. M., Kraemer, M., Carter, E. J., & Monsees, E. (2021) · American Journal of Infection Control · doi:10.1016/j.ajic.2021.08.029 · Cited by 24 · see citing works
van Gulik, N., Hutchinson, A. F., Considine, J., Driscoll, A. L., Malathum, K., & Botti, M. A. (2021) · Infection Disease & Health · doi:10.1016/j.idh.2021.04.003 · Cited by 22 · see citing works
Antimicrobial Stewardship: The Role of the Patient
Ewers, T., Knobloch, M. J., & Safdar, N. (2017) · Current treatment options in infectious diseases/Current treatment options in infectious disease · doi:10.1007/s40506-017-0106-z · Cited by 21 · see citing works
Hashem, F., Brigden, C., Wilson, P., & Butler, C. (2019) · Palliative Medicine · doi:10.1177/0269216319867424 · Cited by 21 · see citing works
Hansen, M. J. T., Storm, M., Syre, H., Dalen, I., & Husebø, A. M. L. (2023) · Journal of Clinical Nursing · doi:10.1111/jocn.16657 · Cited by 20 · see citing works
Bonacaro, A., Solfrizzo, F. G., Regano, D., Negrello, F., Domeniconi, C., Volpon, A., Taurchini, S., Toselli, P., & Baesti, C. (2024) · Healthcare · doi:10.3390/healthcare12212122 · Cited by 19 · see citing works
Empowerment of nurses in antibiotic stewardship: a social ecological qualitative analysis
Wong, L. H., Ibrahim, M. A. B., Guo, H., Kwa, A. L., Lum, L. H.-W., Ng, T. M., Chung, J. S., Somani, J., Lye, D. C., & Chow, A. L. (2020) · Journal of Hospital Infection · doi:10.1016/j.jhin.2020.09.002 · Cited by 19 · see citing works
Courtenay, M., Castro‐Sánchez, E., Gallagher, R., Gould, D. J., Hawker, C., Hennefer, D., Liptrott, C., Cooper, D., Smith, E. J., Craig, R., et al. (2021) · Journal of Hospital Infection · doi:10.1016/j.jhin.2021.09.027 · Cited by 18 · see citing works
Lukes, T., Schjodt, K., & Struwe, L. A. (2019) · Journal of Pediatric Nursing · doi:10.1016/j.pedn.2019.02.028 · Cited by 17 · see citing works
Zhou, Y., Wang, A., Ellis-Smith, C. I., Braybrook, D. E., & Harding, R. (2022) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2022.104277 · Cited by 16 · see citing works
Fitzpatrick, E. R., Pogorzelska‐Maziarz, M., Manning, M. L., & Gleason, V. M. (2020) · Dimensions of Critical Care Nursing · doi:10.1097/dcc.0000000000000450 · Cited by 16 · see citing works
Danielis, M., Regano, D., Castaldo, A., Mongardi, M., & Webber, T. B. (2022) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-022-01189-6 · Cited by 15 · see citing works
Rout, J., Essack, S. Y., & Brysiewicz, P. (2021) · Southern African Journal of Critical Care · doi:10.7196/sajcc.2021.v37i2.481 · Cited by 14 · see citing works
Nurses’ engagement in antimicrobial stewardship and its influencing factors: A cross-sectional study
Nie, H., Yue, L., Peng, H., Zhou, J., Li, B., & Cao, Z. (2023) · International Journal of Nursing Sciences · doi:10.1016/j.ijnss.2023.12.002 · Cited by 14 · see citing works
Zhao, W., Guo, W., Sun, P., Yang, Y., Ning, Y., Liu, R., Xu, Y., Li, S., & Shang, L. (2023) · Journal of Clinical Nursing · doi:10.1111/jocn.16731 · Cited by 13 · see citing works
Triage Standing Orders Decrease Time to Antibiotics in Neonates in Pediatric Emergency Department
Reynolds, M. S., Dunaway, A., Stevens, C., Shoemaker, D., BUCKINGHAM, D. A., & Spencer, S. P. (2020) · Journal of Emergency Nursing · doi:10.1016/j.jen.2020.06.008 · Cited by 11 · see citing works
Fabre, V., Pleiss, A., Klein, E. Y., Demko, Z. O., Salinas, A. B., Jones, G. F., Gadala, A., Hicks, L. A., Neuhauser, M. M., Srinivasan, A., et al. (2020) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2020.07.003 · Cited by 10 · see citing works
Mula, C. T., Middleton, L. E., Muula, A. S., Solomon, V. P., & Varga, C. A. (2021) · International Journal of Africa Nursing Sciences · doi:10.1016/j.ijans.2021.100311 · Cited by 8 · see citing works
Nurse Engagement in Antibiotic Stewardship Programs: A Scoping Review of the Literature
Johnson, C. T., Ridge, L. J., & Hessels, A. (2022) · Journal for Healthcare Quality · doi:10.1097/jhq.0000000000000372 · Cited by 8 · see citing works
Nurse practitioner and midwife antibiotic prescribing in Australia
Hawley, G., Grogan, A., McGuire, T., van Driel, M., & Hollingworth, S. (2023) · European Journal of Midwifery · doi:10.18332/ejm/162439 · Cited by 8 · see citing works
Hamilton, R. A., Williams, N., Ashton, C., Gilani, S., Hussain, S., Jamieson, C., Razaq, S., & Jenkins, A. (2024) · Journal of Hospital Infection · doi:10.1016/j.jhin.2024.05.007 · Cited by 6 · see citing works
Wright, R. J., Ferguson, C., Bodrick, M. M., Balkhy, H. H., Jackson, D. W., & Davidson, P. M. (2020) · Journal of Clinical Nursing · doi:10.1111/jocn.15185 · Cited by 5 · see citing works
Paz, V., Paniagua, M., Santillán, A., Alaniz, M., D’Agostino, L. E., Orellana, R. C., & Rodriguez, C. (2019) · Infection Prevention in Practice · doi:10.1016/j.infpip.2019.100030 · Cited by 5 · see citing works
Walker, S. T., Grigg, S. E., Kirkpatrick, C. M. J., Urbancic, K. F., Cohen, E., Grigg, A., & Trubiano, J. A. (2020) · Supportive Care in Cancer · doi:10.1007/s00520-019-05290-2 · Cited by 5 · see citing works
Monsees, E., Jackson, M. A., Popejoy, L., Lee, B. R., & Goldman, J. L. (2017) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofx163.1294 · Cited by 4 · see citing works
Lozano, C. M. (2024) · JAC-Antimicrobial Resistance · doi:10.1093/jacamr/dlae133 · Cited by 3 · see citing works
Ha, D. R., Forte, M. B., Broberg, V., Olans, R. D., Olans, R. N., OYong, K., Kullar, R., Catipon, N., Ancheta, V., Desai, M., et al. (2019) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofz360.1765 · Cited by 2 · see citing works
Gupta, R., Sharma, S., Bablani, V., Manocha, S., & Srinivasan, M. (2024) · Nurse Education in Practice · doi:10.1016/j.nepr.2024.104223 · Cited by 2 · see citing works
Monsees, E., Monsees, E., Goldman, J. L., & Popejoy, L. (2019) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofz360.1718 · Cited by 2 · see citing works
Ha, D. R., Forte, M. B., Nguyen, K., Ancheta, V., Catipon, N., Chan, S., Lira, D., Legge, J., Olans, R. D., Gluckstein, D. P., et al. (2017) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofx163.1252 · Cited by 2 · see citing works
Gerostergios, H., & Soroken, L. (2024) · Nurse Leader · doi:10.1016/j.mnl.2024.05.009 · Cited by 1 · see citing works
2086. Antimicrobial Stewardship: Why Do Not Nurses Question the White Coat?
Sumner, S., Hanson, S. F., & Merrill, K. C. (2019) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofz360.1766 · Cited by 1 · see citing works
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- Authors
- Luo, Y., He, L., Li, W., Zhao, J., Deng, R., & Zong, Z.
- Affiliations
- Sichuan University (CN)
- Corresponding author
- Deng, Rong
- Venue
- International Journal of Nursing Studies
- Publisher
- Elsevier BV
- Published
- 2025-09
- Volume
- 169
- Pages
- 105142
- ISSN
- 0020-7489 (ISSN-L)
- OpenAlex
- W4411146250
- Cited by
- 1
- References
- 68
- Citations by year
- 2026: 1
- FWCI
- 0.09
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- Locations
- International Journal of Nursing Studies (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
- Health Sciences › Medicine › Infectious Diseases › Infection Control in Healthcare
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Keywords
- antimicrobial stewardship, multidisciplinary team collaboration, organizational support, Normalization Process Theory, nursing competencies, continuous quality improvement, antimicrobial resistance, patient outcomes, nursing education, hospital culture, patient safety, length of hospital stay, mortality reduction, antibiotic prescribing, nosocomial infections
- MeSH terms
- Antimicrobial Stewardship, Humans, Nursing Staff, Hospital, Nurse's Role
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