
==== Front
Infect Prev Pract
Infect Prev Pract
Infection Prevention in Practice
2590-0889
Elsevier

S2590-0889(24)00045-3
10.1016/j.infpip.2024.100381
100381
Review
Diagnostic stewardship: establishing the role of the hospital nurse to inform local engagement strategies
Bowler Sue SusanBowler2@nuh.nhs.uk
a⁎
Brown Jo b
a Antimicrobial Stewardship Team, Nottingham University Hospitals NHS Trust, Nottingham, UK
b School of Social Sciences, Nottingham Trent University, Nottingham, UK
⁎ Corresponding author. Address: Nottingham University Hospitals NHS Trust, City Campus, Infection Prevention and Control, James Unit, Hucknall Road, Nottingham NG5 1PB, UK. SusanBowler2@nuh.nhs.uk
24 7 2024
9 2024
24 7 2024
6 3 10038130 1 2024
4 6 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Summary

Background

Diagnostic stewardship is ‘coordinated guidance and interventions to improve appropriate use of microbiological diagnostics to guide therapeutic decisions’ and a fundamental part of antimicrobial stewardship and the nursing role. The role of the nurse in diagnostic stewardship is relatively unknown and an underused resource. Lack of involvement and training in diagnostic stewardship can lead to inaction or incorrect actions, either of which may be detrimental to patient management, outcomes and care.

Aim

To determine the role of the hospital adult nurse in diagnostic stewardship to inform local engagement strategies.

Methods

The methodology was informed by Whiffin's (2020) systematic search approach. Electronic databases were searched from 2016 to 2022. The studies included were primary research papers involving adult nurses working in a hospital setting, with findings relevant to a diagnostic stewardship role. Thematic analysis was chosen to understand and compare the results, findings and recommendations of the studies.

Findings

Seven studies were included in the review. The identified themes were: (i) nursing role – to recognize infection, aid diagnosis and review results; (ii) nurse challenges – lack of knowledge and confidence to implement diagnostic stewardship; and (iii) Nurse education, empowerment and use of clinical tools.

Conclusion

Research studies do not consistently recognize the full scope of the diagnostic stewardship nursing role, signifying that nurses remain an underused resource in promoting diagnostic stewardship. Research-based clarification of the role of the nurse in diagnostic stewardship, outlined in this review, is therefore vital. Further UK-based, nurse-led research is needed to capture the impact of nurse-driven diagnostic stewardship interventions.

Keywords

Antimicrobial stewardship
Diagnostic stewardship
Nursing role
Nursing challenges
Nurse education
Nurse empowerment
==== Body
pmcIntroduction

More than one-third of emergency admissions are associated with a bacterial infection, and one in three patients are being treated with antibiotics at any given time in the UK [1]. Antimicrobial stewardship (AMS) programmes play an important role in ensuring that antibiotics are only used when appropriate. Stewardship programmes, however, are vital to guide diagnostics as well as therapeutics [2].

Diagnostic stewardship promotes appropriate/timely testing, pathogen identification, and accurate, timely reporting of results to guide patient care [3]. It discourages tests that are unnecessary or which can yield misleading results, and advocates for high-quality specimen collection [3]. Diagnostic stewardship is a fundamental part of AMS efforts and the nursing role. AMS supports the timely treatment of sepsis, severe infection and appropriate targeted antibiotic use to reduce adverse effects and antimicrobial resistance (AMR), and to improve patient outcomes [4].

Initial UK AMS policy was predominately prescriber focused; however, European Union guidelines on the prudent use of antimicrobials and a key white paper ‘Redefining the AMS Team’ recognized and detailed the components of the diagnostic stewardship role of the hospital nurse [5,6]. International AMR competencies for healthcare workers and AMS nursing competencies have also been developed, highlighting diagnostic stewardship nursing responsibilities [[7], [8], [9]]. Furthermore, the UK Nursing and Midwifery Council's ‘Future Nurse’ specifies that registered nurses require knowledge and skills in AMS and AMR to care for patients in all care settings [10]. More recently, the updated ‘Start Smart then Focus’ (SSTF) toolkit includes nursing responsibilities to support the diagnosis of infection [11].

Nurse involvement in AMS has been widely advocated in the literature, yet the role of the nurse is relatively undefined, understated and misunderstood [[12], [13], [14]]. Indeed, a recent scoping review emphasized ‘although research into the clinical nursing role is growing, continued definition of this role is needed’ [13].

It is therefore unsurprising that a recent study looking at the effect of hospital nurse-driven diagnostic stewardship highlighted that the role of the nurse in diagnostic stewardship is also relatively unknown and an underused resource [15]. This seems compounded by lack of education for nurses in undertaking relevant activities, such as specimen collection, transportation, interpretation of certain laboratory results, and effective communication with the interprofessional team [3]. Worryingly, this lack of involvement and education can lead to inaction or incorrect actions, either of which may be detrimental to patient management, outcomes and care [3,16].

Relatively few studies have determined the role of the hospital nurse in AMS, with publications predominantly either from outside of the UK or not authored by nurses [12,14], and this also appears to translate to diagnostic stewardship [15]. This literature review will investigate this knowledge gap to provide clarification of the diagnostic stewardship nursing role, and an understanding of the educational challenges that nurses face to inform local engagement strategies. Notably, whilst the focus here is the role of the hospital adult nurse in diagnostic stewardship, it is acknowledged that infection management requires interprofessional collaborative practice and expertise [17].

Methods

Search strategy and selection criteria

The methodology structuring the literature search is informed by Whiffin's systematic search approach [18]. It was selected due to two key strengths: the credibility of the findings; and conclusions made through the rigorous and transparent methodology and the practical value it offers in providing clear recommendations for practice and future research. With the research question framed within the Population Intervention Comparator Outcome model [19], the aim was to examine the role of the hospital nurse in diagnostic stewardship. The search terms used were Nurs∗ and (‘Diagnostic stewardship’ or ‘Antimicrobial stewardship’ or ‘Antibiotic stewardship’ or Antimicrobial∗ or ‘Antimicrobial resistance’ or Antibiotic∗ or ‘Diagnosis of infection’) and (Role∗ or Competencies). In May 2022, the first author searched CINAHL, Medline and PsychINFO for papers published since 2016 in English (abstract available and peer reviewed). Papers published prior to 2016 were excluded to reflect the mandatory implementation of AMS programmes within organizations delivering care, and to give consideration to the fact that key publications for AMS prior to this date were slow to recognize the role of the nurse [5,35]. Papers were screened for suitability and inclusion [18,20].

The PRISMA flowchart details the process followed by the first author to identify studies for inclusion (Figure 1). In total, 307 records were found through the database search, and duplicates (N=98) were removed. Abstracts were evaluated for applicability to the research question, and 163 records were excluded [not specific to stewardship, did not refer to adult nurses, or alternative study theme (primary care, prevention or treatment, nurse practitioners or prescribers)]. Papers involving nurse practitioners were excluded due to the advanced practice and often highly specialized roles. Complementary searching through AMS networks on social media (X, formerly known as Twitter) highlighted five additional records, not available in the databases listed above, for full-text screening. Fifty-one full-text articles were read and evaluated alongside the pre-specified inclusion and exclusion criteria. The exclusion criteria are detailed in Figure 1, including the number of papers meeting each criteria. The inclusion criteria were: primary research papers involving nurses working in a hospital setting, with findings relevant to a diagnostic stewardship role and recommendations for engagement strategies. This resulted in the inclusion of seven studies: six quantitative and one qualitative. All studies were observational in design.Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart of the process to identify studies for inclusion, adapted from [20].

Figure 1

Data extraction, analysis and quality assessment

The first author managed data extraction. The demographics, design, aim and sampling frame of the included studies were added to Table I. Thematic analysis was conducted according to existing frameworks [21,22]. Three areas relating to the research question were highlighted: diagnostic stewardship nursing role; educational challenges; and engagement strategies. Initial codes were generated under these three areas of focus (Table I). Simultaneously, the number of times that a similar or new code was found in the papers was also captured. Initial codes were then grouped together and evaluated, forming eight initial themes, four modified themes, revealing three final themes: (i) nursing role – to recognize infection, aid diagnosis and review results; (ii) nurse challenges – lack of knowledge and confidence to implement diagnostic stewardship; and (iii) Nurse education, empowerment and use of clinical tools.Table I Data extraction

Table IAuthor, year and country	Design	Aim, sample and setting	Findings relevant to DS nursing role, challenges and engagement strategies	Initial codes relevant to DS nursing role, challenges and engagement strategies	
Fabre et al. (2020)
USA [15]	Quantitative quasi-experimental	Aim: assess the influence of a nurse-driven urine culture DS intervention
Sample: 568 patients
Setting: 1194-bed academic hospital
Intervention: 37 nurses working in a
24-bed adult medicine unit	DS role: enhanced DS nursing role in sending appropriate cultures was associated with a decrease in the number of inappropriate cultures. Rate of inappropriate urine cultures decreased from 0.83 and 0.71
Challenges: no data collected
Engagement strategy: nurse education, nurse champion, nurse decision support tool, communication tool (SBAR), physician support	Nursing role: cultures
Strategy: education champion, guidelines/algorithm,
communication,
physician support	
Wilcock et al. (2019)
UK [23]	Quantitative cross-sectional	Aim: establish the views of nurses and midwives about a potential role in AMS and develop future engagement strategies
Sample: 76 nurses (and four midwives)
Setting: 750-bed NHS trust	DS role: supporting care bundles (87%), taking appropriate samples/cultures (74%), use of MicroGuide (62%), role model/raise awareness (60%)
Challenges: lack of knowledge (68%), lack of education/training (66%), confidence in challenging doctors/ prescriptions (52%)
Engagement strategy: pharmacy-led education and support	Nursing role: care bundles, cultures, guidelines, awareness
Challenges: knowledge, confidence
Strategy: education support (pharmacy)	
Carter et al. (2018)
USA [24]	Qualitative descriptive	Aim: study the attitudes of nurses towards five nurse-driven antibiotic stewardship practices
Sample: 61 nurses (49 clinical nurses, five nurse managers and seven IPC nurses)
Setting: two academic paediatric and adult hospitals	DS role: patient advocate
Two roles relating to DS were perceived most favourably: questioning the need for urine cultures,
ensuring correct culturing technique
Challenges: knowledge/awareness, confidence
Engagement strategy: training, guideline,
audits, education (IPC), the why behind nursing practices	Nursing role: cultures, patient advocate
Challenges: knowledge, confidence
Strategy: education/training,
guideline, audits,
the ‘why’	
Monsees et al. (2020)
USA [25]	Quantitative cross-sectional	Aim: establish nurses’ understanding and confidence in AMS
Sample: 558 nurses (including three licensed practical nurses)
Setting: nine hospitals (42–562 beds) serving paediatric and adult populations	DS role: obtaining cultures, reviewing preliminary microbiology culture results and comparing susceptibilities
Challenges: lack of confidence
Engagement strategy: formal education, empowerment, team-based stewardship interventions, interdisciplinary learning and rounds	Nursing role: cultures, results
Challenges: confidence
Strategy: education, empowerment, interdisciplinary learning and rounds	
Sakaguchi et al. (2022)
Japan [26]	Quantitative cross-sectional	Aim: establish the perceptions of nurses in Japan regarding recognition and implementation rates of nursing AMS role
Sample: 400 (IPC) nurses
Setting: 400 hospitals (78–1208 beds)	DS role: highlights 21/80 roles related to DS, recognition and implementation rate was highest for collecting and transporting specimens, with a lower implementation rate for both assessing and suggesting the need for a specimen (blood and urine culture) to the physician.
Challenges: implementation of role, lack of confidence, lack of education
Engagement strategy: education	Nursing role: infection, cultures,
education
Challenges: confidence, education
Strategy: education	
Keizer et al. (2019)
Germany/Netherlands [27]	Quantitative cross-sectional	Aim: evaluate healthcare workers from Germany and the Netherlands on how they understand and practice AMR and APM
Sample: healthcare workers (N=574) including nurses (N=397)
Setting: six hospitals (1500–400 beds)	DS role: 2/4 APMs relate to DS role – screening diagnostics (cultures) and infection diagnosis (mean ≥4.5/5 importance for nurses)
Challenges: feeling sufficiently equipped, education, social support
Engagement strategy: empowering nurses by providing them with tools, knowledge and skills; problem-based learning, audit and feedback	Nursing role: cultures, infection diagnosis
Challenges: feeling equipped, education, social support
Strategy: empowerment (tools, knowledge and skills; problem-based learning; audit and feedback)	
Catanzaro (2022)
USA [28]	Quantitative post-intervention	Aim: evaluate if nurses felt more ready to participate (in AMS) after completing AMS e-learning modules
Sample: 425 front-line staff nurses
Sample: several hospitals	DS role: appropriate collection and transport of specimens, interpretation of microbiology results, and antibiogram
Challenges: lack of education (45%)
Engagement strategy: education (e-learning)	Nursing role: cultures, results
Challenges: education, culture
Strategy: education (e-learning)	
DS, diagnostic stewardship; AMS, antimicrobial stewardship; SBAR, situation, background, assessment, recommendation; IPC, infection prevention and control; APM, AMR prevention measures; NHS, National Health Service.

Three appraisal tools (for cross-sectional, qualitative and mixed methods studies) were used to evaluate the methodological quality of the seven studies; however, papers were not excluded based on this critique of quality [[29], [30], [31]].

Results

Seven papers involving adult nurses working in a hospital setting with findings relevant to diagnostic stewardship were identified and included in the review (Table I). These studies were published between 2017 and 2022. The countries of origin of the papers were all high-income settings, with the majority undertaken in the USA (N=4), Japan (N=1), Germany and the Netherlands (N=1), and the UK (N=1). Of the seven papers, six were quantitative in design, with four cross-sectional studies, one quasi-experimental study and one post-intervention study. One paper was qualitative in design and a descriptive study. A nurse was identified as the lead author in more than half (N=4) of the seven papers. All studies were undertaken in a hospital environment. One study focused on the role of the nurse in diagnostic stewardship; however, most of the studies looked at the wider AMS nursing role (including antibiotic stewardship and AMR prevention). The nursing role in diagnostic stewardship was identified from these papers, and therefore any identified roles within these studies relating to infection recognition, diagnosis and review were determined as diagnostic stewardship nursing roles.

Methodological assessment

The quality assessment tools revealed high levels of methodological quality for four studies [[24], [25], [26], [27]], some concerns regarding both the internal and external validity for one study [15], and a lack of consistent methodological quality in two studies [23,28]. Convenience sampling methods were used in six studies, potentially creating non-representative samples [29]. The number of hospital beds in the institutional settings described ranged from 42 to 1500 beds. The sample sizes of the quantitative studies ranged from 76 to 568 nurses or patients. For some studies, this may have affected the significance of the findings, leading to potentially incorrect conclusions being drawn [29]. The majority of the studies used a survey (N=5) as their study method. Survey questions were incompletely validated in (N=4) papers, possibly affecting some of the data and conclusions drawn.

Themes

Thematic analysis of the papers uncovered three main themes: nursing role – to recognize infection, aid diagnosis and review results; nurse challenges – lack of knowledge and confidence to implement diagnostic stewardship; Nurse education, empowerment and use of clinical tools.

Nursing role – to recognize infection, aid diagnosis and review results

Two studies discussed the diagnostic stewardship nursing role in recognizing signs and symptoms of infection. Sakaguchi et al. [26] revealed that more than one-quarter of the AMS roles identified related to diagnostic stewardship. Four of these roles require the nurse to observe, assess, inform and record signs of infection, with a high recognition rate from infection control nurses as a nursing role (mean 93%). In the same way, Keizer et al. [27] recognized the diagnosis of infection as an important role for nurses [mean 4.5/5 (90%)].

All studies acknowledged the diagnostic stewardship nursing role to aid diagnosis through collecting [23,26,27] and sending [15,23,26] appropriate microbiology specimens, including assessing and/or questioning the need for specimens (e.g. urine cultures) [24,26], ensuring proper specimen collection techniques [24], and obtaining specimens prior to commencing antibiotics [25]. This nursing role had a high recognition rate [23,25,26], and was viewed as important [27] and positively [24] by nurses. However, nurses reported that education on the appropriate collection and transport of microbiology specimens was slightly less useful than other included AMS content [28].

Three studies identified the diagnostic stewardship nursing role in reviewing microbiology results. Monsees et al. [25] and Sakaguchi et al. [26] demonstrated that nurses recognize [mean 4.03/5.0 (80.6%) and 93.2%, respectively] reviewing microbiology culture results and comparing susceptibilities as nursing practice that contributes to AMS. By way of contrast, other elements related to this role such as ‘inform the physician of the culture result’ [26] had a much lower recognition rate (54.3%). Correspondingly Catanzaro [28] illustrated the diagnostic stewardship role though module content choice; ‘interpretation of laboratory results and the antibiogram’ was regarded as the most useful content by nurses.

Nurse challenges – lack of knowledge and confidence to implement diagnostic stewardship

Six studies identified barriers to implementing and advocating the nursing role in clinical practice. Five studies discussed a lack of AMS nursing knowledge [23,24,26,27] and three studies discussed the lack of provision of AMS nurse education [23,24,28] as challenges to implementing the diagnostic stewardship nursing role.

Five studies highlighted lack of confidence as a challenge to implementing the diagnostic stewardship nursing role. In Wilcock et al. [23] and Carter et al. [24], nurses reported a lack of confidence and discomfort (’ … it might [be] a little bit anxiety-producing to question the order’) in challenging and questioning prescribing staff as both a common and major challenge to the diagnostic stewardship nursing role. Notably, Monsees et al. [25] identified ‘a positive association between [nurses’] beliefs about nursing practices that contribute to the antibiotic stewardship process and their perceived confidence to perform … ’ (P<0.001). However, at the same time, reviewing culture results and susceptibilities had the lowest confidence score [mean 3.13/5 (62.6%)] compared with the other identified AMS nursing practices.

Sakaguchi et al. [26] also revealed higher implementation rates for more traditional nursing roles [e.g. ‘collect urine culture specimen’ (91.3%)] than more unconventional diagnostic stewardship nursing roles [ e.g. ‘assess need to collect urine culture specimen’ (28.8%)]. In addition, in Keizer et al. [27], whilst the diagnostic stewardship role was viewed as important [mean 4.6/5 (92%)], feeling sufficiently equipped to undertake the role was lower [mean 3.3/5 (66%)].

Nurse education – empowerment and use of clinical tools

All seven studies recognized the provision of education as a key strategy to progress the nursing role in diagnostic stewardship. Three studies identified that nurse education could be undertaken by a nurse champion [15], senior nurse [23], infection prevention and control nurse [23,24], AMS doctor [15] or pharmacist [23]. Nurse education on both diagnostic stewardship and AMS aimed to: address the education gap [[24], [25], [26],28]; overcome challenges [23] due to lack of knowledge [24,25], confidence [25] and prescriber pushback [24]; and empower nurses [27]. Specifically, studies discussed providing education both informally [15,23] (during shift change, via safety briefing and e-mail) and formally [[23], [24], [25]] with dedicated skills days and protected time, delivered through continuing [23,24,26] and interprofessional learning [25], using innovative approaches such as problem-based learning [27] and e-learning modules [28].

Four studies identified empowering nurses together with interprofessional support and enhanced communication as key strategies to progress the nursing role in diagnostic stewardship. Fabre et al. [15] and Wilcock et al. [23] illustrated the need for nursing support from various interprofessional colleagues, line managers and clinicians (by 74% of nurses) [23].

Specifically, to empower nurses as ‘owners and leaders of practice’ and encourage input into stewardship discussions, Monsees et al. [25] proposed the use of empowerment techniques to improve communication. Similarly, Keizer et al. [27] explained that ‘nurses are less confident about their role in diagnostics [and] diagnosis’, so strategies should focus on empowering nurses to proactively undertake diagnostic stewardship activities, proposing that this requires ‘more coordinated and innovative approaches to … education and communication’.

Five studies advocated the use of clinical tools as strategies to progress the nursing role in diagnostic stewardship. These included: the use of communication tools [15], such as the situation, background, assessment, recommendation (SBAR) tool [32]; and hospital guidelines [23,24] which include diagnostic algorithms [15,[23], [24], [25]] that nurses can refer to when assessing the need for specimen cultures, and to guide diagnostic stewardship questions and discussion with clinicians, both in clinical practice and nurse education [24,25]. However, more than half of nurses (54%) responded that they never look at guidelines, and 38% of nurses only looked at them once per month [23]. Studies also advocate the use of audit [24,27] and feedback [15,27] to measure and report AMS performance and outcomes [27].

Discussion

Recognizing signs of infection was identified as an important nursing role in the included studies, and is reflected in international competencies for AMS nursing practice [9] and the recently updated SSTF toolkit [11]. In comparison, in the World Health Organization (WHO) framework for education and training on AMR, diagnostic stewardship was deemed to have average relevance for nurses [7]. However, identifying clinical signs and symptoms is essential in the diagnosis of infection [3], and vital before sending any microbiology specimens to the laboratory [33]. Notably, a change in national guidance on the use of urinalysis (dipstick) to diagnose urinary tract infections in patients aged >65 years has started to shift nursing focus to a diagnosis based on documented clinical signs and symptoms [34].

Obtaining appropriate microbiology specimens was identified as an important nursing role in the included studies, and is reflected in a key white paper ‘Redefining the AMS Team’ [6], competencies for AMS nursing practice [9] and the SSTF toolkit [11]. This role is vital, resulting in both patient and AMS benefits if the causative pathogen can be identified [1], enabling narrow-spectrum antibiotics to be prescribed or antibiotics to be stopped if infection is unlikely [11]. Obtaining an appropriate specimen is central here, taken only when there is clinical suspicion of infection, with understanding of why the specimen is being obtained and using the correct technique [33]. Otherwise, results may represent contamination or colonization rather than true infection requiring treatment with antibiotics [36].

Reviewing microbiology results and antibiotic susceptibilities was also recognized as an important nursing role in the included studies, and is detailed within the white paper [6], competencies for AMS nursing practice [9] and the SSTF toolkit [11]. Disappointingly, however, the WHO competency framework [7] leaves this role with the prescriber. In contrast, the white paper [6] extends this nursing role further to include interpretation of the hospital's antibiogram. Nursing understanding of the difference between colonization and active infection is essential to enable correct interpretation of results in the clinical context of the patient [6,17,33].

There is insufficient knowledge and expertise on AMS for all healthcare workers [7], including nurses, reflected in the included studies and other reports and research papers [6,12,14,[37], [38], [39]], specifically in relation to the microbiological knowledge of nurses [6,12,16]. A survey of nurse knowledge of microbiology and its relevance to clinical practice identified a knowledge shortfall [16], and an integrative review highlighted that basic knowledge of culture indications and technique was suboptimal [12].

It is proposed that this lack of knowledge is likely to impact nurse confidence [12,39], and is therefore a key barrier to AMS interprofessional collaborative practice [17]. In the included studies, this lack of confidence was identified as nurses feeling unable to implement elements of the diagnostic stewardship role, including reviewing microbiology results and susceptibilities [25,26], challenging and questioning prescribing colleagues, and contributing effectively to AMS interprofessional discussions [23,24,27]. Nurses therefore need to feel confident to speak up if they are to implement and advocate the nursing role [39].

All included studies recognized education as a key strategy to enhance knowledge, build confidence and empower nurses. This need for nurse education is reflected in both national and international guidance and policy [6,10,11].

A scoping review of AMS international guidelines concluded that there is lack of information about what nursing competency is required [13]. International competencies, however, provide both this detail and some consensus that this is a priority for nursing education [7,9]. Furthermore, a recent multi-country survey found that nurses who had undergone AMS training were significantly more likely to undertake AMS behaviours, including those related to diagnostic stewardship and interprofessional working, than those who had not received AMS training (P<0.001) [37].

It is recommended that such education should be tailored to nurses [6,11] to reflect their learning needs [12,16]. Training provided by the interprofessional AMS team [6] using a variety of teaching approaches and resources [12,40], problem-based learning [17,41] and assertiveness training [17,42] is likely to support application of learning into clinical practice. Mandating this training and repeating every 3 years [11] is recommended to assure competency [5].

In comparison, it is argued that education should be interprofessional, enabling clinical teams to learn from and about each other's roles [7,9,12,17]. In clinical practice, the inclusion of nurses in interprofessional AMS rounds is advocated [6,17,25], empowering nurses to implement their diagnostic stewardship role, understand, ask questions and increase their confidence in communicating with other members of the clinical team [3,7,17].

National and international guidance and research studies also highlight the importance of developing and implementing antimicrobial guidelines [3,5,7,24,40], which crucially contain diagnostic stewardship algorithms, vital for nurses. However, recognition in international diagnostic stewardship competencies [7], and by nurses, that such guidance is relevant to nurses is lacking [15].

There is also a lack of measurement that determines the impact of nurses on antimicrobial and diagnostic stewardship efforts [6]. To address this, the UK AMR strategy [2] proposed the use of electronic prescribing data to make evident the impact of diagnostics on prescribing and clinical outcomes.

Limitations

There are limitations to this review, particularly transferability of results and findings. It is recognized that the role of the nurse varies from country to country, and that studies from several countries have been included here. Most included studies were from high-income countries, and therefore caution must be applied when considering transfer of these results to low- or middle-income settings. Methodological biases have also been highlighted, possibly affecting the reliability of some results. Lastly, there is a lack of published literature on this topic, and therefore only a small number of studies were eligible for inclusion in this review.

In conclusion, international guidance and policies have started to recognize the role of the nurse in diagnostic stewardship. In the UK, this has been strengthened by the development of national nursing competencies which include all components of the diagnostic stewardship role. Despite this, research studies do not consistently recognize the full scope of this nursing role. Specifically, it is acknowledged that reviewing microbiology results and susceptibilities is not currently embedded in clinical nursing practice. Vitally, the role of the nurse must consist of three sequential steps: (i) recognize signs and symptoms of infection; (ii) aid diagnosis by obtaining appropriate microbiology specimens; and (iii) review microbiology results and susceptibilities to guide antibiotic therapy. This can ensure that infection management is right first time, every time for patients [43].

The findings of this review reveal challenges in implementing the nursing role in diagnostic stewardship. From both the research studies and wider evidence base, there are gaps in nursing knowledge about AMS and microbiology that need to be addressed urgently. Indeed, it is proposed that this lack of knowledge is likely to be impacting nurse confidence to fully implement the diagnostic stewardship role.

The local engagement strategies proposed start to address the knowledge/confidence gap identified to implement the diagnostic stewardship nursing role. There is agreement that education is a key strategy to enhance nurse knowledge and build confidence to undertake AMS behaviours, including those relating to diagnostic stewardship and interprofessional working.

The need for an empowered workforce is recognized both in global AMR recommendations [44] and AMS research studies. Here, the tailored nurse education described is blended with interprofessional education and collaborative practice. One practical approach may be to involve nurses in AMS ward rounds to help nurses learn, ask questions and to increase their confidence in communicating with other members of the clinical team.

National and international guidance and research studies have highlighted the importance of implementing antimicrobial guidelines, which crucially contain diagnostic stewardship algorithms, vitally relevant for nurses. However, recognition that this guidance is relevant to nurses is low amongst nurses themselves. Therefore, to ensure the adoption of antimicrobial guidelines by nurses, their utility must be demonstrated in both educational and clinical settings. Notably, there is a lack of measurement that determines nursing impact on antimicrobial and diagnostic stewardship interventions. Specifically, use of electronic prescribing systems could be leveraged to make evident the impact of diagnostic stewardship interventions on prescribing practices, and to begin to capture the influence of the nursing role.

Future research must also consider organizational barriers, multi-factorial and complex, yet of equal importance to identify and address.

Conflict of interest statement

None declared.

Funding sources

None.

CRediT author statement

Sue Bowler: Conceptualization, Methodology, Formal analysis, Writing - Original Draft.

Jo Brown: Conceptualization, Methodology, Writing - Review & Editing.

Acknowledgements

The authors wish to thank Liz Eate for guidance, and Annie Joseph for inspiration, encouragement and time given.
==== Refs
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