Show summary
Introduction: Antibiotic resistance is a rapidly escalating global challenge, posing significant threats to health and development. The misuse and overuse of antibiotics are primary contributors to the rise of multidrug-resistant bacteria (MDRB). Meanwhile, infection prevention and control (IPC) is the most prominent tool available to protect against them. In Norwegian hospitals, healthcare-associated infections have a prevalence of 2.7%, often linked to MDRB. Due to their work close to patients, nurses play a crucial role in IPC and antibiotic stewardship in healthcare settings. Nurses need appropriate knowledge and skills when caring for patients with multidrug-resistant bacteria.
Previous studies on nurses' knowledge, attitudes, and practices regarding IPC and antibiotic stewardship and caring for patients with MDRB vary in methodology, validity, and results. Still, studies indicate that nurses often lack sufficient knowledge, fail to adhere to IPC guidelines, and feel insecure when caring for patients with MDRB. Furthermore, despite nurses’ role in antibiotic stewardship being widely discussed, research show that their engagement remains suboptimal.
Given the critical role of nurses in IPC and antibiotic stewardship, understanding their attitudes and self-efficacy is essential, especially during healthcare crises like the COVID-19 pandemic. There is a notable gap in research on how such crises impact nurses’ attitudes and self-efficacy when caring for patients with MDRB. Additionally, there is a scarcity of mixed-method research addressing complex questions in IPC and antibiotic stewardship among nurses. Therefore, longitudinal and mixed-method studies are needed to explore nurses' attitudes and self-efficacy towards caring for patients with MDRB in the context of a pandemic.
Aim: The overall aim of this thesis was to develop a comprehensive understanding of hospital nurses’ attitudes and self-efficacy towards caring for patients with MDRB before and during the COVID-19 pandemic.
To achieve the overall aim of this thesis, three papers were written with the following aims:
• Paper I: To gain a more comprehensive understanding of nurses’ IPC and antibiotic stewardship attitudes and self-efficacy when caring for patients With MDRB in a hospital setting
• Paper II: To explore trends in nurses’ attitudes and self-efficacy when caring for patients with MDRB
• Paper III: To explore hospital nurses’ experiences of change in attitudes and self-efficacy when caring for patients with MDRB before and during the COVID-19 pandemic.
Methods: This thesis employed a longitudinal, convergent mixed methods design. Quantitative data were collected using repeated cross-sectional surveys, comprising two questionnaires in addition to a demographic survey. The questionnaires were the Norwegian Version of the Multidrug-Resistant Bacteria Attitude Questionnaire and the Norwegian version of the General Perceived Self-Efficacy Scale. Data was collected at five time points. February and March 2020 (T1, n=131), May 2020 (T2, n=72), October 2020 (T3, n=109), February and March 2021 (T4, n=108) and February and March 2023 (T5, n=92, see Figure 6).
For qualitative data collection, four focus group interviews were conducted at three intervals: T1 (n=22), T4 (n=23) and T5 (n=24). The serial focus group interviews were guided by an interview guide informed IPC-guidelines, the tripartite model of attitudes and the self-efficacy theory.
Standard procedures for analysing quantitative and qualitative data were followed, before utilizing a mixed methods analysis where the data was merged by comparing the results to confirm, contradict or expand on one another.
Results: Through the process of merging data five themes arose. Steady, but insufficient knowledge levels through the pandemic, Consistent but lacking behavioural intentions persistently hindered by obstacles unchanged by time, Inconsistencies in nurses’ moderate emotional response through time, Strong beliefs in own abilities throughout the pandemic and Positive changes in antibiotic stewardship through time.
The nurses that participated in this study showed steady but insufficient knowledge levels and behavioural intentions throughout the study period. Through the qualitative data an expanded understanding of nurses’ behavioural intentions were gained. Lack of personnel resources, constraining physical work environment and extensive guidelines were described as reasons for the deficiency. The nurses’ emotional responses towards caring for patients with MDRD were found to be stable in the quantitative data, but according to the nurses participating in the interviews it varied throughout the study period. They described that their emotional stability was challenged by the changes implemented because of the pandemic. The quantitative data showed a significant negative change in the “professional approach” subscale of the emotional response measure between T1 and T5, and between T2 and T5, suggesting a reduced professional feeling towards caring for patients with MDRB at the end versus before and during the pandemic. This negative change was not confirmed in the interviews.
Nurses’ self-efficacy towards caring for patients with MDRB remained strong throughout the study period. In the interviews nurses described many challenges in caring for patients with MDRB and adhering to IPC guidelines but provided just as many solutions. The quantitative results suggested a significant positive change in self-efficacy from T2 to T4, which in part was confirmed in the interviews. A positive trend in nurses self-reported engagement in antibiotic stewardship was found in the qualitative data, and not confirmed by the quantitative.
Conclusion: Through this PhD thesis it has been demonstrated that nurses’ overall attitudes towards caring for patients with MDRB were stable and moderate throughout during the COVID-19 pandemic. Nurses also demonstrated strong self-efficacy towards caring for patients with MDRB before and throughout the study period. These results suggest nurses to be a robust and resilient resource when faced with Healthcare crisis such as a pandemic.
Nurses’ knowledge and behavioural intentions regarding IPC and antibiotic stewardship were found to be consistent yet insufficient. Obstacles hindering hospital nurses in caring for patients with MDRB included buildings ill-designed to accommodate IPC compliance, extensive, and illogical guidelines difficult to access, instability in sources of information and stressful workdays leading to downprioritising of IPC measures. These results contribute to valuable insights that can guide improvements in clinical practice, nursing education, policy making and future research.
.jpg)