Table 1.

Data extraction process: steps performed

First author, year and country	Design	Setting	Aim(s)	Participants’ profile	Item(s) under study	Metrics	Key findings
Quantitative descriptive studies
Akbar et al. [29] Saudi Arabia (Asia)	Cross-sectional study	Three programs of the university: clinical laboratory science, nursing, and pharmacy	(i) evaluate the knowledge of future healthcare workers in Saudi Arabia on antibiotics, antibiotic use, and antibiotic resistance; (ii) determine the factors influencing students’ knowledge	HCPs students. 284 clinical laboratory science, nursing, and pharmacy students; mean age was 21.64 (SD = 2.20) years. Among students, 53.9% were male and 52.5% urban dwellers. More than half of the samples comprised nursing students (51.4%), and 28.2% and 20.4% of the respondents were pharmacy and CLS students, respectively. The highest proportion of the sample was sophomores (36.6%), whereas the lowest was seniors (27.8%)	Students’ knowledge of (1) antibiotics, (2) antibiotic use, (3) antibiotic resistance	A questionnaire was used to collect data for the study variables. Ten, five and eight questions assessing students’ knowledge of antibiotics, antibiotic use, and antibiotic resistance (with a 4-point Likert scale measuring the relevance of the items)	The study found that students have above-average knowledge of antibiotics and antibiotic resistance, whereas their knowledge of antibiotic use was inadequate. Several factors, including gender, program, academic level, awareness about antibiotic resistance, attendance to seminars/training, and belief on the seriousness of antibiotic resistance problem, affect students’ knowledge. The findings suggest that students’ knowledge in these areas should be improved
Ashiru-Oredope et al. [33] UK [Multiple European countries] (Europe)	Cross-sectional study	A Project Advisory Group comprising 87 individuals representing 30 EU/EEA countries and European professional organizations	(i) assess knowledge, attitudes, and behaviors of healthcare workers in 30 EU/EEA countries with respect to antibiotics, antibiotic use, and antibiotic resistance; (ii) provide a baseline dataset to design and evaluate future policy, communication, and educational interventions; (iii) support the evaluation of awareness raising campaigns including European Antibiotic Awareness Day	HCPs. 18,365 healthcare workers (7,351 medical doctors, 4,312 nurses, 3,258 pharmacists, 1,085 dentists, 633 allied health professionals) 97% were over the age of 25 years and 70% were women. The respondents predominantly practiced in hospitals (49%), the community (22%), or in pharmacies (10%)	The COM-B (capability, opportunity, motivation and behavior) model (1) Antibiotic use and antibiotic resistance-information available on antibiotic use and antibiotic resistance; (2) Campaign and training; (3) Prescriber questions; (4) Undergraduate health student questions	43-item web-based questionnaire (multiple choice questions, statements testing knowledge using a true or false answer, and statements assessing attitudes and behaviors by seeking agreement using a 5-point Likert scale)	Knowledge of antibiotics and their use was higher (97%) than knowledge of development and spread of antibiotic resistance (75%). 60% of respondents stated they had received information on avoiding unnecessary prescribing, administering or dispensing of antibiotics. Among respondents who prescribed, administered or dispensed antibiotics, 55% had provided advice on prudent antibiotic use or management of infections to patients, but only 17% had given resources. For community and hospital prescribers, fear of patient deterioration or complications was the most frequent reason (43%) for prescribing antibiotics that were considered unnecessary. Community prescribers were almost twice as likely as hospital prescribers to prescribe antibiotics due to time constraints or to maintain patient relationships
Barchitta et al. [34] Italy (Europe)	A clustering analysis from a cross-sectional study	Multi-country and multi-professional survey launched by the European Centre for Disease Prevention and Control	Compare knowledge, attitudes and behaviors on antibiotic use and resistance across different groups of Italian HCW	HCPs. 2,167 healthcare workers; 479 medical doctors (both physicians and surgeons), 354 nurses and midwives, 140 pharmacists (both community and hospital pharmacists), 97 dentists, and 215 other HCW (i.e. hospital managers, pharmacy technicians, physiotherapists, biomedical scientists, and allied health professionals)	Knowledge, attitude and behaviors of HCW on antibiotics, antibiotic use and resistance	Online survey tool to evaluate capabilities, opportunities and motivations that enable prudent behavior on antibiotic use (see Ashiru-Oredope et al. [34])	Italian HCW exhibited different knowledge, attitudes, and behaviors on antibiotic use and resistance. These findings raised the need for educational and training interventions that target specific professional groups
Bouchoucha et al. [25] Victoria (Australia)	Cross-sectional study	Bachelor of Nursing and other combined nursing degrees at a University in Victoria, Australia	Elicit nursing students’ perspectives and perceptions of the nurse’s role in antimicrobial stewardship	Nursing students. 321 nursing students enrolled in an Australian university 291 (91%) were female and 30 (9%) were male with a mean age of 25.7 years (SD = 8.44). Of the participants, 112 (61%) had no experience working in healthcare, 40 (12%) were enrolled nurses and 31 (9.7%) were registered nurses from overseas. The majority (83.2%) of participants were domestic students	Knowledge and opinions regarding the nurse’s role in AMS and on a range of topics relating to antimicrobial stewardship and antimicrobial resistance	Series of closed and open-ended questions	Findings underscore the need to engage nursing students in discussions that explore the problem of antimicrobial resistance and the important role nurses play in Antimicrobial Stewardship programs
Carter et al. [21] Pennsylvania [multiple regions of the States] (USA)	Cross-sectional study	Acute care hospitals that are members of the Association of Professionals in Infection Control and Epidemiology	Describe clinical nurse involvement in antibiotic stewardship programs (ASPs)	RNs. 207 infection preventionists (IPs) working in acute care hospitals	(1) Leadership support of nurses’ involvement in antibiotic stewardship; (2) Nurses’ performance in antibiotic stewardship activities; (3) Nurses’ knowledge and training in antibiotic stewardship	The survey consisted of 40 multiple-choice and free-text questions	Study findings indicate the need for nurse leaders to improve the preparation and integration of clinical nurses in ASPs. While clinical nurses routinely perform activities that contribute to optimal antibiotic use, the knowledge and competency of clinical nurses in these activities and their formal integration in ASPs are minimal
Hamilton et al. [22] Utah (USA)	Cross-sectional study	The 2018 annual American Association of Nurse Practitioners (AANP) conference in Denver, Colorado	Describe the knowledge, attitudes, and perceptions of NPs about antibiotic use, resistance, and stewardship	NPs. 194 NPs completed the questionnaire. 88% were female, and 12% were male. The majority of the respondents (70%) had a master’s degree, and the range of experience was 0–45 years (mean 11 years). Family NP was reported by 65% as the population for their initial NP education, with 12% indicating Adult-Gerontology Primary Care NP and 9% Adult Acute Care NP. 23% of respondents described their current health care setting as Private Office, 18% as Hospital/Acute Care, and 29% as Community	(1) Attitudes that influence decisions; (2) Attitudes toward empiric selection; (3) Perceptions about antibiotic use and resistance; (4) Perceptions toward educational resources	The questionnaire used in this study consisted of 54 items. Attitudes that influence decisions about antibiotics and empiric selection were scored on a 1–5 scale (never, rarely, sometimes, often, and always). The perception questions about antibiotic use and resistance were scored on a 5-point Likert response scale, from “strongly agree” to “strongly disagree.” Education resources were scored on a 5-point scale, from “very useful” to “never useful”	Factors affecting the decisions of antibiotic prescriptions included patient condition (79%) and patient cost (58%). Nurse practitioners based their antibiotic decisions on the antibiogram (63%) in their setting, whereas 56% indicated they start with broad spectrum and tailor antibiotic choices after cultures are received. Nurse practitioners understood that inappropriate antibiotic use causes resistance (97%), harms the patient (97%), and optimum antibiotic use will reduce resistance (94%). Participants also recognized that strong knowledge of antibiotics was important (94%) and felt confident in using antibiotics (86%). However, 94% agreed that antibiotics are overused nationally, and only 62% thought antibiotics were overused in their setting
Herawati et al. [30] Indonesia (Asia)	Observational descriptive study with a cross-sectional design	3 hospitals in the East Java province, Indonesia	Identify the differences among health care professionals’ knowledge and beliefs about antibiotic stewardship	HCPs. The professions included are doctors, pharmacists, midwives, the AMS team members, and nurses. The excluded professions are psychiatrists, radiologists, obstetric and neonatal nurses, and hemodialysis nurses. (65 nurses, 61 midwives, 27 pharmacists, 45 pharmacy technicians, and 59 physicians)	Healthcare professionals’ knowledge and belief (perceived threat, perceived self-efficacy, perceived benefit, and perceived barrier) on antibiotic stewardship to be able to design training that meets their need	The questionnaire consisted of 43 questions: 12 questions were used to assess knowledge, and 31 questions to assess belief. The 31 belief questions consisted of 10 questions to assess perceived threats, 11 questions to assess perceived self-efficacy, 8 questions to assess perceived benefits, and 2 questions to assess perceived barrier	Among healthcare professionals, knowledge and belief differences of antibiotic stewardship vary widely. Antibiotic knowledge is associated with positive belief and behavior that contribute to the adherence to a judicious use of antibiotics and reduce antibiotic utilization. The Health Belief Model (HBM) theory presumes several constructs (perceived severity, perceived benefit, self-efficacy, cues of action) to predict behavior
Lim et al. [31] Singapore (Asia)	Cross sectional survey	acute care tertiary public hospital	Evaluate nurses’ knowledge and perceptions of antimicrobial stewardship	RNs. 241 nurses with enrolled or registered nursing licenses, working in medical, surgical, critical care areas, high-dependency, and isolation wards. About half of the participants were below 30 years old (55.6%); the majority were female (84.6%) and staff nurses (81.3%), while just over half had a clinical experience of 7 years and above (51.4%). Most of the participants were working in general medical and surgical wards (85.5%)	Assess participants’ awareness of the term AMS, level of knowledge, and perception of nurses’ role in AMS, as well as the need for measures to minimize the impact of AMR and AMS to be included in the undergraduate nursing curricula	An online 13-item questionnaire that explored the nurses’ attitudes and knowledge of AMS was used in this study with permission. The questionnaire consisted of ‘yes’ or ‘no’ questions and Likert scale questions, ranging from ‘1’ (none) to ’5’ (excellent).	Improving the awareness of and education on AMS and AMR among nurses is an essential element in infection and prevention control. Nurses’ role can be further strengthened by integrating fundamental training on AMS in the undergraduate nursing curriculum and providing continuing education in the clinical setting, as well as promoting the role of nurses in advocating for patients and AMS
Monsees et al. [23] Missouri (USA)	Cross-sectional survey	Nine hospitals ranged in size from 42 to 562 beds serving pediatric and adult populations in 2 different metropolitan areas	Determine bedside nurses’ recognition and performance confidence in AMS	RNs. A total of 4,282 direct care RN and licensed practical nurses were asked to participate but only 558 study subjects completed the survey. Highest number of respondents were nurses who graduated within1-5 years (n = 190, 34.1%), with the second highest category representing nurses with more than 15 years of experience (n = 176, 31.5%)	General AMS questions were included to bolster understanding of how nurses perceive their participation, knowledge, and role as antibiotic stewards. Using free text, respondents were also asked to identify strategies to enhance nurse engagement or elaborate on their role	The final survey had 48 questions- 9 demographic, 11 general AMS, 10 practice, 10 confidence, and a total of 8 from the Agency of Healthcare Research and Quality Hospital Survey on Patient Safety Culture (public domain), including 5 on teamwork and 3 on communication openness. All items were scored on a 5-point Likert scale	Nurses identified a professional role in AMS processes, even though safety culture inhibited their involvement. These findings can help enhance the inclusion of nurses in AMS efforts
Padigos et al. [26] Auckland region (New Zealand)	A cross-sectional survey design	The greater Auckland region of New Zealand	Investigate knowledge of registered nurses (RNs) on antibiotics, AMR and their understanding of AMS	RNs. Two hundred ninety-eight (n = 298) respondents from diverse nursing backgrounds completed the survey. Most respondents were trained in New Zealand and had more than 5 to 10 years of nursing experience. The median age group was 40–49 years old. More than half (161/298, 54%) had post graduate degrees	The views of RNs on their potential roles in AMS, their knowledge, understanding of AMR and use of antibiotics. The intended outcome was to determine nurses’ gaps in knowledge related to antimicrobials and AMR	A56-item online questionnaire was developed based on existing literature that related to antibiotic use, AMR and AMS principles. In addition, specific questions were also taken from a questionnaire that was previously used in measuring knowledge of AMR in patients and nurses	Nurses play an essential role in promoting AMS practices. However, a good understanding of antibiotics, AMR and AMS is needed to effectively embed these concepts in clinical practice. Hence, addressing these educational needs is of paramount importance
Qualitative studies
Dowson et al. [27] Victoria (Australia)	One-on-one, semi-structured, qualitative interviews	Health professionals (i.e., nurses, general practitioners and pharmacists) working in aged-care homes in Victoria, Australia	(i) Describe health professionals’ perspectives on antimicrobial use near the end of life in aged-care homes. (ii) Investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes	RNs. Twelve nurses, six general practitioners and two pharmacists providing routine care to residents of aged-care homes were interviewed. Diversity in terms of years of experience, aged-care funding type (government, private-for-profits and not-for-profits) and location metropolitan and regional) were sought	1. What is the environmental context and social basis of nurse participation in antimicrobial prescribing near the end of life in aged-care homes? 2. What does this assume implicitly or explicitly about aged-care nurses and their workplace relationships? 3. Of what larger process is this behavior a part? 4. What are the implications of such nurse behaviors for residents, general practitioners and families in aged-care homes with regards to antimicrobial prescribing near the end of life?	Participants were approached for one-to-one interview, after which no further contact was initiated by the researchers. A participant demographic questionnaire recording the participant’s age, profession, years in the profession, and years with their current aged-care home was facilitated by the interviewer. Demographic details about the aged care homes where participants were employed (or serviced) were also recorded by the interviewer. For participants who agreed to be audio recorded, the recorder was turned on after completion of the demographic questionnaire. The interviews followed a pre-set semi-structured interview guide, with early interviews and data analysis informing exploration in later interviews. The semi-structure interview guide was pilot tested with an experienced aged-care nurse and revised once prior to the start of the interviews on the basis of that pilot testing	Nurses have important roles in facilitating advance care planning, care coordination, care delivery and communication with families and medical professionals; these duties present important opportunities for nurses to lead antimicrobial stewardship activities appropriate for care near the end of life in aged-care homes
Kirby et al. [28] New South Wales (Australia)	Qualitative one-on-one, semi structured interviews	Four hospitals (three public and one private), across metropolitan, regional and remote areas, in two Australian states	Explore Australian hospital nurses’ views on antimicrobial resistance and AMS in a hospital setting, in order to better understand the opportunities for and challenges to integration of nursing staff in antimicrobial optimization within hospital settings	RNs. 86 nurses (77 females, 9 males), from a range of hospital departments, at a range of career stages	(1) Accounts of the significance of AMR (Antimicrobial resistance) and use in everyday nursing work, (2) The nursing role in antimicrobial decisions, inter-professional dynamics around antimicrobial use. (3) Nurse’s experiences and knowledge of AMS in the hospital context	Semi structured interviews, lasting between 20 and 60 min, were conducted by four research team members (three females, one male; all university-based sociologists from Anglo-Australian backgrounds, experienced in qualitative interviewing) between 2014 and 2019. Participating nurses worked within a range of departments and had various levels of experience and seniority (Table 1 includes detailed participant characteristics). Following written informed consent, interviews were digitally audio recorded and transcribed in full	As frontline staff in inpatient care, nursing engagement in AMS presents considerable yet currently underused opportunities. Nursing identity is well aligned with stewardship identity, and thus significant missed opportunities currently exist for nurses to contribute to practice, education, and research and policy efforts to reduce AMR. These missed opportunities exist largely because of interprofessional power imbalances within the social world of the hospital. Expanding AMS to better empower nurses is crucial to ongoing attempts to curb the threat of AMR by improving judicious use of antimicrobials
Rout et al. [35] South Africa (Africa)	Qualitative research	This study was conducted in a 20-bed adult ICU/high-care unit in a 200-bed private hospital in KwaZulu-Natal, South Africa (SA), which admits medical and surgical patients managed by non-intensivists	Explore the views of healthcare professionals regarding barriers to the antimicrobial stewardship role of the nurse in intensive care	RNs. Fifteen participants from the disciplines of nursing, surgery, anesthetics, internal medicine, microbiology, and pharmacy in a general intensive care unit. Nursing participants included two nurses from hospital management who had set up the AMS program two years previously, and six clinical ICU nurses whose responsibilities as shift leaders included daily AMS rounds. These were registered professional nurses; one held an additional qualification as an ICU nurse; the remaining five had experience of working in this area of nursing but held no specialist qualification. Non-nursing participants included a microbiologist, pharmacist, two anesthetists, two physicians and two surgeons. The microbiologist was representative of one of the private laboratories that served the study hospital and the pharmacist was a representative from the hospital pharmacy. The clinicians were specialists who had admission rights in the ICU	Barriers of AMS role of nurses in intensive care	Semi-structured individual interviews with all participants	The nursing role within antimicrobial stewardship was negatively affected by both staffing and collaborative difficulties, which impacted on the implementation of antimicrobial stewardship within the unit
van Gulik et al. [32] Thailand (Asia)	Qualitative descriptive study	A 1000-bed university hospital in Bangkok, Thailand	Explore how organizational multidisciplinary leaders and clinical nurses perceive nurses’ roles in AMS	RNs. A sample of 33 participants made up of organizational leaders and nurses. The 15 organizational leaders interviewed were: health service Director, Director of Nursing, Director of Pharmacy, Chair of the Infection Prevention and Control (IPC) committee, IPC nurse manager, infection control specialists, surgeons, an infectious diseases physician, operating suite nurse manager, intensive care unit nurse manager, AMS and clinical pharmacists and the Virology Department head scientist	(1) Current governance, educational and practice context. (2) Nurses’ current role in AMS in hospital. (3) Barriers to nurses’ engaging in AMS Education, knowledge and support, workload, collaboration and communication	Individual and focus group interviews. The topic guide included two open ended questions: “Can you talk about nurses’ current role in AMS in this hospital?” and “What do you think are some of the barriers to nurses’ engaging in AMS? “	Nurses currently participate in AMS by supporting system processes, monitoring safety and optimal antibiotic use, and patient education. A lack of clear articulation of nurses’ role and traditional professional hierarchies limits active participation. Inconsistent engagement was perceived as due to a failure to prioritize AMS activities, a lack of formal policies, and a need for further education
Mixed-methods studies
Knobloch et al. [24] Wisconsin (USA)	Mixed methods study	Interviews were conducted at six community-based outpatient clinics located in rural areas of two states. All three focus groups were conducted at the Madison Veterans Administration facility	i) Identify barriers and facilitators to guide concordant prescribing among NP prescribers in a Veterans Health Administration (VHA) outpatient setting; (ii) Explore perspectives about perceived roles in antibiotic stewardship efforts, both NPs and patient roles	NPs. 14 NPs for an in-person interview; two interviews conducted by phone due to NP preference. A total of 15 Veterans (10 male, 5 female) participated in the focus groups	(1) People involved in the process of prescribing; (2) tasks: diagnosing, guideline retrieval, and prescribing; (3) tools: electronic medical record, guidelines, and testing equipment; (4) organization; policies related to antibiotic prescribing and leadership aspects of implementing stewardship activities; (5) Environment; physical environment of the ambulatory clinics	The Systems Engineering Initiative for Patient Safety (SEIPS) model was used. Face-to-face semi structured interviews were carried out. The interviews covered topics such as appropriate prescribing, perceptions and ideas about the NP role in antibiotic stewardship, participating in developing an intervention targeting NPs, the veteran’s policy mandating antibiotic stewardship, and barriers and facilitators to concordant prescribing in the outpatient VA setting. There were three focus groups. Questions from an existing health care-associated infection patient engagement group, which included Veterans, were used. Quantitative data from over three calendar years (2017–2019) on NP prescribing for diagnoses categories were analyzed	Nurse practitioners reported satisfaction with resources, including ready access to pharmacists and infectious disease specialists. Building patient trust was reported as essential to prescribing confidence level. Veterans indicated the need to better understand differences between viral and bacterial infections. NP prescribing patterns revealed a decline in antibiotics prescribed for upper respiratory illnesses over a 3-year period
Mula et al. [36] Malawi (Africa)	Descriptive qualitative study	A referral hospital which is the largest teaching hospital, with a bed capacity of 1,200 serving a population of approximately 5.5 million. It provides tertiary care to the population in the south west districts of the country and serves an urban population of 920,000	Explore nurses’ role in antibiotic stewardship and the challenges they face in order to provide empirical evidence in support of ways to involve nurses	HCPs. Participants were senior doctors (n = 6), junior doctors (n = 6), pharmacists and laboratory technologists (n = 8, 4 from each discipline) Staffing level was cushioned by locum nurses who come from other wards, from retirement, or who were waiting to be employed	Three key events where antibiotic stewardship nursing activities most commonly take place were purposively selected for their data richness, namely: nursing handover report, which is a nursing care communication that routinely takes place at the end of each shift; night and day in order to ensure continuity of nursing care, antibiotic preparation event and ward rounds. Participants were encouraged to explain, based on their experience working with nurses, the roles of nurses and the challenges they face in antibiotic stewardship	The introductory question asked participants to describe their perceptions of antimicrobial resistance and antibiotic stewardship. Subsequent questions explored participants’ experiences and perceptions of nurse involvement in antibiotic stewardship interventions and perceived challenges	As to nurses’ roles, the main theme that emerged was that nurses have multiple antibiotic stewardship roles. The subthemes were: Nurses have a facilitating role in microbiology specimen investigations; Nurses have a role in contributing to prescription decisions; Nurses have a role to ensure antibiotics are available at point of care. Three main themes that resulted from the challenges were competency gaps, multidisciplinary team work challenges and limited resources

AMS antimicrobial stewardship, AMR antimicrobial resistance, HCPs healthcare professionals, HCW healthcare workers, RNs registered nurses, NPs nurse practitioners, USA United States of America