Discussion

A pilot study assessing the use of asynchronous microlearning was effective in improving nursing KAP surrounding AMS. Participants demonstrated a baseline understanding of antimicrobial resistance (mean precourse score, 4.41) and antibiotic adverse effects (mean precourse score, 4.20), but larger gains were demonstrated for more specific AMS roles and responsibilities. After course completion, participants felt more confident in their ability to recognize antibiotic adverse effects, colonization versus infection, unnecessary urine cultures, and opportunities for IV to PO conversion of antimicrobials. After course completion, more nurses agreed that they have some control over what antibiotics their patients receive and believed that they could serve as antibiotic stewards.

Nurses perceive they have a role in AMS, but knowledge gaps of microbiology and antibiotic use principles are perceived barriers to integrating nurses into AMS. ^{Reference Monsees, Tamma, Cosgrove, Miller and Fabre6,Reference Greendyke, Carter and Salsgiver11–Reference Monsees, Popejoy, Jackson, Lee and Goldman13} Carter et al ^{Reference Carter, Greendyke and Furuya10} reported that practices such as questioning the need for urine cultures, ensuring proper culturing technique, recording an accurate penicillin allergy history, encouraging a prompt switch from IV to PO antibiotics, and initiating antibiotic timeouts are perceived as an extension of nurses’ role. Hamdy et al ^{Reference Hamdy, Neal, Nicholson, Ansusinha and King20} conducted 12 focus groups with 90 pediatric nurses on their role in AMS. They reported that nursing roles in AMS may include advocating for the patient, communicating with the team, administering antibiotics safely, educating caregivers, and educating themselves. ^{Reference Hamdy, Neal, Nicholson, Ansusinha and King20} The role of nurses in AMS has also been endorsed by the American Nurses Association (ANA) and the Centers for Disease Control and Prevention (CDC). ⁸ Nursing competency in AMS is one of the key components of a proposed AMS nursing practice framework that emphasizes the need for development of targeted AMS nursing education programs. ^{Reference Manning, Pogorzelska-Maziarz and Hou21}

Microlearning is an emerging approach in healthcare continuing education. This innovative pedagogy has demonstrated a positive effect on knowledge acquisition, confidence, and in some cases, clinical practice, but data on using this approach in nursing education are lacking. ^{Reference de Gagne, Park, Hall, Woodward, Yamane and Kim18} Some of the benefits of microlearning include the shorter time requirement and the flexibility of completing the activities at the convenience of the learner. In the age of mobile phone applications, learners tend to prefer shorter, more informal content. ^{Reference Tennyson, Smallheer and de Gagne22} Microlearning may be particularly suitable for healthcare professionals, who are often managing multiple patients and tasks at one time. In addition, educational modalities, such as QuizTime, allow for scalable learning interventions in which rapid dissemination of information to large numbers of learners is possible. ^{Reference Triana, White-Dzuro, Siktberg, Fowler and Miller16} Once a question bank is created, the application can deploy the education to more users with little effort by study personnel. Furthermore, this approach promotes high learner engagement with sustained knowledge acquisition. ^{Reference Barrett, McEvoy and Fowler17}

Although additional education remains an important opportunity to increase nursing participation in AMS, another major barrier is prescriber pushback and challenges with interdisciplinary communication. ^{Reference Davey and Aveyard23} One participant in our study stated, “Nurses are not the ones deciding on when to start antibiotics or which [antibiotics] to use. We can advocate for our patients but at times nurses can be overruled by physicians.” This sentiment was a prominent finding in a survey of 451 nurses, in which 92% of respondents reported that initiating discussions with a prescriber about antibiotic changes would benefit their patients but only 16% thought that this could be implemented without difficulty. ^{Reference Greendyke, Carter and Salsgiver11} Interdisciplinary communication is vital for successful nurse-driven AMS interventions. ^{Reference Ha, Forte and Olans7} The SBAR (situation, background, assessment, and recommendation) tool is a successful communication style utilized in health care. A proposed AMS nursing practice framework advocates for using the SBAR to strengthen communication between nurses and providers, and the familiar SBAR tool could be adapted for use regarding AMS nursing interventions. ^{Reference Monsees, Tamma, Cosgrove, Miller and Fabre6}

This study had several limitations. Notably, participation in the intervention was low, which is unsurprising for a pilot study; therefore, our findings lack generalizability to other medical centers. Recruitment was challenged by nursing shortages and increased use of agency and per diem staff due to the COVID-19 pandemic. Even though any inpatient nurse was eligible to participate in the study by receipt of advertisement via an e-mail listserv, many participants joined after engagement by one of our selected nursing champions and thus our sample was not randomly chosen. Additionally, our KAP survey did not undergo reliability and validity testing. Although nurses were included in the development of the survey, we did not assess psychometric properties, which would be valuable prior to large-scale implementation. Also, we did not assess whether our intervention led to meaningful changes in clinical practice, though research has previously demonstrated changes in clinical practice following spaced education interventions. ^{Reference Kerfoot, Lawler, Sokolovskaya, Gagnon and Conlin24–Reference McEvoy, Dear and Buie27}

In this pilot study, we focused on the implementation and utility of the QuizTime platform for AMS education. Future efforts could focus on improving participation, assessing long-term impact, and scaling similar interventions to a broader population. Recruitment could be improved by targeted e-mails rather than through a listserv, repeated notifications rather than a single posting, and increased visibility throughout the institution. Future studies could measure the long-term retention of learned topics as repeated education may be needed for sustained impact. The QuizTime platform may facilitate the ease of subsequent education since the number of participants does not increase the workload for course organizers.

Nursing education and engagement in AMS provided in an asynchronous, microlearning format resulted in significant improvement in the KAP among inpatient nursing staff. Nurses are integral members of a multidisciplinary AMS team and focused AMS education may empower nurses to help reduce unnecessary antibiotic use in their patients. This pilot study supports expanded AMS educational efforts for all healthcare professionals.