Research priorities for nurses in antimicrobial stewardship in a middle-income country: a nominal group technique study

doi:10.21203/rs.3.rs-4391774/v1

Background

Antimicrobial Stewardship Programmes (ASP) have become an important strategy to address antimicrobial resistance (AMR). Despite the increasing number of international publications, identifying the roles played by nurses as part of ASPs, in low and middle-income countries this theme is poorly researched. This study aimed to identify priority research gaps in the Brazilian context on nurses' performance in ASPs from the perspective of nursing professionals and explore the main themes among the ideas generated by these nurses.

Methods

This was a qualitative study using the modified Nominal Group Technique (mNGT) during a 3-day online workshop. Thematic analysis was performed based on the ideas proposed by the participants after the clarification stage.

Results

The participants suggested 68 ideas at the first phase. After the idea’s clarification phase, 45 ideas were included in the voting rounds. The ideas prioritized by participants voting addressed: i) attributions and competencies of nurses in the ASP; ii) planning and implementation of ASP nurses' activities, and iii) use of information and communication technologies to assist nurses. The thematic analysis highlighted nine main themes.

Conclusions

The role of nursing in dealing with AMR and, more directly, its role in ASP are still unknown and under-researched topics in Brazil. The participants identified ideas that were mainly focused on elementary aspects of ASP. These themes should be further studied in the Brazilian context, but may potentially be applicable to other similar socio-economic contexts.

Nursing

Nursing Research

Antimicrobial Stewardship

Antimicrobial Resistance

Nominal Group Technique

Group Processes

Antimicrobial resistance (AMR) is the ability of a microorganism to overcome the effects of antimicrobial agents resulting in their ineffectiveness(1) AMR has emerged as a major global public health challenge with socio-political consequences, overwhelming the health systems and threatening the sustainability of contemporaneous society (2–4). Antimicrobials have contributed to advances in the treatment and prophylaxis of infections, allowing therapeutic procedures such as transplants and complex surgeries. However, the inappropriate use of antibiotics, fostered by poverty, lack of hygiene and sanitation have encouraged the development of AMR worldwide (5–8).

The Global Action Plan on AMR adopted by the World Health Assembly in 2015, aimed to identify, manage and mitigate the risks involved with AMR (9). A strategic objective includes optimising the use of antimicrobials through Antimicrobial Stewardship Programmes (ASP), multimodal interventions requiring interdisciplinary and collaborative engagement of health care professionals (10). However, most ASP guidelines typically recognise the contribution of physicians, pharmacists, and microbiologists yet rarely include nurses (11–13). In many situations, nursing engagement in ASPs is most often seen under the lens of infection prevention and control (IPC) (14–16). Nonetheless, nurses perform other pivotal actions towards optimal management of antibiotics and infections within their scope of practice, including central roles as communicators and co-ordinators of care between health professionals, patients, and their families (11, 17, 18).

Nursing holds a significant position among healthcare professionals due to its major contribution to patient care (11, 18, 19). Evidence suggest that nurses may contribute by assessing and monitoring patients’ clinical status, participating in diagnostic culture and antimicrobial treatment management, and educate patients and families (18, 20, 21). However, in Brazil there are still research gaps related to the nurses’ role in ASPs that need to be identified and prioritised for future investigations in order to strengthen the contribution of nurses in ASPs (20, 22). Addressing these gaps would be particularly valuable for low- and middle-income countries, where the contribution of nursing in combating ASP is unknown or underestimated (23).

This study aimed to identify priority research gaps in the Brazilian context on nurses' performance in ASPs from the perspective of nursing professionals and explore the main themes among the ideas generated by these nurses.

Study design

The study was a qualitative study using Nominal Group Technique (NGT) modified to adapt to a virtual scenario (mNGT). The NGT is a structured method for the development of consensus, using a focus group modality in which the contribution of the participants is obtained through the presentation of a predetermined guiding question during the discussion. Answers are obtained from the participants through the presentation of a question on the topic addressed. NGT allows participants to identify, evaluate and rank important aspects of a specific topic or problem (24). The decision to use the mNGT considered the study objectives, the need for consensus, practicalities and associated limitations, such as participant’s time and availability, and Brazil's geographical dimensions. Compared to the Delphi Technique, NGT has a lower drop-out rate throughout the process (25,26). Given the challenges of running in-person event during the COVID-19 pandemic (27) and the desire to include participants from different Brazilian regions, a careful adaptation of the traditional technique was used to allow for its application online Supplementary file (Additional file 1) (28).

Participants

Nurses working professionally in Brazil in different contexts were invited, including members of hospital infection prevention and control (IPC) committees, public health organizations, professional councils, such as the Regional Nursing Council. Academics and researchers as well as frontline nurses from primary health care (PHC), outpatient and general hospitals were also invited.

In order to ensure a proportional distribution of the guests according to their work context among the five regions of Brazil, a proportion matrix was constructed according to the percentage distribution of health facilities and university hospitals in the country. The proportion matrix included four categories: PHC and outpatient clinics, general hospitals, universities, and the "other" category included health surveillance agencies, professional councils, and professional associations in IPC. To assist in the construction of the matrix, a search was carried out in the database of the National Register of Health Establishments (CNES) and the Ministry of Education, looking for the percentage of health facilities and universities distributed in the five regions of Brazil. Details of the distribution of healthcare facilities, and the proposed matrix of participant’s is available in the Supplementary file (Additional file 2).

In order to ensure equitable participation and a more efficient discussion, it is recommended that the number of NGT participants range between 7 and 10 guests (24,29). The number of guests was carefully planned with the expectation that approximately 30 individuals would participate in the consensus group. By utilizing the recommended group size, it was envisioned to establish three groups, each consisting of a maximum of ten professionals.

Ethical approval

The study received ethical approval from the Research Ethics Committee of the School of Nursing of University of São Paulo, with approval nº 5.381.334. All participants have signed an informed consent form before taking part in the virtual workshop.

Recruitment of participants

Initially, the recruitment of participants involved inviting nurses nominated by the research executive team. Subsequently, snowball sampling was employed to identify potential participants. Participants were then invited to identify others who could fulfil the research inclusion criteria. Those individuals who consented to participate in the research were notified via email of the invitation letter, consent form, and additional details regarding the virtual workshop, including the program, explanations about mNGT, and a list of publications on the subject.

Data Collection

The data was collected during a virtual workshop called “The Role of Nursing in Antimicrobial Stewardship Programs” using the Google Meet® platform with an upgrade to Google Workspace®. The workshop duration was for three four-hour sessions (12 hours total) over three days, with an interval of two weeks between each day. The aim of the workshop was to identify and prioritize knowledge gaps about nurses' engagement in ASPs in the Brazilian context. All sessions were recorded (audio and video), and field notes were taken. The authors of this paper actively participated in the workshop from its initial planning stage, serving as lecturers, hosts, facilitators, and supporters during the NGT, and as manager of information and communication technology (ICT).

On the first day of the workshop, the guests were provided with information about AMR, the actions to tackle the problem and the potential nurses’ role in ASPs. The agenda included short lectures and moments dedicated to questions and clarifications on the subject. After day 1, the participants received, via email, a link to a digital form containing the guiding question, “What do you consider to be an important research gap to be explored regarding the role of nursing in antimicrobial stewardship?”. The electronic form contributed to the idea generation stage of mNGT. Considering their own views and work experience, the participants were instructed to answer the form with up to three ideas considered research gaps to be explored in future investigations (Figure 1).

Figure 1. Planning the online workshop

After a two-week interval, the second day of the four-hour workshop was held. Day 2 aimed to explore the preliminary ideas proposed by the participants on the first day and to reach a consensus on the priorities for future research. All participants were received in the main virtual room, called “plenary”. The host explained the importance of the research question and used the FINER criteria—feasible, interesting, novel, ethical, and relevant—to ensure that appropriate research questions could be formulated (30,31). Participants were advised that ideas entered into the electronic form during the idea generation stage should be converted into research questions using the FINER criteria.

To clarify and discuss the ideas previously identified, participants were randomly allocated into three small groups (A, B, and C), with up to 10 participants in each group. The division of the groups considered the excessive time and dispersion caused by tiredness that could be generated by discussing all the ideas with all the participants. Therefore, the discussions took place independently in each thematic room, limiting themselves to the ideas generated by their participants. Each group was assigned a facilitator and a supporter.

The purpose of the presentation and clarification phase was to clarify the ideas entered into the electronic form. The ideas were then converted into research questions. If the ideas were similar and the group agreed, the facilitator made adjustments, such as combining them or editing or deleting repetitions.

The voting round took place in two stages using the SurveyMonkey® virtual platform: the first in the breakout room, where participants voted anonymously choose up to three relevant research questions for future investigations according to their point of view. The second round of voting took place in the plenary room, where each participant and the facilitators could vote individually on a single most relevant research question. The choice of two rounds of voting was made so that all participants could discuss and vote on the most relevant research questions in each breakout room. At the end of the process, the participants prioritised the research questions democratically.

After a three-week break, day 3 was held. The aim was to develop the three main research gaps prioritised in the consensus groups during day 2 into preliminary research projects. The methodology used was based on a group discussion following a previously prepared roadmap. The participants were divided into three groups where each group worked on one of the three prioritised research questions. At the end, the participants presented their projects in the plenary room.

Data analysis

The mNGT results and the demographic data of participants were presented using descriptive statistics (frequencies, mean, standard deviation, and range). Content analysis was performed to the research questions after the idea’s clarification stage to characterise and identify common topics and to create categories in the research priorities (32,33). Two researchers carried out the analysis independently in the categorisation phase (AMSF and VCLG). Conflicting categorisations were discussed and agreed upon. A third researcher (MCP) then assessed the relevance of the categorisation.

During the planning phase, 69 nurses were invited, but only 26 (37.7%) attended. According to the proportion matrix, there were gaps observed in the Northeast and South regions. Regarding the practice areas, PHC exhibited the smallest number of participants. The participants were predominantly female (n=22, 84.6%), aged between 30 and 63 years (mean 43.5 years, SD 8.2). They had professional experience of between 8 and 39 years (mean 20.6 years, SD 8.1), with the most prevalent work in hospital environments (n=11 nurses, 42.3%), followed by professionals working in academic environments developing research (n=6, 23.1%). Nurses from all five Brazilian regions took part, covering ten of the twenty-six states and the Federal District. Most of the participants (n=20 nurses, 73.1%) had no experience with the NGT method (Table 1).

Table 1. Demographics of workshop participants, 2022.

Participants characteristics	Distribution
Age, mean (SD), range years	43.5 (8.4) 30-63
Professional experience, mean (SD), range years	20.5 (8.2) 8-39
Gender, n (%)
Female	22 (84.6)
Male	4 (15.4)
Professional expertise, n (%)
Hospital	11 (42.3)
Academic	6 (23.1)
Primary Health Care (PHC) and Outpatient	4 (15.4)
Management	3 (11.5)
Professional Association	1 (3.8)
Nursing Council	1 (3.8)
Brazilian Region, n(%)
Southeast	12 (46.2)
Central-West	4 (15.4)
Northeast	4 (15.4)
North	3 (11.5)
South	3 (11.5)
Prior experience with NGT, n (%)
No	23 (88.5)
Yes	3 (11.5)

The participants generated 68 preliminary ideas for discussion. The clarification phase, following the presentation, saw the ideas reworked, compiled, or even discarded, depending on how the group viewed them. The ideas were then converted into 45 research questions, a reduction of 33.8%. The first round of voting, still in the breakout rooms, prioritized nine ideas. During the second round of voting, the three most relevant research questions were prioritized according to the group's perspective (Figure 2). Details of the ideas are available in the Supplementary file (Additional file 3).

Although it was not the aim of this study, it was noted that during the clarification stage, participants had difficulty converting the preliminary ideas generated into relevant research questions. This was observed when the ideas were portrayed in sentences containing only the main theme: “Nursing training needed” [Group A], "Ongoing education with professionals" [Group B] or in long texts. The facilitators provided opportunities for groups to overcome this challenge through discussion and understanding.

Figure 2. Development of the number of ideas during the NGT stages, 2022.

The research questions that garnered the majority of votes in the second round of voting were centred around the following subjects: i) the roles and competencies of nurses in ASPs; ii) the planning and execution of nurses' activities in ASPs; and, iii) the utilization of digital technologies to aid nurses in ASPs (Table 2).

Table 2. Result of the second round of voting (plenary), 2022.

Research Questions	n (%)
What are nurses' competences when it comes to managing antimicrobials?	8 (26.7)
How should nurses plan and implement their antimicrobial stewardship activities?	6 (20.0)
How can digital technologies help nurses in ASPs?	5 (16.7)
What knowledge do nurses have about the factors that interfere with ASPs?	4 (13.3)
What teaching strategies can be used to educate nursing technicians, undergraduates, and postgraduate students about ASPs?	3 (10.0)
Do professional nurses know their role in ASP?	1 (3.3)
Has providing undergraduate nursing students with knowledge about antimicrobial stewardship resulted in clinical practice?	1 (3.3)
What are the duties and responsibilities of the care nurse in an ASP?	0 (0.0)
What is the level of knowledge that undergraduate nursing students possessing regarding antimicrobial stewardship?	0 (0.0)
Total	30 (100.00)

The mNGT to be completely online required the use of ICT resources acquired free of charge. All workshop activities were conducted remotely without any travel or accommodation costs. The number of participants and their geographical location were not limiting factors. Throughout the workshop, the participants experienced no difficulties in interacting with the facilitator and other guests, there were no issues with internet connectivity or navigating between virtual rooms, and the voting rounds were conducted as planned. The agenda was fulfilled as per the planned schedule (28).

The content analysis was conducted based on the research questions that emerged during the clarification phase. In addition, group work recordings and field notes were used. The topics are shown in the Table 3.

Table 3. Results of content analysis of the preliminary ideas by the participants, 2022.

Topics	n (%)
(1) Nurses’ knowledge of AMR/ASP and nurses’ education in ASPs (formal and continuing education)	16 (35.6)
(2) Outcomes of nurses’ participation in the ASPs	7 (15.6)
(3) Nurses’ attributions and practice in ASPs	6 (13.3)
(4) Implementation of nurse’s participation in ASPs	4 (8.9)
(5) Barriers for nurses' engagement in ASPs	4 (8.9)
(6) Nurses' autonomy and leadership related to ASPs	3 (6.7)
(7) Nurses’ competencies for ASPs	2 (4.4)
(8) Public policies related to the nurse’s role in ASPs	2 (4.4)
(9) Technological innovations to promote the nurse’s engagement in ASPs	1 (2.2)
Total	45 (100.0)

The most prevalent topics related to nurses learning needs, both in formal education and in-service education, are related to subjects related to AMR and the functioning of the ASP. This aspect of education was relevant to the discussions. Participants expressed concern regarding the curriculum of undergraduate courses currently utilized in Brazil, which allocates a limited number of hours to subjects such as microbiology, parasitology, pharmacology, and health and disease processes. According to the participants' perspective, the inadequate provision of these subjects may hinder nurses' comprehension of AMR and its implications for their clinical practice. The topic of nurses' prior knowledge regarding AMR, its objectives, and the functioning of ASPs was addressed within the realm of expertise of professionals. According to the participants, it is important to carry out research to measure this knowledge to structure a relevant educational programme.

In the topic of outcomes of nurses' participation in ASPs, the participants suggested research on how to evaluate the efficacy of nurses' participation in interdisciplinary rounds, influence on antimicrobial prescribing, and the proper collection of cultures. The participants emphasized the significance of conducting research into the working process and the roles of nurses in practice: “What are the general and specific attributions of nurses in ASPs?”, “Do nurses know their role in the ASP?” [Group A]; “What is the nurse's role in the early detection of infection in the ASP?” [Group C].

The topic of implementation discussed aspects of implementing nurses' participation in the ASP in different work contexts. The participants also addressed the barriers that prevent nurses from participating in ASPs, as well as their perceptions of these barriers: "What factors hinder the nurse's participation in the ASP?" [Group A], “What factors hinder the nurse's work in controlling antimicrobial stewardship?”, “What is the nurse's perception of the factors that interfere with their participation in the ASP?” [Group B]. However, during the NGT, there were no topics identified that were mentioned about the investigation of facilitators or accelerators.

In the topic on nurses' autonomy, we addressed the perceptions of the nursing and the multidisciplinary team about the nurses' performance in the ASPs. Participants expressed the importance of researching nurses' competences in ASP, such as their skills, attitudes, values, and capabilities. One participant presented a research proposal that inquired the potential benefits of digital tools for nurses in ASPs. However, this research question was placed third in the final priority list. One interesting fact to note is that the three priorities obtained in the mNGT emerged from group C.

Despite the substantial number of studies conducted in Europe, the United States, and Australia that examine the significance of nursing in ASP (11,18,19,21,23,34–40), there persists a lack of knowledge regarding the role of nurses in these programs in Brazil. As up to our knowledge there is no similar study on research priorities for the nurses’ role in ASP. A recent review conducted in Brazil that examined the available evidence regarding nursing strategies in ASP in the hospitals, revealed that due recent involvement of Brazilian nurses in the ASPs, there is a dearth of Brazilian studies published on the subject. This underscores the significance of conducting research that is relevant to clinical practice (20). In order to address this challenge, the objective of this investigation was to identify and categorise the priority areas for future research from the nurses' perspective using the mNGT.

In health research, both the NGT and the Delphi technique serve as valuable methods for gathering and synthesizing expert opinions (41). While NGT involves structured face-to-face group discussions, the Delphi technique relies on iterative rounds of anonymous surveys among geographically dispersed experts. Additionally, NGT typically results in quicker consensus due to real-time interaction, whereas the Delphi technique may require multiple rounds of feedback and analysis, potentially extending the timeline(42). Research in health science underscores the significance of the NGT as a powerful tool for gathering insights and perspectives from diverse stakeholders (24,29,43) . Utilized in various stages of research, from problem identification to solution generation, NGT has also been applied to identify research priorities (44,45). The option for mNGT in our study considered research question, the availability of participants, and the quantity of outcomes obtained within a brief period of time.

Despite claims that nurses should be engaged with ASP, in many countries as in Brazil, nurses remain disconnected from this activity. A national evaluation survey in Brazilian adult intensive care units revealed that, although 667 (77.29%) of the hospitals reported that they had the human resources needed to implement ASP, only 497 (57.6%) institutions reported that there were nurses on the ASP management teams (46).

Nursing research evolves and matures as its results fill the gaps in the topics investigated (47). During the mNGT, the research questions were limited to identifying knowledge acquired through formal education, setting up training programmes, and mapping the attributions and competences of nurses working in the ASP. The topics involving the implementation of interventions, the use of technologies, and the evaluation of the effectiveness of the ASPs, with the participation of nurses, were barely suggested. This demonstrates that the stage of research maturity we are at is still incipient in the national context.

While physicians traditionally lead ASP efforts, nurses play a central role in antimicrobial management, patient education, and infection prevention (18,20). Understanding and optimizing the role of nursing in ASP is essential for effective healthcare delivery. The priority discussed by the participants was the mapping of nurses' attributions in the ASP. There was emphasis on future research into the description of workflows, the general and specific attributions of front-line nurses in ASP and in the early detection of healthcare-associated infections (HAIs). Defining roles and responsibilities is an essential step in behaviour change to make the work environment more fluid and efficient. Studies have indicated that the lack of definition of roles is a considerable barrier to the implementation of ASPs, as it leads nurses further from their expected duties, generates interprofessional dissonance, lacks recognition, reduces productivity, and causes professional dissatisfaction (23,48,49).

During the mNGT discussions, the participants indicated that, although nurses already carry out activities related to the ASP, neither they nor other professionals consider these actions to be important for them to become part of the decision-making process. These findings were similar in the reviews published by Gotterson et al. (23) and Bos et al. (18) which both emphasize that nurses' contributions, despite being grounded in clinical practice, are not yet acknowledged as a component of the ASP.

Participants suggested research questions that reinforce the call for research into how to implement nurses' participation in ASPs, including identifying barriers to this participation. Although the Brazilian Health Regulatory Agency (Anvisa) has updated the national guideline for the development of ASPs in healthcare facilities, strategies for involving nurses were not yet addressed (50). One study (51) recommended utilizing tools such as PDCA to implement the role of nurses, in conjunction with a meticulous assessment of the organizational culture and obstacles, available resources, and workflows. A literature review (23) pointed to the advantages of applying the behaviour change theory as a strategy to encourage nurse engagement. However, none of these alternatives have been so far applied to the Brazilian scenario to assess the viability of these proposals.

Digital technologies and nurse engagement were also discussed during the mNGT. According to participants, by harnessing the capabilities of digital technologies, nurses can strengthen their contributions to antimicrobial stewardship efforts. These tools can empower nurses with the information, support, and resources needed to optimize antimicrobial use and promote responsible prescribing practices. Research has explored technological innovations in nursing education with significant results (52). An American study has described how technology, grouped into a set of ICT tools, can support nurses and doctors in making decisions about the prescription and administration of antimicrobials. Other resources, using artificial intelligence, are intended to implement alerts and notifications on patients' clinical condition and to carry out clinical audits on outcomes in ASPs. These resources are intended to implement alerts and notifications on patients' clinical condition and to carry out clinical audits on outcomes (53). Nonetheless, the utilization of ICT tools to aid nurses in ASP in Brazil still requires exploration, as it has the potential to enhance the knowledge and engagement of these professionals.

The limitations of this research are related to the limited number of participants, which is inherent to the NGT itself, which does not allow for more guests giving their opinion in each group. However, an attempt was made to minimise this limitation through proportional distribution in terms of regional representation and the participants' institutions of origin. The number of participants was representative, but not enough to allow an exhaustive approach to the subject. Another limitation was that not all the participants were able to discuss and vote on all 45 ideas, since they were organized into themed rooms, but considering the operational issue, this was a pragmatic decision from the researchers. Finally, the presentations offered to participants might have influenced their decisions about research priorities. However, as this is an incipient topic in Brazil, we believe that providing clear, relevant, and accurate information led to more discussions and better results, as well as collaboration towards a collective contribution from the participants in a fair and balanced way.

In Brazil, the priority research gaps concern the mapping of nurses' attributions and practical actions in these programmes, how to implement ASPs with the participation of nurses, and how the use of digital technologies can support the inclusion of nurses in ASPs. This indicates that these are still key issues in terms of knowledge and therefore need to be further explored in new research adapted to the Brazilian context. The development of this study led to the creation of a network of Brazilian nurses who will work to tackle AMR. The research questions that emerged during the mNGT in the form of research questions have been incorporated into the research and are currently being planned.

AMR

antimicrobial resistance

ASP

antimicrobial stewardship programmes

CNES

national register of health establishments

FINER

feasible, interesting, novel, ethical, and relevant

HAI

healthcare-associated infection

ICT

information and communication technology

IPC

infection prevention and control

mNGT

modified nominal group technique

NGT

nominal group technique

PHC

primary health care

Ethics approval and consent to participate

This research was assessed and approved by the Ethics Committee of the University of São Paulo School of Nursing (EEUSP) — CAAE: 55672722.9.0000.5392, with approval number 5.381.334.

All participants were informed about the purpose of the study and their implications. All participants have signed an informed consent form before taking part in the virtual workshop. As the data was collected in a virtual environment, all the prerequisites for research procedures at every stage were adhered to. All data related to this research was stored on a personal computer with a non-shared login and password. No records were maintained in the cloud.

Consent for publication

This manuscript does not contain data from any individual person.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary additional files]. Original data are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

The present research was not funded institutionally or by anyone else.

Authors' contributions

All authors formed the executive team and made substantial contributions towards the planning and conduct of the study, revised earlier versions of the manuscript and approved the final version for submission. MC, VN, ECS, RMF, MCP contributed as shared-senior supervisors who guided study conceptualization and reviewed the final version of the manuscript. VCLG carried out the data collection and analysis, writing original draft, review and editing. VCLG, LMA, AMSF, CLCS, RMF, MCP participated in the data collection as NGT facilitators. VCLG, LMA, MCP carried out content analysis.

Acknowledgements

We are very appreciative for the contribution of Tatiane Garcia do Carmo Flausino e Daniela Sanches Couto during the workshop. We are thankful to all Workshop Participants Group for sharing their valuable time: Monik Gomes do Nascimento Lousada, Claudia Silva Marinho, Eliana Auxiliadora Magalhães Costa, Nayara Carvalho Oliveira, Waldélia Monteiro, Beatriz Murata Murakami, Andreza Manhezi, José Rodrigues do Carmo Filho, Zilah Cândida Pereira das Neves, Viviane Gonçalves Sena, Glaucia Ribeiro Goncalves, Ieda Pontes da Cruz, Fernando Augusto Pinheiro, Camila Piuco Preve, Eliane Carlosso Krummenauer, Renata Neto Pires, Amanda Luiz Pires Maciel, Ana Claudia Cascardo, Daiane Patrícia Cais, James Francisco Pedro dos Santos, Lilian Farah, Maria Fernanda Zorzi Gatti, Meire Cristina Novelli e Castro, Mônica Taminato, Thatiara Cardoso da Silva and Tiago Cristiano de Lima.

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No competing interests reported.

Research priorities for nurses in antimicrobial stewardship in a middle-income country: a nominal group technique study

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Abstract

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