Research Proposal

Dissertation guide for write up

Font: Arial 12.

Aims of the Module
Students will develop critical appraisal skills in independent study to write a dissertation that
evaluates the quality and effectiveness of nursing care within their chosen field of nursing.

Learning Outcomes
Students who successfully complete this module will be able to:

Conduct a comprehensive and systematic review of the available literature. Critically engage and

analyse a range of relevant evidence, demonstrating the capacity to work independently and

organise work logically and coherently

Synthesise findings from research to evaluate the quality and effectiveness of the literature.

Critically discuss and analyse the implications of the findings and make recommendations for

continuing practice improvement for future nursing care.

Assessment

An 8000 word dissertation

Assessment description.

An 8000 word dissertation where students are required to
undertake independent study to develop a literature review, analyse findings and make
recommendations for practice within their own field of nursing

Assignment Guide
Writing your dissertation
The following is a guideline on how to structure your dissertation and what each

Chapter may include:

Chapter 1: Introduction: this is the chapter in which you introduce your topic area
and give a rationale for why you have chosen it. You will also explain how it relates
to your field of nursing, and include a summary of the main aspects of the topic area
contained in your dissertation, along with the aims and objectives of your project.

Chapter 2: Literature review: You will start by outlining your search questions and then outline your search strategy which includes details of your search terms and
how you formulated them using a framework such as PICO for example, if PICO is used or if they were truncated, MESH, Boolean or thesaurus terms used and in what
sequence you combined the terms using OR and AND to find your articles.
The inclusion and exclusion criteria used for selecting your literature should be outlined and evidence provided to support your decisions.
Acknowledgement that an appraisal of the literature (using a CASP tool or other appropriate critiquing tool) and synthesis of the literature findings outlining the themes, perspectives etc and how you reached them. These can be related to local, national and international policy backdrop.
You should ensure that your discussion and analysis of the findings from the literature is continually related back to the subject area of your dissertation. A data extraction table of the retrieved articles should be referred to and included in the appendix.
The critique of the literature (which may include book chapters, journal articles, policy and guidelines for example) takes place as an activity before you start writing your literature review chapter. The results of this critique are integrated into the narrative of the literature review and does NOT take the form of simply critiquing a small number of studies. The intention of the literature review is to create an eloquent explanation of the background and body of research evidence relating to your chosen subject. As stated above, this may be structured around themes, perspectives or a review of the historical development of your subject or the main themes relating to your subject. NB: thematic analysis or critique of literature is advised, discuss with as much literature as possible, with a similar theme or findings and critique including how they were not present in order bodies and what the possible reason could be.
Your literature review should flow logically and coherently so as to take the reader through your synthesis of the material in a clear, accurate and interesting manner. It should be noted that your search question should not be too broad, or you may run the risk of having too large a number of final articles to critique which may be unmanageable, given the word limit for this dissertation. Therefore, ensure that your initial search question is refined and concise to avoid this. You should critique ALL the relevant literature which addresses your search question and you DO Not choose the best ones and critique them only. This does not represent a thorough literature review of your subject and does not provide you with the opportunity to demonstrate your critical and analytical skills. If you fulfil all the above this will demonstrate a thorough and structured approach to your literature search and review which is expected for a piece of work like this at level 7
Chapter 3:strengths and limitations
This chapter offers opportunity for consideration and critique of limitations which could have affect the study. Eg. Financial constraint leading to exemption literature which require fees to access (remember to reference). You can also emphasize the strength of your work or methods.

Chapter 3: Recommendations for Practice: This Chapter offers you the
opportunity to consider what the findings of your literature review may mean for practice. For example, Does the literature review suggest a way practice may be improved? Does the review suggest a change to some aspect of care would improve the outcomes for patients or perhaps the experience of patients or staff? It could be that your literature review provides validation for current practice illustrating that care given is based on current best available evidence
Chapter 4: Conclusion: in this chapter you will summarise how you have achieved what you set out in your introduction. You should not be introducing any new information in your conclusion

References: using the APA referencing system as outlined in the Referencing
Guidance handbook. Please note that a bibliography is not required

Appendices: this should include the data extraction table from your literature search and any other relevant information. Information included in the appendices is not included in the word count.
This would include: data extraction table for your research including thematic grouping
Prisma flow diagram and casp tool or any tool used in the appraisal of literature.

Further instructions
Remember to justify your reason behind any approach used in your work e.g. justify your inclusion and exclusion criteria why are you excluding some literature and using some. Remember to reference every sentence or point made while critically discuss and analysing with appropriate and correct literature e.g. journals, articles…

NB: below is a research proposal however it is not required to be copied word for word and a new set of original search terms and method is to be developed in line with the dissertation needs.

Exploring the role of nurses in antimicrobial stewardship for the reduction of antibiotic misuse and antimicrobial resistance: A literature review
TOPIC OF INTEREST
The subject area of interest for the research proposal is antimicrobial resistance. In this subject area, the topic of focus is “exploring the role of the Nurses in Antimicrobial Stewardship for reducing antibiotics misuse and antimicrobial resistance”. Accordingly, the SPIDER framework has been applied in developing the research question which reads, “What is the role of Nurses in Antimicrobial Stewardship for reducing antibiotics misuse and antimicrobial resistance?.
According to Cooke et al., (2012), the SPIDER framework although derived from the PICO framework for research question formulation is considered an appropriate tool for formulating qualitative or mixed-method research questions for literature reviews. This is because unlike the PICO framework which focuses on the intervention and population and is commonly applied in quantitative studies (Methley et al., 2014), the SPIDER framework focuses more on the study design and samples to be utilized in qualitative research and less on intervention and populations (CSU, 2021). Additionally, the framework allows for the synthesis of qualitative evidence and can aid in the development of a search strategy to address the research question (Cooke et al., 2012). Considering the aforementioned, the SPIDER framework is considered appropriate for this qualitative literature review.
The breakdown of the research question using SPIDER framework is shown below:
Sample (S)…………………………Nurses
The phenomenon of Interest (PI)…. Antimicrobial stewardship for reducing antibiotic misuse and antimicrobial resistance
Design (D)………………………… focus groups, questionnaire, interviews, surveys, literature reviews.
Evaluation (E)………………………. Roles
Research type (R)…………………. Qualitative

Antimicrobial resistance is a known global health concern which has led to the call for rapid interventions from all stakeholders (Smith et al., 2015). Consequently, most hospitals worldwide have developed antibiotic stewardship programs to optimize antibiotic use and reduce antimicrobial resistance (Nathwani et al., 2019). However, (Gotterson, Buising & Manias, 2021) reports that majority of the implementation of these programs focuses on other health professionals, leaving out the nurses. Nevertheless, Major national and global health organizations have called for the formal involvement of nurses in the stewardship efforts by forming Nurses Antimicrobial Stewardship Programs, as nurses constitute the largest proportion of healthcare professionals and are involved in widespread activities related to antibiotic use (Gotterson, Buising & Manias, 2021). Therefore, failure to include nurses entirely will limit the success of these programs (Kuhn et al., 2021). Nevertheless, for a successful implementation, the role of nurses in reducing antibiotic misuse and antimicrobial resistance must be identified first.
Drawing from personal experience as a student nurse, working in the hospital especially during the outbreak of Carbapenemase Producing Enterobacteriaceae (antibiotic resistant bacteria) within the ward, the importance of nurses’ roles as well as their involvement and contributions in managing the antibiotic use and the antimicrobial resistance outbreak amongst patient has become clearer. However, there is paucity in literature which provide an overview of the nurses’ roles in antimicrobial stewardship for reducing antibiotic misuse and antimicrobial resistance (Kuhn et al., 2021), thereby making it difficult to not only identify these role nurses play as antimicrobial stewards, but also increase the difficulty in raising nurses’ awareness on their roles and its importance (Merrill et al., 2019). Thus, it is imperative that this paucity in literature be addressed (Merrill et al., 2019). This research therefore aims to explore the role of nurses in antimicrobial stewardship for the reduction of antibiotic misuse and antibiotic resistance. Upon completion the proposed research would not only explore the gap in literature but also provide fresh explanations or findings which could add to existing knowledge, serve as a base for further research, and provide a clear insight to the role of nurses in antimicrobial stewardship aimed at reducing antibiotic misuse and antimicrobial resistance which could positively aid in service improvement.
INTRODUCTION AND BACKGROUND
Antibiotics are widely acknowledged life-saving medicines used for treating bacterial infections (CDC,2021). Their significance on health can be seen in their use, which has resulted in lower incidence of bacterial infections and resulting fatality rates (Ventola, 2015). Even though antibiotics are among the most influential families of medications for treating bacterial diseases, its misuse has become a significant concern for healthcare organizations worldwide, and it is said to give rise to antimicrobial resistance (AMR) which is thought to occur when bacterial strains are treated with antibiotics inappropriately (CDC,2021).
Even with reasoned antibiotic administration, bacteria can choose from a variety of resistance routes. One of the resistance routes microorganisms like bacteria utilise is through changes in their genetics which occurs as a result of regular exposure to antibiotics in human and livestock (WHO, 2018; Aslam et al., 2018). Antibiotics are being overused in large quantities, especially in Asia and Africa where they can be obtained without prescription or illicitly (Llor and Bjerrum, 2014). Antibiotic use in humans is said to have increased by 46% between 2000 and 2018 (Browne et al., 2021), and as a result of covid is predicted to skyrocket as the medication is noted by Hsu, (2020) to be misused and overprescribed during the pandemic. According to O’Neill, (2016), if antibiotic usage is not controlled and antimicrobial resistance continues to develop as a result of this, more than 10 million people are predicted to die every year by 2050.
Antimicrobial drug resistance, which is partly caused by the misuse of antimicrobial compounds, is a serious public health burden that causes substantial morbidity and mortality and results in high economic cost (Martins & Rabinowitz, 2020). According to Dadgostar, (2019),antimicrobial resistance causes about 23,000 deaths per year and results in a cost of 55 billion dollars yearly in the United States of America alone. Additionally, it is noted to cause 700,000 deaths every year globally (O’Neill, 2016; Dadgoster, 2019). AMR is predicted to lead to a significant drop in the annual GDP of low- and middle-income countries (approx. 100-210 trillion dollars) by 2050 , and It has also resulted in a projected global cost of 16.7 trillion dollars being spent globally to address resistant tuberculosis only by 2050 (Dadgostar, 2019).
In order to address the issue of AMR due to antibiotic misuse, several policies and interventions were created by different governing bodies in different countries. An example of a suggested intervention is the Antimicrobial stewardship program which according to WHO, 2019 and Majumder et al., (2020) is often a strategy used by an organization or medical system to promote and regulate cautious antimicrobial use to protect their future viability. Antimicrobial stewardship is a comprehensive approach aimed at lowering significantly higher rates of antimicrobial misuse and antimicrobial resistance(NICE, 2014). It also includes recommendations for what should be incorporated in any antimicrobial stewardship strategy(Majumder et al., 2020).
Several studies have highlighted the importance of AMS, and Public health England one of the health bodies in England have joined in urging that more actions be taken by medical professionals including nurses with regards to becoming antimicrobial stewards (PHE, 2015). Nurses play an essential part in AMS, performing several activities ranging from drug management to recommendation development, including preparation, administration as well as disposal Which is part of their daily activities in hospitals (Kuhn et al., 2021). Thus, it is noted that the primary goal of antimicrobial stewardship for nurses is to improve medical outcomes while minimizing unanticipated adverse effects of antibiotic use, such as toxicity and resistance (Sloan & Dudjak, 2020).
Regardless of how vital nurses’ activities in AMS are to the reduction of antibiotic misuse and the resulting global burden (AMR), existing policy on AMS and its application to reducing antibiotic misuse and resistance focus mostly on the roles of prescribers or pharmacists and pay less attention to identifying the role of all nurses in AMS beyond infection control nurses (Sloan & Dudjak, 2020; Kuhn et al., 2021). Therefore, the awareness of nurses on their roles in AMS and how this relates to their everyday practice which could ultimately reduce antibiotic misuse and AMR is quite limited (Gotterson, Buising & Manias, 2021). Although nurses could be aware of issues leading to antimicrobial resistance, such as the misuse of antibiotics, the inappropriate prescribing of antibiotics, they may not link their activities in practice to AMR (Gotterson, Buising & Manias, 2021). This limitation in nursing awareness on their role as AMS could have negative implications on the bid to reduce antibiotic misuse as well as antimicrobial resistance (Kuhn et al., 2021).
Following a scoping review performed by the researcher on CINHAL database, it was observed that research which specifically explore the role of nurses in antimicrobial stewardship for reducing antibiotic misuse and antimicrobial resistance were limited (4). This findings are similar to findings of which also observed a similar occurrence in literature (Gotterson, Buising & Manias, 2021). Therefore, in order to address this issue and add to the existing body of knowledge as well as contribute to nursing awareness of their roles in AMS, this study aims exploring the role of nurses in antimicrobial stewardship for the reduction of antibiotic misuse and antibiotic resistance. Thus, providing a fresh explanation of current literature in line with the proposed research topic and research question to be addressed.

PLAN OF INVESTIGATION
AIM AND OBJECTIVES
Aim: The aim of this study is to explore the role of nurses in antimicrobial stewardship for the reduction of antibiotic misuse and antibiotic resistance.

Objectives:
1) identify the roles of nurses in antimicrobial stewardship.
2) explore how these roles aid in reducing antibiotic misuse and antimicrobial resistance.

METHOD OF LITERATURE REVIEW:
The method which would be utilized in reviewing the qualitative literature extracted for the proposed research would be a narrative method. This is suitable for answering the research question because it would enable the researcher to synthesize the different literature extracted and provide a comprehensive summary and fresh interpretation of findings (Bettany-Saltikov & McSherry, 2016), unlike the realist review method which only allows for the exploration of why or how an intervention works (Aveyard, Payne & Preston, 2021).
Additionally, the narrative review method allows for the interpretation of findings while considering peoples reality and opinions within a given context (Aveyard, Payne & Preston, 2021). This is in line with the interpretivist ontological underpinning which is the underpinning for the proposed research (McGregor, 2018).

SEARCH STRATEGY
This section encompasses the key search terms and the list of databases to be searched for the proposed literature review.

Key search terms
Majority of the key search terms to be utilized in addressing the research question, have been mapped using the SPIDER framework as shown in table 1 below:
SEARCH FRAMEWORK KEY SEARCH TERMS
Sample “Nurse” or “Nurses”
Phenomenon of Interest “Antimicrobial stewardship”, “Antimicrobial resistance”, “Antibiotic misuse”, “Reducing antibiotics misuse and antimicrobial resistance”, “reducing antibiotic misuse or use”, “reducing antimicrobial resistance”,
“Antimicrobial stewardship” and “Antibiotic misuse”
“Antimicrobial Stewardship” and “Antimicrobial resistance”
Design “Focus group”, “interviews”, “questionnaire”, “surveys”, “literature reviews”.
Evaluation “Roles”, “Responsibility”
Research Type “qualitative”
Table 1: Key search terms mapped on SPIDER framework.
NB: One example of the search term applied in a database is: “nurse” and “antimicrobial stewardship” and “roles” and “focus group” and “roles” and “qualitative”.

Electronic databases
The search terms identified would be utilized in searching electronic databases for published and peer reviewed articles as well as grey literature which are also in line with the study inclusion and exclusion criteria. The following electronic databases would be searched to extract existing literatures: Pub med, Medline, CINAHL, grey literatures, google scholar, Keele library search.

Study selection criteria; inclusion and exclusion criteria:
This is used in filtering the research obtained. In addition to the exclusion of studies which were not in English. Other exclusion and inclusion criteria are shown in table 2 below:
SEARCH FRAMEWORK INCLUSION CRITERIA EXCLUSION CRITERIA
S Nurses Other health professionals
PI Antimicrobial resistance and antibiotic misuse Antimicrobial medications and studies on other medical interventions
D Focus groups, interviews, survey, different literature reviews, questionnaires Case studies, cohort studies, RCT’s
E Roles or responsibility NIL
R qualitative Quantitative and mixed methods

Table 2: inclusion and exclusion criteria.

Methods of Data Collection and Analysis
This is a literature review and not primary research; hence did not involve data collection or analysis.
However, the qualitative literature obtained would be synthesized to provide a clear explanation of findings and identify the gaps in knowledge.

ETHICAL CONSIDERATIONS
Since this is not primary research, hence no need for ethical considerations. However, I understand the importance of research ethics and my responsibilities while undertaking a literature review. In a literature review, it is ethical to identify the authors of all articles reviewed, therefore all the authors of the literature reviewed would be appropriately referenced in line with the university guidelines.
CONCLUSION
Misuse of antibiotics has led to the rapid increase and spread of antimicrobial resistance globally. Consequently, antimicrobial stewardship programs have been created to enhance optimal use of antibiotics and reduce antibiotic resistance. Nevertheless, studies which specifically show the role of nurses in AMS to reduce AMR and antibiotic misuse are scare, thus there is a need for the proposed research in order to fill the research gap and add to existing literature.

TIMETABLE
The timetable showing the time management of the proposed research project is attached in Appendix 1.

REFERENCES
Aslam, B., Wang, W., Arshad, M., Khurshid, M., Muzammil, S., Rasool, M., Nisar, M., Alvi, R., Aslam, M., Qamar, M, et al., (2018). Antibiotic resistance: a rundown of a global crisis. Infection and Drug Resistance, Volume 11, pp.1645-1658, Available at https://www.dox.doi//10.2147/IDR.S173867.
Aveyard, H., Payne, S., & Preston, N. (2021). A post-graduate’s guide to doing a literature review in health and social care (2nd ed., pp. 15-93). England: Open university press.
Bettany-Saltikov, J., & McSherry, R. (2016). How to Do a Systematic Literature Review in Nursing (2nd ed.). England: McGraw-Hill Education (UK) Ltd.
Browne, A., Chipeta, M., Haines-Woodhouse, G., Kumaran, E., Hamadani, B., & Zaraa, S. et al. (2021). Global antibiotic consumption and usage in humans, 2000–18: a spatial modelling study. The Lancet Planetary Health. doi: 10.1016/s2542-5196(21)00280-1
CDC. (2021). Be Antibiotics Aware: Smart Use, Best Care | Patient Safety | CDC. Retrieved 7 December 2021, from https://www.cdc.gov/patientsafety/features/be-antibiotics-aware.html
Cooke, A., Smith, D., & Booth, A. (2012). Beyond PICO: The SPIDER Tool for Qualitative Evidence Synthesis. Qualitative Health Research, 22(10), 1435–1443. https://doi.org/10.1177/1049732312452938
CSU. (2021). Evidence-Based Practice: PICO and SPIDER. Retrieved 6 December 2021, from https://libguides.csu.edu.au/ebp/pico_and_spider
Dadgostar P. (2019). Antimicrobial Resistance: Implications and Costs. Infection and drug resistance, 12, 3903–3910. https://doi.org/10.2147/IDR.S234610
Gotterson, F., Buising, K., & Manias, E. (2021). Nurse role and contribution to antimicrobial stewardship: An integrative review. International Journal Of Nursing Studies, 117, 103787. doi: 10.1016/j.ijnurstu.2020.103787
Hsu, J. (2020). How covid-19 is accelerating the threat of antimicrobial resistance. BMJ, m1983. doi: 10.1136/bmj.m1983.
Kuhn, L., Van Huizen, P., Russo, P., & Connell, C. (2021). The nurses’ role in antimicrobial stewardship: A scoping review. International Journal Of Nursing Studies, 113, 103772. doi: 10.1016/j.ijnurstu.2020.103772
Llor, C. and Bjerrum, L. (2014). Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety, 5(6), pp.229-241. Available at: https://dx.doi.org/10.1177/2042098614554919
Majumder, M. A. A., Rahman, S., Cohall, D., Bharatha, A., Singh, K., Haque, M., & Gittens-St Hilaire, M. (2020). Antimicrobial stewardship: fighting antimicrobial resistance and protecting global public health. Infection and drug resistance, 13, 4713.
Martins, A., & Rabinowitz, P. (2020). The impact of antimicrobial resistance in the environment on public health. Future Microbiology, 15(9), 699-702. doi: 10.2217/fmb-2019-0331.
McGregor, S. (2018). Understanding and evaluating research. Thousand Oaks: SAGE Publications.
Merrill, K., Hanson, S., Sumner, S., Vento, T., Veillette, J., & Webb, B. (2019). Antimicrobial stewardship: Staff nurse knowledge and attitudes. American Journal Of Infection Control, 47(10), 1219-1224. doi: 10.1016/j.ajic.2019.03.022
Methley, A. M., Campbell, S., Chew-Graham, C., McNally, R., & Cheraghi-Sohi, S. (2014). PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC health services research, 14, 579. https://doi.org/10.1186/s12913-014-0579-0
Nathwani, D., Varghese, D., Stephens, J., Ansari, W., Martin, S., & Charbonneau, C. (2019). Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrobial Resistance & Infection Control, 8(1). doi: 10.1186/s13756-019-0471-0
NICE. (2014). Quality statement 1: Antimicrobial stewardship | Infection prevention and control | Quality standards | NICE. Retrieved 7 December 2021, from https://www.nice.org.uk/guidance/qs61/chapter/quality-statement-1-antimicrobial-stewardship
O’Neill, J. (2016). Tackling drug-resistant infections globally: final report and recommendations. [Pdf] united Kingdom: Amr-review.org. Available at: https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf [Accessed 7 Dec. 2021].
Penders, B. (2018). Ten simple rules for responsible referencing. PLOS Computational Biology, 14(4), e1006036. doi: 10.1371/journal.pcbi.1006036.
PHE. (2015). Make your pledge today and join over 17,000 Antibiotic Guardians. Retrieved 7 December 2021, from https://www.gov.uk/government/news/make-your-pledge-today-and-join-over-17000-antibiotic-guardians
Sloan, A. M., & Dudjak, L. (2020). Bedside Nurses: Champions of Antimicrobial Stewardship. Critical Care Nurse, 40(6), 16-22.
Smith, R. A., M’ikanatha, N. M., & Read, A. F. (2015). Antibiotic resistance: a primer and call to action. Health communication, 30(3), 309–314. https://doi.org/10.1080/10410236.2014.943634
Ventola C. L. (2015). The antibiotic resistance crisis: part 1: causes and threats. P & T : a peer-reviewed journal for formulary management, 40(4), 277–283.
WHO. (2018). Antimicrobial resistance. [Online]. Retrieved 7 December 2021, from https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
WHO. (2019). Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries. A practical toolkit. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0.