Antimicrobial stewardship as a jurisdictional project: A grounded theory of nursing roles in the intensive care unit

Antimicrobial stewardship (AMS) is a systematic programme to optimise antimicrobial use and forms a key pillar of the strategies that are developed to address the global threat of antimicrobial resistance. Nurses constitute the highest number of healthcare professionals, and engagement of nursing is key to AMS. Intensive care units (ICUs) have a high-volume antimicrobial use, and yet nursing integration in AMS in the ICUs is undertheorised. Using constructivist grounded theory, we conducted 36 in-depth interviews with ICU clinicians in two Australian hospitals to explore the processes involved in navigating their roles in AMS. The resulting theory, metaphorised as ‘ Setting a bonfire in a newfound cave ’ mapped a phased process of integration reflecting the situated and variable ways nurses encounter, interpret and engage with AMS in practice. Beyond clinical insights, this study theorises AMS as jurisdictional project where nurses negotiate limits of expertise and authority, while navigating organisational and interprofessional challenges. Findings reframe AMS as a politics of care wherein players experience tensions between bureaucratic constraints and ethical obligations. The resulting theory specified the processes required to embed AMS into the core of nursing identity and practice. Situating the discretionary actions of nurses within logic and bureaucracy, we offer nuanced accounts and perspectives of how power, hierarchy and cultural norms influence and shape implementation of innovative strategies such as AMS. The theoretical insights of this study contribute to health sociology, ethics of care and implementation studies by illustrating how authority and transactions in AMS are negotiated, shared and redistributed in practice.