Study design

This was a cross-sectional survey study conducted from 18 January to 14 June 2023 involving nurses registered with Oman’s Ministry of Health (MOH). The survey used an adapted European Centre for Disease Prevention and Control (ECDC) questionnaire [16,17], Which has been used in previous studies, and permission to use the questionnaire was obtained from ECDC. Minor contextual adjustments were made to ensure relevance to the healthcare system in Oman while maintaining the original structure and intent of the questions. The original instrument was developed in English. The study survey was available in both English and Arabic to accommodate all participating nurses. The Arabic version was developed using a forward translation approach, in which the English questions were translated into Arabic by bilingual clinical experts. To ensure the meaning remained the same in both languages, a panel of bilingual specialists reviewed the final version for clarity and accuracy. During the study, participants used a Qualtrics platform to choose their preferred language before answering. The original ECDC instrument has demonstrated content validity in prior applications. As the questionnaire was adopted without structural modification and consisted primarily of knowledge-based items, internal consistency reliability testing was not re-assessed in the present study. The survey was distributed via the web-based Qualtrics software through the MOH’s email system and WhatsApp groups. The invitation message included information about the study objectives, voluntary participation, and confidentiality of responses. Participants were informed that completing the questionnaire implied their consent to participate in the study. Measures were implemented to ensure that each participant provided only one response. Participation was voluntary, and responses were anonymized and kept confidential.

The research approved by the Health Studies and Research Approval Committee in Muscat, Oman (Moh/DGPS/CSR/PRO/approved/137/2022) and the University of Huddersfield Research Integrity and Ethics Committee (SAS-SRIEC-21.12.22–1).

Survey tool

The behaviour is affected by an individual’s competence, opportunity, and motivation; therefore, the questionnaire was developed based on the COM-B behavioural change theory. The survey had seven sections. Section one collected demographic data (age, gender, governorate, profession, workplace, and experience). Section two measured respondents’ knowledge using eight true-or-false questions, including awareness of antibiotic usage, inappropriate usage, adverse effects, antibiotic resistance, and the application of antibiotics in the agricultural sector. Correct responses received one point on this scale, which ranges from 0 to 8. The third section used a 5-point Likert scale, along with “not applicable” or “I don’t understand” options, covering resistance in food and the environment, perceived knowledge, opportunities for prudent antibiotic use and infection management, and opportunities to support AMR control.

Section four asked three questions on the frequency of opportunities to provide antibiotics or resources, with response options ranging from more than once a day, more than once a week, once a day, once a week, never, rarely, “not applicable”, and “I do not remember”.

The fifth section covered resources used in managing infections. The sixth section enquired if nurses received information on avoiding unnecessary antibiotic administration and whether it changed their views and practices. The seventh section explored sources of information for improving antibiotic administration, and awareness of national initiatives and action plans within the country, as well as topics of interest to nurses.

Statistical analysis

A sample size of 375 was calculated using the Raosoft calculator (http://www.raosoft.com/samplesize.html), based on a 5% margin of error, a 95% confidence level (Z = 1.96), and a 50% response distribution. The calculation was based on a total of 14,361 nurses registered with the Ministry of Health in Oman, as reported in the MOH annual health report 2021. The calculated sample size was considered sufficient to provide a representative estimate of nurses working within the MOH healthcare system. Data were analyzed using IBM SPSS Statistics version 28.0 (IBM Corp., Armonk, NY, USA). In this study, only fully completed survey responses were included in the final analysis (n = 424). To ensure data quality, only surveys that were fully completed and saved by the platform were included in the final analysis. Incomplete entries, where participants exited before finishing, were automatically excluded during the data cleaning phase. Consequently, there were no missing values in the final dataset (n = 424) used for statistical analysis. Sociodemographic variables were reported as frequencies and percentages. Knowledge scores were summarized using the median and interquartile range and analyzed using the Mann-Whitney U test and the Kruskal-Wallis rank-sum test. In contrast, differences in full knowledge scores were assessed using chi-square or Fisher’s exact test, both two-tailed. The p-value threshold for statistical significance has also been specified. Univariable and multivariable linear regression analyses were performed to identify independent predictors of participants’ knowledge scores. Initially, all demographic variables were screened using univariable analysis. Variables with p-values < 0.20 or identified as clinically relevant were included in the final multivariable model to adjust for potential confounding. Statistical significance was defined as a two-tailed p-value < 0.05, and results were reported as unstandardized coefficients (B) with 95% confidence intervals (CI). To ensure the validity of the regression model, statistical assumptions, including normality, homoscedasticity, and multicollinearity (via Variance Inflation Factor, VIF), were verified and met.

Key findings

Demographics data.

A 424 nurses responded to the survey, 46.7% were originating from Muscat Governorate, and 49.3% of participants were aged 24–35 years. Most respondents (63.7%) were general nurses, and 81.1% worked in hospitals. There was a 31.8% participant-to-experience ratio between 11 and 15 years (Table 1).

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Table 1. Nurses’ sociodemographic characteristics (n = 424).

https://doi.org/10.1371/journal.pone.0342371.t001

Actual capability

Table 2 displays the nurses’ actual knowledge across eight questions: 64.2% and 48.8% correctly identified the ineffectiveness of antibiotics against viruses and colds, 93.2% recognized risks of overuse, and 74.1% acknowledged increased resistance. 58.5% understood the potential for spread of resistance, 66.3% knew that healthy individuals can carry resistant organisms, and only 21% were aware that antibiotic use in agriculture is legally restricted, indicating moderate overall awareness of AMR.

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Table 2. Respondents’ actual knowledge (n = 424).

https://doi.org/10.1371/journal.pone.0342371.t002

Table 3 presents the multivariable linear regression model, while the univariable linear regression results are provided in Supplementary S1 Table in S3 File. The final model demonstrated a statistically significant (F = 4.546, p < 0.001), with an Adjusted R² of 0.091. This indicates that the included demographic predictors collectively account for 9.1% of the variance in the participants’ knowledge scores. After adjusting for potential confounders, gender and years of practice emerged as the only independent predictors of knowledge. Specifically, male nurses achieved significantly higher knowledge scores than their female counterparts (B = 0.678, 95% CI: 0.271–1.084, p = 0.001). Regarding professional experience, staff with 16–20 years of practice demonstrated positive association with knowledge (B = 1.116, 95% CI: 0.419–1.813, p = 0.002), followed by those with 21–25 years (B = 1.053, p = 0.021) and >25 years (B = 1.683, p = 0.023) of experience. Notably, while age groups and professional specialisms were significant in univariable screening, they lost statistical significance in the multivariable model (p > 0.05), suggesting that the observed effects of age were largely confounded by accumulated years of professional practice. Collinearity diagnostics confirmed the model’s stability, with all Variance Inflation Factors (VIFs) remaining below 5.0 model’s stability, with all Variance Inflation Factors (VIFs).

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Table 3. Multivariable linear regression analysis of the relationship between knowledge scores and demographic characteristics of respondents.

https://doi.org/10.1371/journal.pone.0342371.t003

S2 Table presents the differences in median knowledge scores across demographic groups. The bivariate analysis revealed that gender was a significant factor, with male nurses achieving higher median scores than female nurses (6.0 vs 5.0; p = 0.008). Similarly, age played a critical role (p < 0.001), with the 46–55-year-old age group demonstrating the highest knowledge levels. In Oman, nurses generally complete a diploma followed by a bachelor’s degree, with some pursuing further specialization. Nurses with specialisms—those with higher diplomas or additional training in areas such as emergency care, critical care, infection control, maternity, or management—showed significant median knowledge scores (p = 0.008; S2 Table in S3 File). Finally, clinical experience is significantly related to expertise, with nurses with over 25 years of practice recording the highest median score (6.5; p < 0.001).

S3 Table in S3 File compares demographic factors between participants with full knowledge (n = 15) and those with incomplete scores (n = 409). Statistical analysis using Fisher’s Exact test revealed that gender (p = 0.007), age (p = 0.024), and governorate (p = 0.036) were significantly associated with achieving a perfect score. Notably, while males represented a small portion of the total sample, they accounted for 40% of the full-knowledge group. In contrast, profession, place of practice, and years of experience did not significantly influence the likelihood of achieving a perfect score (p > 0.05).

Perceived capability and opportunity

Data in Table 4 show that 79.5% of nurses agree or strongly agree that they are aware of antibiotic resistance, 81.8% indicate they have sufficient information regarding antibiotic use, and 86.4% report being able to educate others about antibiotic resistance.

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Table 4. Nurses’ perceived knowledge (n = 424).

https://doi.org/10.1371/journal.pone.0342371.t004

Over 72.6% and 65.8% of the respondents strongly agreed that they had easy access to guidelines and materials to advise others regarding resistance. In comparison, 73.6% reported opportunities to educate individuals about prudent antibiotic use (Table 4).

Motivation and one health

Seventy-two percent of respondents agreed that they are aware of the link between antibiotic use and the spread of resistance, and 72.2% acknowledged their key role in controlling it (Table 4).

Table 4 presents a One Health-related question, revealing that around 53% of respondents agreed that excessive antibiotic use in livestock and food production, as well as environmental factors, contributes to antibiotic resistance in bacteria affecting humans, reflecting the One Health concept, which emphasizes the interconnection between people, animals, plants, and their shared environment. Meanwhile, 65.3% were unsure about the legality of antibiotic use on animal farms (Table 2).

Behaviour

Table 5 presents nurses’ behaviour in promoting the appropriate use of antibiotics: 42.2% administered antibiotics at least once daily, 65.8% did not provide adequate information on proper use and infection management, and 39.3% offered little to no guidance on responsible use.

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Table 5. The frequency with which nurses provided antibiotics or resources related to the prudent use of antibiotics (n = 424).

https://doi.org/10.1371/journal.pone.0342371.t005

Table 6 shows that 55% of the nurses received information on avoiding unnecessary antibiotic use, with 92.7% reporting it changed their opinions and 91.7% stating it influenced their antibiotic administration practices.

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Table 6. Number of respondents (%) who received information on avoiding unnecessary administration of antibiotics and, of those, the number (%) reporting that the information contributed to changing their views or practice.

https://doi.org/10.1371/journal.pone.0342371.t006

The survey reveals that over 72.6% of participants received workplace advice on minimizing the use of unnecessary antibiotics, leading to a change in the views of 66.3%. Over 24.8% gained knowledge via social media, with only 16% altering their practices (Fig 1).

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Fig 1. Sources of information about avoiding unnecessary administration of antibiotics and their influence on changing nurses’ views (n = 424).

https://doi.org/10.1371/journal.pone.0342371.g001

Awareness of the Oman National Action Plan and National Initiatives

Among the nurses surveyed, 59% showed awareness of the Oman National Action Plan on antibiotic resistance, 5% were unaware of it, and 36% were unsure whether the country had a National Action Plan.

Surveys on antibiotics and resistance initiatives revealed that professional organizations educated 43.3% of respondents, 38.7% were aware of national or regional infection management protocols, and 32.3% were familiar with healthcare toolkits. Approximately 23.1% of respondents were aware of World Antibiotic Awareness Week, and 10.6% indicated no awareness of these activities (S4 Table in S3 File).

Resources for managing infections and information gaps highlighted by nurses

S5 Table in S3 File shows that nurses primarily used clinical practice guidelines (58.7%) to manage infection, followed by continuing education (36.6%), consultation with infection specialists (34.9%), social media (22.6%), and 2.8% reported using no resources.

S1 Fig indicates nurses’ information needs: 54.7% wanted guidance on antibiotics for specific medical conditions, 52.1% wanted to know about antibiotic resistance, 41.5% wanted to understand how to use antibiotics, 30.4% requested to learn how to get prescriptions, and 30% needed to know how the link between human, animal, and environmental health.

The results of this study highlighted the need to enhance understanding of AMR and to increase nurses’ knowledge.

Knowledge and awareness of antimicrobial resistance among nurses

The study was carried out with nursing professionals working across healthcare institutions within the Ministry of Health in Oman. Only 15 of 424 (3.5%) nurses completed all actual knowledge questions correctly in our survey. 45.1% of nurses reported not receiving or recalling instructions on antibiotic avoidance in the past year. Clinical practice guidelines are used by 58.7% of nurses, and 72.6% find them easy to access.

Our findings show that nurses demonstrated a moderate level of knowledge about antibiotic resistance. In contrast, a European study revealed a high level of knowledge, but an opposite result regarding the amount of sufficient information they have about antibiotic use in their practice [17]. A study conducted in Saudi Arabia revealed moderate knowledge and positive attitudes, but no significant relationship between them [11]. Higher education and training may support more positive attitudes, but not better knowledge [11]. In our study, 51.1% of nurses incorrectly believed that antibiotics are effective against the common cold. This result is highly consistent with a similar study in Saudi Arabia, which found that 53% of participants held the same misconception [18]. These findings suggest that a significant number of healthcare providers in the region still struggle to distinguish between viral and bacterial infections.

Regarding the use of antibiotics for viral infections, 64% of nurses in our study correctly identified them as ineffective. This is a better result than a similar study in India, where 54% of participants incorrectly agreed that antibiotics should be used for viral infections [19]. While our findings show a higher level of awareness, there remains a 36% knowledge gap that needs to be addressed through education.

Our findings indicate that above 53% of nurses believe that environmental factors and the overuse of antibiotics in food production significantly contribute to antibiotic resistance in humans.

At the same time, the percentage is higher, at around 88%, regarding the excessive use in livestock and around 67% agreed that environmental factors contribute to AMR [20]. Our nurses have a limited understanding of the prohibited use of antibiotics in animal growth, compared to 47% in a similar Italian study [20].

The study revealed that 41% of nurses had limited awareness of the Oman National Action Plan against antibiotic resistance, underscoring the need for all nurses to be informed about the plan and the use of antibiotics in agriculture [21]. A study conducted in Italy among ICU staff also revealed low awareness of national and international AMR campaigns [20]. Similarly, our findings suggest that the low awareness of AMR initiatives both nationally and internationally needs to be addressed.

Nurses’ role and barriers in antimicrobial stewardship

Our findings suggest that nurses play a crucial role in mitigating antibiotic resistance. Previous studies have highlighted their role in antibiotic use and the implementation of antimicrobial stewardship programs [22,23]. Evidence from the literature shows that nurses demonstrate strengths in assessing adverse drug reactions, obtaining cultures, and educating patients; however, they often report low confidence in interpreting microbiology results [24]. To enhance their contributions to AMS, clear role definitions, leadership support, and additional research are needed [25,26]. In our survey, nurses reported gaps in knowledge and confidence related to antibiotics. However, the literature also identifies broader barriers to nurses’ involvement in AMS, including patient influence, environmental factors, underlying beliefs, attitudes, and lack of cooperation from prescribers [27,28].  These findings emphasize the importance of educational and training programs in strengthening nurses’ clinical assessment and communication skills with both patients and healthcare teams, which may improve patient outcomes and enhance nurses’ contributions to the care of patients with AMS [27,28].

In this study, 29% of nurses reported administering antibiotics more than once daily. While they support optimal use, their integration and competency in AMS remain limited, highlighting the need for stronger education, training, and institutional support [29].

Education, training, and future directions

In Oman, formal training specifically dedicated to antimicrobial resistance (AMR) is not currently a standardized part of the national nursing curriculum. Instead, education is primarily provided through hospital-based Infection Prevention and Control (IPC) programs and Antimicrobial Stewardship (AMS) activities. The availability of these resources varies by workplace; nurses in large tertiary hospitals often have more access to specialized workshops and bedside clinical teaching compared to those working in primary healthcare centers.

Our findings highlight the importance of nurses enhancing their understanding of antibiotic use and resistance. Therefore, specialized training is needed to equip them with the knowledge, skills, and attitudes required to combat AMR, with WHO and CDC programs offering valuable support in areas such as antimicrobial stewardship, infection prevention and control, surveillance, and communication skills [26,30,31].

Research has shown that nurses’ training in AMS activities leads to improvements in AMS behaviours [32]. As our data indicate that nurses require further education and support to optimize antibiotic use, enhancing training in areas such as microbiology and pharmacy, alongside leadership support, may encourage stronger AMS involvement [33]. The nurses felt excluded from responsibilities and training related to AMR [34]. Although they are aware of the importance of hand hygiene, they hold a negative perception of it and struggle to maintain good hand hygiene standards in practice [35].

Our results showed that over 72.6% of nurses received information about the unnecessary administration of antibiotics in their workplace, and around 66.3% changed their view accordingly. Nursing facilities lack formal AMS and access to infectious disease experts, with programs often led by nurses or infection preventionists, and limited involvement from pharmacists and medical directors, leading to high antibiotic use and complex decision-making [36]. Communication gaps between the prescribers and the nurses also persist [36]. A systematic review found that AMS in nursing homes reduced antibiotic prescriptions and improved adherence to guidelines, but had no significant effect on mortality, infection rates, or hospitalization rates [37]. Integrating diagnostic stewardship into nursing education and practice is essential to strengthen knowledge of AMR, specimen handling, culture use, and interpretation of diagnostic reports [10].

This study showed that 65.8% and 39.3% of nurses either never or rarely, educate patients on the use and resistance to antibiotics. In the Arab population, limited knowledge, misconceptions, and self-medication are common, highlighting the need for public health campaigns, patient education, and stricter regulations on antibiotic distribution [38].

This study’s strengths include being the first in Oman to assess nurses’ knowledge, attitudes, and behaviours on antibiotic use and resistance, using validated ECDC instruments, a large sample, and bilingual questionnaires to enhance accessibility. However, its cross-sectional design limits causal inference, self-reported responses may introduce bias, and findings may not fully represent nurses outside the Ministry of Health, highlighting the need for further research.