Nurse prescriber's understanding of their antimicrobial stewardship role: a qualitative study.

Introduction Antimicrobial resistance is an infectious disease threat to public health globally, and antimicrobial stewardship among healthcare professionals is one key way to address this potential problem. Registered nurse designated prescribers are the newest group of health professionals to gain prescribing authority in Aotearoa New Zealand, yet little is known about their understanding of their antimicrobial stewardship role. Aim The aim of this study was to explore registered nurse designated prescribers' understanding of their antimicrobial stewardship role through their prescribing practices and approaches to clinical reasoning. Methods This exploratory descriptive qualitative study used individual semi-structured interviews with six registered nurse designated prescribers. Thematic analysis was used to analyse the interviews. Results Four themes were identified: antibiotic prescribing practices and antimicrobial resistance; clinical indicators for prescribing antibiotics, with the sub-themes of history taking, presence of infection and bacterial versus viral infection; patient education; and safety and monitoring. These themes provide insight into registered nurse designated prescribers' understanding of their antimicrobial stewardship role and prescribing of antibiotics. Discussion This research found that the registered nurse designated prescribers had an awareness of the importance of their antimicrobial stewardship role in relation to antibiotic prescribing and reducing antimicrobial resistance. Education about antimicrobial resistance and antimicrobial stewardship for this professional group can be effective, but further research is needed to understand their ongoing educational needs.

Assessing antibiotic prescribing in nurse practitioners: Applied cognitive task analysis.

Background: Prescribing antibiotics is a demanding and complex task where decision-making skills are of critical importance to minimize the risk of antimicrobial resistance. Despite its importance, little is known about the decision-making skills and cognitive strategies new Nurse Practitioners (NPs) use when prescribing antibiotics. Objective: To identify the cognitive demands of antibiotic prescribing complexity and to explore the cognitive strategies that new NPs in New Zealand use when prescribing antibiotics. Design: A qualitative approach using Applied Cognitive Task Analysis (ACTA) methodology. Participants: A purposive sample was recruited consisting of five NPs who had been registered within the last five years and were prescribing antibiotics as part of their scope of practice. Methods: In-depth face-to-face interviews consisting of a task diagram interview and a knowledge audit were conducted and analyzed following the ACTA protocol. Results: Four cognitive elements were identified from the data which showed the cognitive demands of prescribing antibiotics, and the cues and strategies NPs use for safe practice. These were: 1 prescribing in the face of uncertainty (complex patients and diagnostic uncertainty); 2 making clinical decisions with insufficient/poor guidance (lack of guidelines, conflicting information); 3 producing an individualized treatment plan in view of clinical and non-clinical patient factors (patient demand/expectation, inadequate patient education, risks versus benefits of antibiotic treatment); 4 ensuring treatment efficacy and continuity of care (ineffective treatment, patient care follow up). Conclusion: The ACTA framework has given insight into the current antibiotic prescribing practice of new NPs, identifying areas where professional development courses and treatment resources can be targeted to support antibiotic prescribing. NPs are likely to benefit from resources that are freely available and reflect national or local antimicrobial data. Further work is also warranted to determine whether targeted education resources and clinical pathways will help with diagnostic uncertainty, and how this could be embedded into existing curricula.

Performativity, identity formation and professionalism: Ethnographic research to explore student experiences of clinical simulation training.

Developing professional identity is a vital part of health professionals' education. In Auckland four tertiary institutions have partnered to run an interprofessional simulation training course called Urgent and Immediate Patient Care Week (UIPCW) which is compulsory for Year Five medical, Year Four pharmacy, Year Three paramedicine and Year Three nursing students. We sought to understand student experiences of UIPCW and how those experiences informed student ideas about professional identity and their emergent practice as health professionals within multidisciplinary teams. In 2018, we commenced ethnographic research involving participant observation, field notes, interviews, photography and observational ethnographic film. A total of 115 students participated in this research. The emergent findings concern the potentially transformative learning opportunity presented within high fidelity multi-disciplinary simulations for students to develop their professional identity in relation to peers from other professions. Our work also exposes the heightened anxiety and stress which can be experienced by students in such interdisciplinary simulations. Student experience suggests this is due to a range of factors including students having to perform in front of peers and staff in such simulation scenarios when their own professional identity and capabilities are still in emergent stages. Staff-led simulation debriefs form a critical success factor for transformative learning to be able to occur in any such simulations so that students can reflect on, and move beyond, the emotion and uncertainty of such experiences to develop future-focused concepts of professional identity and strategies to support effective interprofessional teamwork.

Identifying the nontechnical skills required of nurses in general surgical wards.

AIMS AND OBJECTIVES: To identify the nontechnical skills (NTS) required of nurses in general surgical wards for safe and effective care. BACKGROUND: As the largest occupational group, nurses are in an ideal position to block the vulnerabilities of patient adverse events in a surgical ward. Previous studies in the surgical environment have identified the NTS required of nurses for safe care in operating rooms; however, these skills have not been identified for nurses in general surgical wards. DESIGN: A nonparticipant observational descriptive design was used. METHOD: A purposive sample of 15 registered nurses was recruited from four surgical wards and observed for a full shift on a morning, afternoon or night shift. Nonparticipant observations were conducted using field notes to collect data. A coding frame was developed, and an inductive process was used to analyse the data. RESULTS: A taxonomy comprising seven NTS required of nurses in their roles in surgical ward teams emerged from the data analysis. They are communication, leadership and management, planning, decision-making, situation awareness, teamwork and patient advocacy. CONCLUSION: Patient care provided by general surgical nurses involved the seven identified key NTS. These particular NTS are an important component of safe nursing practice as they underpin the provision of safe and effective care for general surgical patients. Nurses block the trajectory of error by using NTS to address the vulnerabilities in the system that can lead to adverse patient events. RELEVANCE TO CLINICAL PRACTICE: Identifying general surgical nurses' NTS enables the development of teaching strategies that target the learning of those skills to achieve successful work outcomes and improve patient safety.

Inpatient hypoglycaemia: a study of nursing management.

Optimised glycaemic management during hospital admission is critical to good patient outcomes. Inpatient hypoglycaemia is associated with increased morbidity and mortality during the hospital stay and post-discharge. To mitigate the deleterious effects of hypoglycaemia, many hospitals have an inpatient protocol to guide clinicians. Earlier research has shown that nurses fail to follow such protocols. This descriptive study used a retrospective audit of inpatients' treatment and progress notes to examine nursing adherence to a hypoglycaemia protocol. Adult medical and surgical inpatients with Type 1 or Type 2 diabetes mellitus and who had experienced hypoglycaemia during a three month period were included. One hundred and seventeen episodes of hypoglycaemia were identified in 32 patients who met the inclusion criteria. A predominance of these, 29 patients (90.6%), had Type 2 diabetes with 20 (62.5%) of the sample being medical patients. Diabetes medications included the use of insulin only (n = 18, 56.2%), oral hypoglycaemic agents only (n = 9, 28.1%) and five patients (15.7%) received a combination of these therapies. Three of the 117 episodes were treated with administration of intravenous glucose whilst the remaining 114 episodes were able to be treated with oral therapy. The recommended oral treatment to correct hypoglycaemia is 9-15 grams of glucose only. Adherence to most steps of the hypoglycaemia protocol was low. Initial treatment with glucose was administered in 46 (40.4%) cases. The required repeat capillary blood glucose test in 10-15 minutes was obtained in 35 (30.7%) cases. Within thirty minutes of detection, only 36.7% of episodes were corrected. A high degree of prolonged and recurrent hypoglycaemia was identified, with 40% of the episodes lasting more than one hour, and 72% of patients having more than one hypoglycaemic episode during their admission. Recommendations from the study include review of the hypoglycaemia protocol, development of strategies to help nurses prioritise the management of hypoglycaemic episodes, ongoing education for nurses, and regular re-audit.

Developing education tailored to clinical roles: genetics education for haemophilia nurses.

BACKGROUND: Genetics is an important component of the clinical work of haemophilia nurses, but little was known about the genetic education needs of haemophilia nurses. AIM: To develop, deliver and evaluate genetic education for haemophilia nurses, based on clinical roles. METHODS: Perceived relevance of genetics to haemophilia nursing practice was explored using electronic voting (response rate 75%, 58/77). A follow-on questionnaire to a volunteer sample of participants explored educational preferences (response rate 41%, 17/41). Results informed development of a two-hour genetics workshop session, evaluated by questionnaire (response rate 67%, 47/70). RESULTS: Genetic competences were considered relevant to the clinical practice of haemophilia nurses, and learning needs were identified. Preference was expressed for education focused on practical skills. During the subsequent workshop, participant confidence ratings significantly increased in the four areas addressed. Planned changes to clinical care and training were reported. CONCLUSION: Within new areas of advanced nursing practice, learning needs can be addressed by: identifying relevant clinical activities and associated learning needs; creating a strategy and resources using preferred forms of delivery; implementing the strategy; and evaluating its effect. This will enable development of education that addresses the real needs of practising nurses, grounded in their daily clinical practice.

Genetics and paediatric nursing.

In response to major research initiatives in genetics, the government has invested significantly in new programmes of research and development for NHS staff (Department of Health (DH) 2003. Nurses may feel that these programmes have not yet impacted on their area of practice and are unlikely to for some time. Other priorities may be felt to be more important. This article considers the impact of genetics on the work of nurses who care for children and young people. It introduces a short questionnaire which we are using to identify and fill any gaps in knowledge, training and resources for nurses to prepare them to 'realise the potential of genetics' (DH 2003) in their practice.

The effect of nateglinide taken with food on gastric emptying rates in healthy subjects.

OBJECTIVES: The aim of this study was to determine the effect of the timing of food intake on the pharmacokinetics and pharmacodynamics of oral nateglinide 60 mg and the effect of nateglinide on the rate of gastric emptying. METHODS: A randomized, double-blind, placebo-controlled, single-dose, 6-period, crossover study conducted in healthy male volunteers aged 18 to 50 years. On 5 occasions, subjects received a single 60-mg tablet of nateglinide at -30, -10, -5, -1, or 40 minutes from the start of a standard metal. Treatment blind was maintained by administration of placebo tablets at all other time points. On the sixth occasion, subjects received placebo tablets at all dosing time points. Each subject received acetaminophen 1 g at the beginning of the standard breakfast on each treatment day as an indicator of the rate of gastric emptying. Plasma samples were collected over a 6-hour period to determine nateglinide, glucose, insulin, and acetaminophen concentrations. RESULTS: Twelve white men with a mean (SD) age of 30 (6.8) years (range, 21-47 years) and mean (SD) weight of 73.3 (11.0) kg completed all 6 periods of the study. Nateglinide absorption was faster when administered at -5 or -10 minutes relative to food, as characterized by higher nateglinide area under the concentration-time curve from 0 to 5 hours (AUC(0-5)) and maximum plasma concentration (C(max)) values, compared with those observed at other dosing time points. Mean time to C(max) (T(max)) was also shorter when nateglinide was given at -10 minutes versus other dosing time points. Mean nateglinide half-life was similar for all 5 treatments (range, 81.3-94.6 minutes). The overall treatment effect was statistically significant for nateglinide AUC(0-5) (P = 0.031), C(max) (P = 0.001), and T(max) (P < 0.001). Insulin T(max) was shorter after nateglinide administration at -30 or -10 minutes, which was associated with lower glucose C(max) values (-30 minutes, P < 0.05) and a tendency for lower glucose AUC(0-5) values (-10 minutes, P = NS). NS). No treatment effects were observed for any of the acetaminophen indices, as demonstrated by the absence of any change in acetaminophen T(max) or C(max) value. CONCLUSIONS: Nateglinide was well tolerated and no treatment-limiting adverse events were reported in the population studied. Nateglinide administration appeared to have no effect on the rate of gastric emptying as indicated by acetaminophen indices, regardless of the time of nateglinide administration. The findings imply that the time for nateglinide administration to obtain optimal pharmacodynamic effects is prior to food consumption.