The application of antimicrobial stewardship knowledge to nursing practice: A national survey of United Kingdom pre-registration nursing students.

AIM: To assess student nurses understanding and skills in the application of antimicrobial stewardship knowledge to practice. DESIGN: Quantitative. METHODS: Cross-sectional survey. RESULTS: Five hundred and twenty three student nurses responded across 23 UK universities. Although students felt prepared in competencies in infection prevention and control, patient-centred care and interprofessional collaborative practice, they felt less prepared in competencies in which microbiological knowledge, prescribing and its effect on antimicrobial stewardship is required. Problem-based learning, activities in the clinical setting and face-to-face teaching were identified as the preferred modes of education delivery. Those who had shared antimicrobial stewardship teaching with students from other professions reported the benefits to include a broader understanding of antimicrobial stewardship, an understanding of the roles of others in antimicrobial stewardship and improved interprofessional working. CONCLUSION: There are gaps in student nurses' knowledge of the basic sciences associated with the antimicrobial stewardship activities in which nurses are involved, and a need to strengthen knowledge in pre-registration nurse education programmes pertaining to antimicrobial management, specifically microbiology and antimicrobial regimes and effects on antimicrobial stewardship. Infection prevention and control, patient-centred care and interprofessional collaborative practice are areas of antimicrobial stewardship in which student nurses feel prepared. Interprofessional education would help nurses and other members of the antimicrobial stewardship team clarify the role nurses can play in antimicrobial stewardship and therefore maximize their contribution to antimicrobial stewardship and antimicrobial management. IMPLICATIONS FOR THE PROFESSION: There is a need to strengthen knowledge from the basic sciences, specifically pertaining to antimicrobial management, in pre-registration nurse education programmes. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. IMPACT: What Problem Did the Study Address? Nurses must protect health through understanding and applying antimicrobial stewardship knowledge and skills (Nursing and Midwifery Council 2018); however, there is no research available that has investigated nurses understanding and skills of the basic sciences associated with the antimicrobial stewardship activities in which they are involved. What Were the Main Findings? There are gaps in student nurses' knowledge of the basic sciences (specifically microbiology and prescribing) associated with the antimicrobial stewardship activities in which nurses are involved. Problem-based learning, and activities in the clinical setting, were reported as useful teaching methods, whereas online learning, was seen as less useful. Where and on Whom Will the Research Have an Impact? Pre-registration nurse education programmes. REPORTING METHOD: The relevant reporting method has been adhered to, that is, STROBE.

Adapting the Nominal Group Technique to a virtual version: an experience report.

OBJECTIVE: To report on the adaptations made to the original Nominal Group Technique (NGT), allowing it to be applied to the virtual format, preserving all its key elements. METHOD: An experience report on the adaptations and adjustments made to the original NGT to the virtual format using Information and Communication Technologies (ICT), using digital tools that are available free of charge or are low cost and easy to use. RESULTS: The NGT was carried out entirely virtually and underwent adaptations in each of its four stages through the incorporation of specific digital resources. It was possible to present the most voted ideas and obtain final approval from the participants. The participants had no difficulty in using the virtual resources provided and, based on the reaction evaluation, they were satisfied with the tools provided. CONCLUSION: The adapted NGT proved to be an effective method when used in a virtual setting, capable of producing a significant number of ideas and developing consensus. The adapted tool can be used by other researchers in countries with similar resources or dimensions to Brazil.

Adapting the Nominal Group Technique to a virtual version: an experience report / Adaptación de la Técnica del Grupo Nominal a una versión virtual: informe de una experiencia / Adaptação da Técnica de Grupo Nominal para versão virtual: relato de experiência

ABSTRACT Objective: To report on the adaptations made to the original Nominal Group Technique (NGT), allowing it to be applied to the virtual format, preserving all its key elements. Method: An experience report on the adaptations and adjustments made to the original NGT to the virtual format using Information and Communication Technologies (ICT), using digital tools that are available free of charge or are low cost and easy to use. Results: The NGT was carried out entirely virtually and underwent adaptations in each of its four stages through the incorporation of specific digital resources. It was possible to present the most voted ideas and obtain final approval from the participants. The participants had no difficulty in using the virtual resources provided and, based on the reaction evaluation, they were satisfied with the tools provided. Conclusion: The adapted NGT proved to be an effective method when used in a virtual setting, capable of producing a significant number of ideas and developing consensus. The adapted tool can be used by other researchers in countries with similar resources or dimensions to Brazil.

RESUMEN Objetivo: Informar sobre las adaptaciones realizadas a la Técnica de Grupo Nominal (TGN) original, permitiendo su aplicación al formato virtual, preservando todos sus elementos clave. Método: Se trata de un informe de experiencia sobre las adaptaciones y ajustes realizados a la TGN original para el formato virtual mediante el uso de las Tecnologías de la Información y la Comunicación (TIC), utilizando herramientas digitales disponibles de forma gratuita o de bajo coste y fácil uso. Resultados: El TGN se realizó íntegramente de manera virtual y sufrió adaptaciones en cada una de sus cuatro etapas mediante la incorporación de recursos digitales específicos. Fue posible presentar las ideas más votadas y obtener la aprobación final de los participantes. Los participantes no tuvieron dificultades para utilizar los recursos virtuales proporcionados y, según los comentarios recibidos, se mostraron satisfechos con las herramientas facilitadas. Conclusión: El TGN adaptado demostró ser un método eficaz cuando se utiliza en un entorno virtual, capaz de producir un número significativo de ideas y desarrollar el consenso. La herramienta adaptada puede ser utilizada por otros investigadores en países con recursos o dimensiones similares a las de Brasil.

RESUMO Objetivo: Relatar as adaptações realizadas na Técnica de Grupo Nominal (TGN) original, permitindo sua aplicação ao formato virtual, preservando todos os seus elementos-chave. Método: Relato de experiência sobre as adaptações e adequações realizadas na TGN original ao formato virtual aplicando as Tecnologias da Informação e Comunicação (TIC), por meio de ferramentas digitais disponibilizadas gratuitamente ou de baixo custo e de fácil manejo. Resultados: A TGN foi realizada integralmente de forma virtual e sofreu adaptações em cada uma das suas quatro etapas através da incorporação de recursos digitais específicos. Foi possível apresentar as ideias mais votadas e obter a aprovação final dos participantes. Os participantes não apresentaram dificuldade para utilizar os recursos virtuais disponibilizados, e, partir da avaliação de reação, mostram-se satisfeitos com as ferramentas disponibilizadas. Conclusão: A TGN adaptada mostrou-se um método efetivo quando utilizada em cenário virtual, sendo capaz de produzir um significativo número de ideias e desenvolver consenso. A ferramenta adaptada pode ser usada por outros pesquisadores em países com recursos ou dimensões semelhantes ao Brasil.

Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using normalisation process theory.

BACKGROUND: Antimicrobial stewardship (AMS) describes activities concerned with safe-guarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uni-professional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives. METHODS: This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n = 72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions 'which group of actors have which problems, in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice'. RESULTS: Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners. CONCLUSIONS: This study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts.

Interventions to improve the review of antibiotic therapy in acute care hospitals: a systematic review and narrative synthesis.

OBJECTIVES: To synthesize current evidence for the effectiveness of interventions to ensure the timely review of antibiotics in acute care hospitals. METHODS: Five databases were searched from 1 January 2015 to 8 March 2019 for studies in English, focused on the timely review of antibiotics in acute care hospitals. Randomized controlled trials, non-randomized studies, case-control and cohort study designs were eligible. Intervention strategies were categorized according to the Cochrane Effective Practice and Organisation of Care taxonomy of health interventions, then mapped to the intervention functions of the behaviour change wheel. RESULTS: Fourteen studies were included. Most studies (11 out of 14) were conducted in single sites. Nine out of 14 reported intervention delivery by more than one healthcare professional. Physicians were the main targets of interventions in all studies. Thirteen out of 14 studies tested interventions comprising more than one strategy. The three most commonly utilized strategies within interventions were clinical practice guidelines, audit and feedback, and educational materials. Only one study employed theory in intervention evaluation. Reported interventions led to timely review and switch of IV antibiotic therapy, and shortened durations of overall antibiotic therapy. CONCLUSIONS: Interventions to improve the review of antibiotics were found to be effective in the short to medium term, with limited evidence of long-term sustainability in multiple sites. Future research may benefit from the application of theory to intervention design and detailed specifications of interventions to aid their easy replication and implementation in different contexts.

Effectiveness of national and subnational infection prevention and control interventions in high-income and upper-middle-income countries: a systematic review.

Evidence-based guidance for national infection prevention and control (IPC) programmes is needed to support national and global capacity building to reduce health-care-associated infection and antimicrobial resistance. In this systematic review we investigate evidence on the effectiveness of IPC interventions implemented at national or subnational levels to inform the development of WHO guidelines on the core components of national IPC programmes. We searched CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS databases for publications between Jan 1, 2000, and April 19, 2017. 29 studies that met the eligibility criteria (ie, economic evaluations, cluster-randomised trials, non-randomised trials, controlled before-and-after studies, and interrupted time-series studies exploring the effective of these interventions) were categorised according to intervention type: multimodal, care bundles, policies, and surveillance, monitoring, and feedback. Evidence of effectiveness was found in all categories but the best quality evidence was on multimodal interventions and surveillance, monitoring, and feedback. We call for improvements in study design, reporting of research, and quality of evidence particularly from low-income countries, to strengthen the uptake and international relevance of IPC interventions.

The effect of fake tan on hand hygiene practice.

Hand hygiene is the single most important measure in reducing the spread of infection. The aim of this study was to assess the uptake of fake tan in nursing students and evaluate the impact of wearing fake tan on hand hygiene training lotion removal during handwashing with soap and water. Of the 217 participants recruited, 21% wore fake tan. Statistical analysis revealed no significant difference between fake tan and non-fake tan wearers. Consequentially, no guidelines regarding the wearing of fake tan in clinical practice are currently required.

Influences on independent nurse prescribers' antimicrobial prescribing behaviour: a systematic review.

AIMS AND OBJECTIVES: To present the findings of a systematic review which explored the influences on the antimicrobial prescribing behaviour of independent nurse prescribers. BACKGROUND: Antimicrobial resistance is an urgent public health concern and inappropriate antibiotic prescribing is linked to an increase in this resistance. With a growing number of nursing staff potentially prescribing. DESIGN: A systematic review. METHODS: A comprehensive search strategy was employed to identify appropriate research papers. Results were screened for relevance using eligibility criteria, and the assessment of the methodological quality of the papers was conducted using a critical appraisal tool. RESULTS: Seven studies were found which explored influences on nurse prescribers' antimicrobial prescribing behaviour. Three of these expected that an antimicrobial would be given and therefore influences discussed were on the choice of the antimicrobial given. Guidelines/protocols, safety, tolerability and efficacy of the antimicrobial itself, patient/parent pressure and training/experience were mentioned as influencing factors within the reported studies. The other four studies explored influences on whether to prescribe an antimicrobial or not and also found that guidelines/protocols were an influencing factor, however, the influence occurring most frequently was diagnostic uncertainty. CONCLUSIONS: The studies were limited by methodological issues and therefore further research is recommended to explore all influencing factors on prescriber behaviour. RELEVANCE TO CLINICAL PRACTICE: It has been recommended that interventions to change healthcare professionals' behaviour must be based on theory-based research. Future research should therefore focus on the use of sound theoretical frameworks in the planning of the studies if we are to be able to understand and, if required, change nurses' behaviours.

Growth in nurse prescribing of antibiotics: the Scottish experience 2007-13.

OBJECTIVES: The objective of this study was to retrospectively analyse patterns of primary care antibiotic prescribing by nurse prescribers in Scotland. METHODS: Data on dispensed antibiotic prescriptions written by nurse prescribers in 2007-13 were obtained from the Prescribing Information System, a database of all NHS prescriptions dispensed in Scotland. RESULTS: Since 2007, there has been a steady increase in the volume of antibiotic prescribing in primary care undertaken by nurse prescribers. There was considerable variability in the frequency of antibiotic prescribing among nurses and across NHS regions. Since 2007, an increasing proportion of antibiotics prescribed by nurses are those recommended for first-line empirical treatment of infection, with a reduction in the proportion of broader-spectrum agents. Other measures of prescribing quality (duration of treatment of adult females with urinary tract infection and use of recommended doses) have improved since 2007. CONCLUSIONS: This paper is the first, to our knowledge, to present an analysis of data on antibiotic prescribing in primary care by nurse prescribers. Inappropriate prescribing is a problem and, given the impact that antibiotic prescribing has on antimicrobial resistance, it is important that the prescribing behaviour of nurses is explored. This is especially significant as this is a growing body of prescribers who predominately work in the community, where the majority of antibiotics are prescribed. This analysis showed that practice varies across NHS regions and between prescribers and although more information is needed to establish whether nurse prescribers are prescribing appropriately, some quality indicators may suggest that they are following best practice.

Are theoretical perspectives useful to explain nurses' tolerance of suboptimal care?

AIM: This paper explores two theoretical perspectives that may help nurse managers understand why staff tolerate suboptimal standards of care. BACKGROUND: Standards of care have been questioned in relation to adverse events and errors for some years in health care across the western world. More recently, the focus has shifted to inadequate nursing standards with regard to care and compassion, and a culture of tolerance by staff to these inadequate standards. EVALUATION: The theories of conformity and cognitive dissonance are analysed to investigate their potential for helping nurse managers to understand why staff tolerate suboptimal standards of care. KEY ISSUES: The literature suggests that nurses appear to adopt behaviours consistent with the theory of conformity and that they may accept suboptimal care to reduce their cognitive dissonance. CONCLUSION: Nurses may conform to be accepted by the team. This may be confounded by nurses rationalising their care to reduce the cognitive dissonance they feel. IMPLICATIONS FOR NURSING MANAGEMENT: The investigation into the Mid Staffordshire National Health Service called for a change in culture towards transparency, candidness and openness. Providing insights as to why some nursing staff tolerate suboptimal care may provide a springboard to allow nurse managers to consider the complexities surrounding this required transformation.

Getting published: reflections of a collaborative writing group.

BACKGROUND: Writing for publication, in the nursing profession, is considered essential for the development of the profession and individual career advancement. In education there is also the increasing pressure to produce University research output. OBJECTIVE: To develop a collaborative writing group to develop and write articles relating to our teaching practice. METHOD: The idea of forming a writing group was discussed at a module team meeting where five academics expressed an interest. The process of forming the group involved an initial meeting to discuss and agree to the aims, interests, expertise and areas of responsibility for each member. Regular meetings are held and each member takes on responsibility for an aspect of work towards completing the articles. RESULTS: Three articles and one editorial have been published and another is under peer review. We have endeavoured to develop and maintain a theme, this being supporting nursing students' development with an emphasis on an aspect of their decision making skills. Also, importantly, we have created a supportive environment and friendships. CONCLUSIONS: The demands made upon the nurse educator to be clinically, educationally and research active can be difficult to meet. Collaborative writing groups may be one way to fulfil the scholarly activity element.

Developing nursing students' decision making skills: are early warning scoring systems helpful?

This paper is presented to contribute to the emerging debate on Early Warning Scoring Systems. The Early Warning Scoring System was introduced, and has been implemented internationally, to aid in the identification of the patient whose condition is deteriorating. Early identification of patient deterioration is of vital importance for patient safety. Therefore how we teach this skill to students and how they become competent and confident in its utilisation, interpretation and subsequent clinical decision-making is crucial. The paper initially explores the competence of student nurses in this area. The discussion then focuses on three models of clinical decision making to illustrate why the introduction of Early Warning Scoring Systems has hindered student nurses in the development of the decision-making skills required to identify and manage the patient whose condition is deteriorating.

Supporting students in clinical practice: pre-registration nursing students' views on the role of the lecturer.

Learning in clinical practice is an essential aspect of student nurse education yet debate persists in the United Kingdom regarding the role of the lecturer in supporting the student within clinical practice. This debate has been rekindled with developments in mentorship and establishment of a clinical role designed to facilitate and support mentors; the Practice Education Facilitator. Hence it is timely to re-examine the role of the lecturer in providing clinical support to students. This article discusses nursing students' views of clinical support provided by lecturers on a Diploma/Degree programme. Qualitative and quantitative data was obtained from an online questionnaire which indicated that students thought the most important part of the lecturers' role was to provide academic support for assignments. The students also appreciated lecturers visiting them in clinical placement to facilitate the student-mentor relationship and to provide personal support. It is argued, that with the enhancement of other supportive mechanisms for students and mentors and the current economic climate, lecturers should work in partnership with mentors and practice education facilitators to avoid duplication of effort. The students in this evaluation suggested that academic support for assignments should be the main focus for lecturers.

Exploring nursing students' decision-making skills whilst in a Second Life clinical simulation laboratory.

AIM: To explore nursing students' decision-making skills through the use of a 3D virtual environment such as Second Life. METHOD: An exploratory qualitative evaluation of the students' experience of learning decision-making skills whilst in a Second Life clinical simulation laboratory. A convenience sample of five third year student nurses entered a simulated world environment where they cared for six patients over 1h. The written communication text from the Second Life scenario was saved into a Microsoft Word document. Additionally a semi-structured tape-recorded one to one interview was conducted immediately after the Second Life simulation in order to explore the students' decision-making skills. RESULTS: The communication text illustrated that the majority of decisions (n=21) were made in response to a situation or a patient request, therefore 'reactive' rather than proactive (n=9). Only one student carried out a vital signs assessment on a newly admitted patient (Willie). The interviews produced two themes, performing decision-making and improving learning. The absence of 'visual cues' such as pre-operative checklists, vital sign observation charts and 'Nil by Mouth' signs may offer a rationale for why students were more reactive. CONCLUSION: Further work is required for students to practice decision-making skills. With further development the innovative 3D virtual worlds such as Second Life could provide this experience.

Supporting and mentoring nursing students in practice.

Decision making is a fundamental skill required by the Nursing and Midwifery Council (NMC) for entry to the nurse register. It is required for the completion of the essential skills clusters - skills identified by the NMC that must be achieved in pre-registration nursing programmes. Often students do not recognise that many of the tasks they perform on clinical placement involve decision-making skills and therefore find it difficult to show their attainment in their record of achievement. This article explores how students can demonstrate their decision making and suggests techniques for mentors to support students.

Preoperative fasting for preventing perioperative complications in children.

BACKGROUND: Children, like adults, are required to fast before general anaesthesia with the aim of reducing the volume and acidity of their stomach contents. It is thought that fasting reduces the risk of regurgitation and aspiration of gastric contents during surgery. Recent developments have encouraged a shift from the standard 'nil-by-mouth-from-midnight' fasting policy to more relaxed regimens. Practice has been slow to change due to questions relating to the duration of a total fast, the type and amount of intake permitted. OBJECTIVES: To systematically assess the effects of different fasting regimens (duration, type and volume of permitted intake) and the impact on perioperative complications and patient well being (aspiration, regurgitation, related morbidity, thirst, hunger, pain, comfort, behaviour, nausea and vomiting) in children. SEARCH STRATEGY: We searched Cochrane Wounds Group Specialised Register (searched 25/6/09), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2 2009), Ovid MEDLINE (1950 to June Week 2 2009), Ovid EMBASE (1980 to 2009 Week 25), EBSCO CINAHL (1982 to June Week 3 2009), the National Research Register, relevant conference proceedings and article reference lists and contacted experts. SELECTION CRITERIA: Randomised and quasi randomised controlled trials of preoperative fasting regimens for children were identified. DATA COLLECTION AND ANALYSIS: Data extraction and trial quality assessment was conducted independently by three authors. Trial authors were contacted for additional information including adverse events. MAIN RESULTS: This first update of the review identified two additional eligible studies, bringing the total number of included studies to 25 (forty seven randomised controlled comparisons involving 2543 children considered to be at normal risk of regurgitation or aspiration during anaesthesia). Only one incidence of aspiration and regurgitation was reported.Children permitted fluids up to 120 minutes preoperatively were not found to experience higher gastric volumes or lower gastric pH values than those who fasted. The children permitted fluids were less thirsty and hungry, better behaved and more comfortable than those who fasted.Clear fluids preoperatively did not result in a clinically important difference in children's gastric volume or pH. Evidence relating to the preoperative intake of milk was sparse. The volume of fluid permitted during the preoperative period did not appear to impact on children's intraoperative gastric volume or pH contents. AUTHORS' CONCLUSIONS: There is no evidence that children who are denied oral fluids for more than six hours preoperatively benefit in terms of intraoperative gastric volume and pH compared with children permitted unlimited fluids up to two hours preoperatively. Children permitted fluids have a more comfortable preoperative experience in terms of thirst and hunger. This evidence applies only to children who are considered to be at normal risk of aspiration/regurgitation during anaesthesia.