Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings.

Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might 'tip the balance' towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

Integration of TeamSTEPPS Framework and Escape Room to Improve Teamwork and Collaboration.

BACKGROUND: As the need for healthcare professionals continues to grow, different learning environments have been assessed to optimize knowledge while keeping the student engaged. Escape rooms, live action, team-based exercises, supplemented with TeamSTEPPS tools can assist in overall team performance, while keeping the participant engaged in a new learning environment. OBJECTIVE: The goal of this quality improvement project was to enhance teamwork and collaboration through the integration of TeamSTEPPS concepts and escape room active learning. This concept was explored through the integration of TeamSTEPPS tools and strategies in an escape room setting. The purpose was to improve team dynamics and cohesiveness in a new dynamic way with a small cohort of nurse leaders in a large urban academic medical center, while exploring the engagement and depth of learning experience for the participant. METHODS: Twelve nurse leaders completed two different escape rooms while observers completed the TeamSTEPPS observation tool assessing team dynamics and performance and participants assessed their perceptions before and after intervention. These nurses also were observed at staff meetings and completed a perceptions tool on teamwork pre- and postintervention. A postescape room survey was completed by participants to assess learning and interest in this interactive learning exercise. RESULTS: There was a significant statistical difference after TeamSTEPPS and escape room intervention (Mean 17.3 and p = 0.004 SD 5.9) when compared to before intervention as well as has a more positive sense of teamwork was noted. In addition, 75% of the nurses strongly agreed that the escape room was engaging and fun with 25% agreeing. Ninety-one percent agreed or strongly agreed that the escape room was an effective team-building exercise with 100% agreeing or strongly agreeing to recommend the escape room experience to others. CONCLUSIONS: This cohort validated the integration of TeamSTEPPS tools and strategies in an escape room setting as an enjoyable and engaging way to learn while providing an effective team-building activity. This small cohort demonstrates that new methods of learning such as an escape room should be explored further for engaging participants and improving communication and teamwork skills. IMPLICATIONS FOR NURSING: Integrating TeamSTEPPS into an escape room offers this institution a way to continue this project while providing valuable team-building skills to its participants. While this was just a small sample in one intercity hospital, new methods for learning should be reviewed for successful teamwork in nursing and in healthcare as a whole, as there was some data to suggest that utilizing an escape room could have a positive impact on team cohesiveness as well as leadership skills for the individual.

Understanding surgical antimicrobial prescribing behaviour in the hospital setting: a systematic review and meta-ethnography protocol.

BACKGROUND: Surgical specialities use extensive amounts of antimicrobials, and misuse has been widely reported, making them a key target for antimicrobial stewardship initiatives. Interventions informed by, and tailored to, a clear understanding of the contextual barriers to appropriate antimicrobial use are more likely to successfully improve practice. However, this approach has been under utilised. Our aim is to synthesise qualitative studies on surgical antimicrobial prescribing behaviour (APB) in hospital settings to explain how and why contextual factors act and interact to influence APB amongst surgical teams. We will develop new theory to advance understanding and identify knowledge gaps to inform further research. METHODS: The meta-ethnography will follow the seven-phase method described by Noblit and Hare. We will conduct a comprehensive search using eight databases (AMED, CINAHL, EMBASE, MEDLINE, MEDLINE-in-process, Web of Science, Cochrane Library and PsycINFO) with no date restrictions; forwards and backwards citation searches; and contacting first authors of relevant papers. Studies will be dual screened and included if they use recognised qualitative methods and analysis; focus on contextual factors associated with surgical APB within hospital settings; are available in full in English; and are relevant to the research question. Any disagreements between reviewers will be resolved through discussion to reach consensus. Included studies will be read repeatedly to illuminate key concepts and the relationship between key concepts across studies. Then, key concepts will be sorted into conceptual categories or 'piles' which will be further abstracted to form a conceptual framework explaining surgical APB. During the synthesis, emerging interpretations will be discussed with stakeholders (including authors of included studies where possible; surgical and stewardship practitioners; and patient representatives) to ensure new knowledge is meaningful. DISCUSSION: This research has several strengths: (1) the protocol has been written with reference to established guidance maximising rigour and transparency; (2) the multi-disciplinary research team bring varied interpretative repertoires and relevant methodological skills; and (3) stakeholders will be involved to ensure that findings are relevant, and disseminated via suitable channels, to support improved patient care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020184343.

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation.

AIMS: To develop and evaluate a feasible, authentic pharmacist-led prescribing feedback intervention for doctors-in-training, to reduce prescribing errors. METHODS: This was a mixed methods study. Sixteen postgraduate doctors-in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi-structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically. RESULTS: During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist-led video-stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice. CONCLUSIONS: Feedback to doctors-in-training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.

Trainee doctors' experiences of common problems in the antibiotic prescribing process: an activity theory analysis of narrative data from UK hospitals.

INTRODUCTION: Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas. OBJECTIVES: Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur? METHODS: We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process. RESULTS: Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating. CONCLUSIONS: Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.

Leveraging Community Engagement to Develop a Mobile Health Application for Older Women With HIV Infection.

OBJECTIVE: To develop a mobile health app for older women with HIV infection that will be used in a larger study. DESIGN: A qualitative study design. SETTING: Baltimore-Washington metropolitan area clinics and communities. PARTICIPANTS: Ten women 50 years and older (mean age = 62.8 years, standard deviation = 3.62, range = 58-69 years) who self-identified as Black or African American and were infected with HIV. METHODS: At the start of the study, we used relevant empirical and the self-determination theory to inform the draft Web-based app content that was shared with two focus groups. Data were analyzed with input from a community advisory board (CAB) to inform the development of the mobile health app. RESULTS: We inductively identified eight subthemes within the coding structure of two overall themes: Navigating Content, Functions, and Features and Enhancing Provider Interaction With Patients that represented the perspectives of participants regarding the app. From the eight subthemes, we integrated the contributions from the CAB, which we then used to further optimize the app. CONCLUSION: The app was designed to provide support, tools, and resources for older women with HIV. Engagement of community collaborators could be challenging because of multiple personal and structural barriers. Nonetheless, the potential community member benefits are invaluable. If successful, the Web-based app could be a model to address the needs of older persons with HIV infection.

The determinants of antimicrobial prescribing among hospital doctors in England: a framework to inform tailored stewardship interventions.

AIM: Little is known about the determinants of antimicrobial prescribing behaviour (APB), how they vary between hospital prescribers or the mechanism by which interventions are effective. Yet, interventions based on a sound theoretical understanding of APB are more likely to be successful in changing outcomes. This study sought to quantify the potential determinants of APB among hospital doctors in south-west England. METHODS: This multicentre, quantitative study employed a closed answer questionnaire to garner hospital doctors' views on factors influencing their APB. Underlying constructs within the data were identified using exploratory factor analysis and subsequent pairwise comparisons assessed for variance between groups of prescribers. RESULTS: The questionnaire was completed by 301 doctors across four centres (response rate ≥ 74%) and three key factors were identified: autonomy, guidelines adherence and antibiotic awareness. The internal consistency for the questionnaire scale and for each factor subscale was good (α ≥ 0.7). Subgroup analysis identified significant differences between groups of prescribers: autonomy scores increased with grade until at the specialist trainee level (P ≤ 0.009), foundation doctors scored higher for guidelines adherence than consultants (P = 0.004) and specialist trainees (P = 0.003) and United Kingdom trained doctors scored higher than those trained abroad for antibiotic awareness (P < 0.0005). Scores did not vary significantly between doctors from different centres. CONCLUSION: Autonomy, guidelines adherence and antibiotic awareness were identified as important factors relevant to APB, which vary with experience and training. A theoretical framework is offered to facilitate development of more effective, tailored interventions to change APBs.

Primary, secondary, and tertiary prevention of cardiovascular disease in patients with HIV disease: a guide for nurse practitioners.

HIV infection elevates a patient's risk for developing cardiovascular disease (CVD), due in part to direct effects of increased infection-producing inflammation and to drugs used to treat the infection, which can have untoward effects on serum lipid profiles. HIV-infected older adults often present with multiple comorbidities, including CVD, making disease management more challenging. Treatment paradigms are evolving, and nurse practitioners (NPs) are expected to play an ever-larger role in the management of HIV infection. Due to their accessibility and close patient contact, NPs are especially well suited to work with and educate patients to manage multiple risk factors. Appropriate use of primary, secondary, and tertiary CVD prevention strategies, including education to modify lifestyle risks, individualized antiretroviral treatment regimens to achieve serum lipid targets, and use of additional lipid-modifying strategies to minimize a patient's overall CVD risk profile will be important throughout the treatment lifecycle.