Search

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.

Background Efforts to address the complex global problem of antimicrobial resistance (AMR) highlight the need for imagination and innovation. However, nursing has not yet leveraged its potential to innovate to prevent AMR advancing. Aims This paper focuses on the initial phase of an ongoing research and development study that seeks to foster nursing imagination and innovation by enhancing the meaningfulness of AMR for practising nurses and by facilitating their creative ideas. Methods This aim is addressed through application of arts and humanities approaches, in particular the use of visualisation, co-design and historical methods, underpinned by the Design Council Double Diamond process model. The first phase with 20 UK participants explored how hospital and community-based nurses understand and respond to the priorities and consequences of AMR within their everyday working lives. Results Nurses varied in their conceptualisations of AMR and in their depictions and explanations of its meaning and priority within everyday practices. Some saw infection prevention and control as bound up with AMR, whereas others differentiated in the context of specific work activities. Insights into related reasoning and practice tactics were also generated. Conclusions The initial project phase provides a basis for fostering nursing innovation in this important field.

Background The link between inappropriate antibiotic prescribing and the global threat of antimicrobial resistance is well documented. International strategies recommend antimicrobial stewardship (AMS) programmes, with improvement interventions to safe-guard antibiotics. Aim This study sought to systematically evaluate the impact of multi-professional Antimicrobial Management Team (AMT) staff resource availability on stewardship activities. Methods We conducted an on-line, cross-sectional survey of AMTs in each regional Health Board and the national specialist hospital in Scotland (n=15). Responses were analysed descriptively, exploring observed relationships between variables to identify patterns. Findings Results highlighted apparent variation in the levels of AMT resource availability across Scotland, not directly influenced by Health Board size, with some larger Health Boards having proportionately poorer AMT resource allocation. However, the range and frequency of activities to support AMS was not directly linked to either Health Board size or staff resource allocation, indicating a more complex inter-relationship between factors. Conclusions There is apparent inequity in staff resource available for AMTs across Scotland, with significantly lower resource allocation in comparison to recommendations from other international studies. However, considering these survey findings with our earlier qualitative research indicates that leadership style and team member enthusiasm may be as, if not more, influential than resource availability on the scope of AMT activities. These findings have international relevance for hospital service managers considering the recruitment, training, and ongoing support of AMTs, in order to maximize impact from a limited resource.

Aim To explore patients' accounts of screening and being managed for colonisation with the antimicrobial resistant organism, carbapenemase-producing Enterobacteriaceae (CPE), when in hospital. Background Antimicrobial resistance (AMR) has been identified as one of the biggest global health challenges of the 21st Century. As the threat from AMR grows, screening to identify patients who are colonised with resistant organisms such as CPE is becoming an increasingly important aspect of nursing practice, in order to reduce risk of transmission of infection within hospitals. There is currently little research evidence on the patient experience of hospital management of CPE colonisation. Methods Qualitative semi-structured telephone interviews were undertaken, using a topic guide. Nine patients participated in the study. The data were analysed thematically, and rigour was maintained through peer review. The COREQ checklist was used. Results Two main themes were identified: "I can't make sense of CPE," illustrating limitations in patients' understandings of CPE; and, "I feel as if they are saying it is my fault," indicating the feelings of responsibility and blame which patients experienced. Conclusions This paper contributes original evidence to the limited literature on patients' experiences of being colonised with CPE. The findings suggest that support and information provided for patients by healthcare professionals needs to be based on current evidence-based guidance on the nature of CPE and its implications for patient care, as well as being responsive to patients' emotional needs. Relevance to clinical practice This study has international relevance for nursing practice. As the global threat of AMR grows, the demands on healthcare providers to manage resistant organisms and their implications for patient care within healthcare settings are increasing. Enabling healthcare professionals to engage sensitively with patients being managed for colonisation with CPE is paramount to providing patient-centred care.

Summary Background To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours. Aim To identify factors which influence staff compliance with hospital MRSA screening policies. Methods A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance. Findings Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which ‘make doing the right thing easy’ influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important. Conclusion To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.

Objectives: Drivers of antimicrobial resistance (AMR) are diffuse and complex including a range of interspecies behaviours between pet owners and their animals. We employed interpretative phenomenological analysis (IPA) to explore the relationship between pet owners and their companion animals in relation to AMR.Design: Cross sectional, qualitative study.Methods: Semi-structured interviews were conducted with twenty-three British pet owners, transcribed verbatim and subjected to Interpretative Phenomenological Analysis (IPA).Results: Three, inter-related Superordinate themes are presented 1) ‘They’re my fur babies’: unconditional love and anthropomorphism; 2) ‘They share everything with you’: affection and transmission behaviours; and 3) ‘We would err on the side of caution’: decision making and antibiotic use’.Conclusions: Affectionate behaviors between companion animals and their owners pose a risk for AMR transmission but they are so deeply treasured that they are unlikely to be amenable to change. In contrast, the promotion of appropriate antibiotic stewardship for pet owners and vets may offer a viable pathway for intervention development, benefitting from synergies with other interventions that target prescribers.

Summary Background The number of nurse prescribers is increasing, yet little evidence exists about their antibiotic prescribing behaviour. Aim To measure nurse independent prescribers' (NIPs) intention to manage patients, presenting with an upper respiratory tract infection (URTI) for the first time, without prescribing an antibiotic and to examine the determinants of this behaviour. Methods This was a mixed-method study using the Reasoned Action Approach (RAA). Content analysis of data from 27 telephone interviews with NIPs informed the development of a questionnaire which was tested for validity and reliability and used in a national survey of NIPs across Scotland. Descriptive and inferential statistical analysis was carried out to determine intention to manage patients without prescribing an antibiotic and the significant influences on this intention. Findings From 184 participants it was found that NIPs intended to manage patients, presenting with a URTI for the first time, without prescribing an antibiotic. Key determinants were perceived norm, perceived behavioural control, and moral norm. Significant beliefs were positive social influence from other non-medical prescribers (P = 0.007) and nurse prescribers (P = 0.045), the enablers of prescriber experience and confidence (P ≤ 0.001), and the barrier of pressure from patients/carers (P = 0.010). Conclusion The findings provide reassurance that NIPs intend to prescribe appropriately. The identification of nurse-specific barriers and enablers to this intention should be acknowledged and targeted in future interventions to manage this behaviour.

ObjectivesTo synthesize current evidence for the effectiveness of interventions to ensure the timely review of antibiotics in acute care hospitals.MethodsFive 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.ResultsFourteen 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.ConclusionsInterventions 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.

Background The global burden of health care–associated infection (HAI) is well recognized; what is less well known is the impact HAI has on patients. To develop acceptable, effective interventions, greater understanding of patients' experience of HAI is needed. This qualitative systematic review sought to explore adult patients' experiences of common HAIs. Methods Five databases were searched. Search terms were combined for qualitative research, HAI terms, and patient experience. Study selection was conducted by 2 researchers using prespecified criteria. Critical Appraisal Skills Programme quality appraisal tools were used. Internationally recognized Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied. The Noblit and Hare (1988) approach to meta-synthesis was adopted. Results Seventeen studies (2001-2017) from 5 countries addressing 5 common types of HAI met the inclusion criteria. Four interrelated themes emerged: the continuum of physical and emotional responses, experiencing the response of health care professionals, adapting to life with an HAI, and the complex cultural context of HAI. Conclusions The impact of different HAIs may vary; however, there are many similarities in the experience recounted by patients. The biosociocultural context of contagion was graphically expressed, with potential impact on social relationships and professional interactions highlighted. Further research to investigate contemporary patient experience in an era of antimicrobial resistance is warranted.

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.

Summary Background Norovirus outbreaks cause significant patient distress and adversely affect healthcare service delivery. Measures to manage outbreaks include controlling patient/staff movement and advising visitors of the risks of infection; temporary suspension of visiting (TSV) is advocated by some. Factors influencing the use of TSV have not previously been reported. Aim To describe current practice in Scotland regarding TSV during norovirus outbreaks. Methods Cross-sectional survey of Scottish Health Boards [National Health Service (NHS)] Infection Prevention Leads ( N = 22) and independent care home (ICH) managers ( N = 107). Findings TSV practice is inconsistent across care settings. NHS findings: although 86.4% reported a recent norovirus outbreak, only 36.4% reported having criteria in place to guide TSV decisions and only 57.9% of those who had an outbreak implemented TSV. Conversely, 77.6% ICH respondents do have TSV criteria in place; 70.1% who had previously experienced an outbreak all reported that they would normally close to visitors. The majority of both NHS (81.8%) and ICH (84.2%) respondents reported making exceptions to TSV for individual cases. Despite variation in practice, 75% NHS and 81.8% ICH respondents agreed that TSV was helpful in controlling outbreaks. Factors influencing TSV implementation decisions included use of judgement in individual cases, perceived lack of evidence for the role of visitors in transmission, and belief in patients' rights to have visitors. Conclusion Implementation of TSV in Scotland is inconsistent, with variation in the use of criteria, personal beliefs, and professional judgements. Further research on the role of visitors in transmission and service-user acceptability of TSV is required for policy development.

Background\ud \ud Noroviruses are a leading cause of outbreaks globally and the most common cause of service disruption due to ward closures. Temporary suspension of visiting (TSV) is increasingly a recommended public health measure to reduce exposure, transmission and impact during norovirus outbreaks; however, preventing patient–visitor contact may contravene the ethos of person-centred care, and public acceptability of this measure is not known.\ud \ud Aim\ud \ud To investigate the acceptability of TSV during norovirus outbreaks from the perspectives of patients, visitors and the wider public.\ud \ud Methods\ud \ud Cross-sectional survey of patients (N = 153), visitors (N = 175) and the public (N = 224) in three diverse areas in Scotland. Health Belief Model constructs were applied to understand ratings of acceptability of TSV during norovirus outbreaks, and to determine associations between these levels and various predictor variables.\ud \ud Findings\ud \ud The majority (84.6%) of respondents indicated that the possible benefits of TSV are greater than the possible disadvantages. Conversely, the majority (70%) of respondents disagreed that TSV ‘is wrong as it ignores people's rights to have contact with family and friends’. The majority (81.6%) of respondents agreed that TSV would be more acceptable if exceptions were made for seriously ill or dying patients. Correlational analysis demonstrated that overall acceptability was positively related to perceived severity (r = 0.65), identified benefits (r = 0.54) and implementing additional communication strategies (r = 0.60); acceptability was negatively related to potential barriers (r = −0.49).\ud \ud Conclusions\ud \ud There is greater service user and public support for the use of TSV than concerns around impinging upon patients' rights to have visitors. TSV should be considered as an acceptable infection control measure that could be implemented consistently during norovirus outbreaks.

Background Carbapenemase Producing Enterobacteriaceae (CPE) has spread rapidly and presents a growing challenge in antimicrobial resistance (AMR) management internationally. Screening for CPE may involve a rectal swab, there are limited treatment options for affected patients, and colonised patients are cared for in isolation to protect others. These measures are sound infection prevention precautions; however, the acceptability of CPE screening and its consequences are currently unknown. The aim of this study was ‘To determine factors influencing acceptability of CPE screening from the perspectives of nursing staff and the general public.’ Methods National cross-sectional surveys of nursing staff (n = 450) and the general public (n = 261). The Theoretical Domains Framework (TDF) guided data collection and analysis. Regression modelling was used to identify factors that predicted acceptability of CPE screening. Results For nursing staff, the following predictor variables were significant: intention to conduct CPE screening (OR 14.19, CI 5.14–39.22); belief in the severity of the consequences of CPE (OR 7.13, CI 3.26–15.60); knowledge of hospital policy for screening (OR 3.04, CI 1.45–6.34); preference to ask patients to take their own rectal swab (OR 2.89, CI 1.39–6.0); awareness that CPE is an organism of growing concern (OR 2.44, CI 1.22–4.88). The following predictor variables were significant for the general public: lack of knowledge of AMR (β − .11, p = .01); social influences (β .14, p = .032); social norms (β .21p = .00); acceptability of being isolated if colonised (β .22, p = .000), beliefs about the acceptability of rectal swabbing (β .15, p = .00), beliefs about the impact of careful explanation about CPE screening from a health professional (β .32, p = .00). Integrating results from staff and public perspectives points to the importance of knowledge of AMR, environmental resources, and social influences in shaping acceptability. Conclusions This is the first study to systematically examine the acceptability of CPE screening across nursing staff and the public. The use of TDF enabled identification of the mechanisms of action, or theoretical constructs, likely to be important in understanding and changing CPE related behaviour amongst professionals and public alike. Electronic supplementary material The online version of this article (10.1186/s13756-018-0434-x) contains supplementary material, which is available to authorized users.

Antimicrobial resistance (AMR) is a global challenge facing both human and animal healthcare professionals; an effective response to this threat requires a ‘One-Health’ approach to antimicrobial stewardship (AMS) to preserve important antibiotics for urgent clinical need. However, understanding of barriers and enablers to effective antimicrobial stewardship behaviour in companion animal veterinary practice is currently limited.We conducted a Delphi Study of 16 nationally recognised experts from UK based veterinary policy makers, university academics, and leaders of professional bodies. This Delphi study sought to identify veterinary behaviours which experts believe contribute to AMR and form vital aspects of AMS. Analysis of Delphi findings indicated a perceived hierarchy of behaviours, the most influential being antibiotic prescribing behaviours and interactions with clients. Other veterinary behaviours perceived as being important related to interactions with veterinary colleagues; infection control practices; and the use of diagnostic tests to confirm infection. Key barriers and enablers to AMS within each of these behavioural domains were identified. Specific interventions to address important barriers and enablers are recommended. To the authors’ knowledge, this is the first study to establish expert consensus at a national level about which ‘behaviours’ (aspects of veterinarian practice) should be targeted in relation to antimicrobial resistance and stewardship in companion animal veterinary practice.

Background:\ud \ud Multi-drug resistant bacteria are an increasing concern in both human and veterinary medicine. Inappropriate prescribing and use of antibiotics within veterinary medicine may be a contributory factor to antimicrobial resistance (AMR). The ‘One Health’ Initiative aims to work across species and environments to reduce AMR, however; little is currently known about the factors which influence antibiotic prescribing among veterinary surgeons in companion animal practice.\ud \ud This paper reports on qualitative data analysis of interviews with veterinary surgeons whose practice partially or wholly focuses on companion animals (N = 16). The objective of the research was to explore the drivers of companion animal veterinary surgeons’ antibiotic prescribing behaviours. The veterinary surgeons interviewed were all practising within the UK (England (n = 4), Scotland (n = 11), Northern Ireland (n = 1)). A behavioural thematic analysis of the data was undertaken, which identified barriers and facilitators to specific prescribing-related behaviours.\ud Results:\ud \ud Five components of prescribing behaviours were identified: 1) confirming clinical need for antibiotics; 2) responding to clients; 3) confirming diagnosis; 4) determining dose, duration and type of antibiotic; and 5) preventing infection around surgery (with attendant appropriate and inappropriate antibiotic prescribing behaviours). Barriers to appropriate prescribing identified include: business, diagnostic, fear, habitual practice and pharmaceutical factors. Facilitators include: AMR awareness, infection prevention, professional learning and regulation and government factors.\ud Conclusion:\ud \ud This paper uses a behavioural lens to examine drivers which are an influence on veterinary surgeons’ prescribing behaviours. The paper contributes new understandings about factors which influence antibiotic prescribing behaviours among companion animal veterinary surgeons. This analysis provides evidence to inform future interventions, which are focused on changing prescribing behaviours, in order to address the pressing public health concern of AMR.

The aim of this article is to explore the positive and negative impacts of working therapeutically in complex psychological trauma (CPT), particularly the field of gender-based violence (GBV) and childhood sexual abuse (CSA), from the clinicians’ perspective. The focus was on the prospect of positive gains and growth for therapists. Twenty-one clinicians ( n = 21; counselors/psychotherapists and psychologists) from National Health Service (NHS) specialist trauma services, a community mental health team, and specialist sexual assault counseling organization participated. Interpretative phenomenological analysis (IPA) was utilized to conduct single one-off interviews and analysis. Six themes were identified: Called to the work; Connection, Separation, and Oneness; Into and out of the darkness; Chaos into meaning; Reparation not repetition; and Expansion and growth. The first “Therapist Led Framework of Growth in Trauma Work” is presented. Vicarious posttraumatic growth (VPTG) was a key finding, with CPT therapists experiencing a “challenge/benefit/change” growth process. Adoption of actively relational strategies to enhance clinicians’ growth process through trauma work is being proposed. The benefits of conceptualizing both the positive and negative impacts of such work for supervision, training, shaping the formal curricula, service management, and continuing professional development (CPD) are being discussed. The need for good practice guidelines on self-care internationally is highlighted.

Infection prevention is an under-resourced research and development topic, with limited evidence for practice in the most basic of measures. A survey of IPS R&D members indicated that what might appear to be simple interactions and interventions in healthcare, such as hand shaking and hand hygiene, should be considered complex interventions taking account of behaviour at the individual and social level as well as contextual factors. Future studies need to be designed utilising comprehensive approaches, for example, the Medical Research Council complex interventions framework, tailored to the country and more local cultural context, if we are to be serious about evidence for infection prevention and control practice.

This systematic review aimed to generate patient-focussed recommendations to enhance support of heart failure self-care by examining patients' experiences, perspectives and self-care behaviours.Despite increased recognition of the importance of heart failure self-care, patients' knowledge and practices around this self-care and interventions to improve it are inconsistent. Consequently, current guidelines focus on what the domains of heart failure self-care are, more so than the ways to improve this care.Systematic review and qualitative interpretive synthesis.A systematic, comprehensive and detailed search of 11 databases was conducted until March, 2012 for papers published 1995-2012: 37 studies were included (1343 patients, 75 caregivers, 63 health care professionals) that contained a qualitative research component and data on adult patients' heart failure self-care.This interpretive synthesis used a recognized approach consisting of a multi-stage analytic process; in addition, the included studies underwent quality appraisal.Findings indicate that while patients could often recall health professionals' self-care advice, they were unable to integrate this knowledge into daily life. Attempts to manage HF were based on how patients 'felt' rather than clinical indicators of worsening symptoms. Self-efficacy and learning from past management experiences facilitated favourable outcomes - these enabled patients and caregivers to adeptly apply self-care strategies into daily activities.Addressing common but basic knowledge misconceptions regarding the domains of HF self-care is insufficient to increase effective HF self-care; this should be supplemented with strategies with patients and family members to promote self-efficacy, learning and adaptation/application of recommendations to daily life.

Context Disease management interventions for heart failure (HF) are inconsistent and very seldom incorporate the views and needs of patients and their caregivers into intervention design. Objective and data To improve intervention effectiveness and consistency, a systematic review identified 49 studies which examined the views and needs of patients with HF and their caregivers about the nature and determinants of effective HF self-care. Results The findings identify key drivers of effective self-care, such as the capacity of patients to successfully integrate self-care practices with their preferred normal daily life patterns and recognise and respond to HF symptoms in a timely manner. Conclusions Future interventions for HF self-care must involve family members throughout the intervention and harness patients’ normal daily routines.

Aims and objectives To explore the patient experience and acceptability of methicillin-resistant Staphylococcus aureus screening of inpatient admissions to acute hospital settings. Background Prevention of healthcare-associated infections such as methicillin-resistant Staphylococcus aureus is a major patient safety concern internationally. Screening of patients for methicillin-resistant Staphylococcus aureus colonisation is becoming a routine aspect of hospital admission; however, evidence of the patient experience and acceptability of methicillin-resistant Staphylococcus aureus screening is limited. Design A mixed-methods study set in six acute care hospitals in three Scottish regions. Methods Data collection involved postdischarge self-report survey of patients who had been screened (n = 54) and qualitative patient interviews (n = 10). Theoretical constructs derived from the Health Belief Model and Theory of Planned Behaviour used in analysis. Results Findings indicated that methicillin-resistant Staphylococcus aureus screening was broadly acceptable to patients. The experience of screening did not appear to be problematic; responses demonstrate that screening provided reassurance and generated confidence that health organisations were tackling healthcare-associated infections. Patients were less positive regarding the provision of information, the possibility of refusing a screen and the consequences of a positive test result. Furthermore, there were indications that patients wanted to be told the results of the screen and strong support for screening of hospital staff. Conclusions Analysis of constructs from our theoretical frameworks provides evidence that attitudes were largely positive; responses indicate a belief in the beneficial impact of methicillin-resistant Staphylococcus aureus screening for patients and the wider community. However, it is important that health professionals continually assess the patient experience of ‘routine’ aspects of health care such as MRSA screening. Relevance to clinical practice The findings from this study suggest that while methicillin-resistant Staphylococcus aureus screening is generally acceptable to patients as a regular patient safety initiative, to enhance the quality of the patient experience, clinicians should consider the timing, content and effectiveness of information provision.

Background Hip fracture is a significant cause of morbidity and mortality in older people. Healthcare professionals have a role to identify and respond to challenges and concerns that older people face as they strive to manage risk of future falls and rebuild confidence and independence after discharge. Aims and objectives This study aimed to explore the postdischarge concerns of older people after fall-induced hip fracture. Method Glaser's approach to the grounded theory method guided qualitative interviews conducted with 19 older people in their own homes up to 3 months post discharge, in two health authority areas. Results A theory of ‘taking control’ was generated. ‘Balancing risk’ emerged as a key strategy that older people employed to help them to take control after discharge home. Older people attempted to control or ‘balance’ their risk of future falls and dependence by implementing two further strategies: ‘protective guarding’ and ‘following orders’. The instinctive strategy of protective guarding and the learned strategy of following orders were implemented simultaneously and were characterised by older people aiming to pace their progress and balance risk safely and appropriately. To apply these strategies, older people required information from healthcare professionals. In circumstances where older people did not receive or did not understand the information provided, they were left ‘grasping to understand’ and were more likely to miscalculate risk. This leads to damaged confidence and in some cases further falls. Conclusions The concept of balancing risk aims to help healthcare professionals understand the older person's perspective of hip fracture and to recognise the efforts that people make to guard against further injury and dependence in the early postdischarge period. Implications for practice Our study suggests that engaging older people and their relatives in discussions to acknowledge their perceptions of future risk and to provide appropriate information on managing risk is crucial, as this will enable older people to balance risk safely and ultimately rebuild independence.

Review question/objective The objective of the review is to synthesise the best available evidence for an association between mild cognitive impairment and self-care activity in patients who have been diagnosed with chronic heart failure. The review question is: What is the evidence for an association between mild cognitive impairment and self-care activity, measured in one or more of the self-care domains related to heart failure in community dwelling adult patients who have a diagnosis of chronic heart failure? Inclusion criteria Types of participants Studies will include community dwelling adult patients (18 years and above) who have a diagnosis of chronic heart failure, at any stage of the New York Heart Association (NYHA) Classification of Heart Failure.35 Patients will be included regardless of gender, age, ethnic origin or any co-morbidity. Focus of the Review: The focus of the review is the epidemiological association between mild cognitive impairment (considered the presupposed risk factor) and self-care activity in the context of heart failure (considered the outcome). For the purposes of this review, mild cognitive impairment will be defined as evidence of impairment on a validated screening tool or diagnostic battery in individuals who do not have cognitive impairment that is severe enough to interfere with their basic activities of daily living. Studies that use validated instruments to measure cognitive function or impairment (as presupposed risk factor) will be considered for inclusion in this review. All included studies must also measure self-care capability or activities as outcomes of interest. This may be performed using validated tools, or more simple measures (such as percentage of missed medications). Self-care will include management of diet (including healthy diet, salt and fluid intake), medicines management, avoidance of risk factors for disease progression/deterioration, and symptom awareness and management.

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.

In this chapter we show that qualitative evidence is needed to understand and address some of the most burdensome problems created by cardiac conditions. Cardiac care is often dominated—even obfuscated—by technology, pharmacology and technical prowess. Yet the health care of people with cardiac conditions should address, respond to, and incorporate patients’ perspectives, beliefs, attitudes and preferences. In this chapter we discuss how qualitative research has contributed to this knowledge in relation to a range of important topics—from how patients make decisions about whether to have potentially life-saving electronic devices implanted into their bodies down to whether they should use a health service or even take a tablet.

Objective: To identify the main mechanisms of heart failure ( HF ) disease management programmes based in hospitals, homes or the community. Methods: Systematic review of qualitative and quantitative studies using realist synthesis. The search strategy incorporated general and specific terms relevant to the research question: HF, self-care and programmes/interventions for HF patients. To be included, papers had to be published in English after 1995 ( due to changes in HF care over recent years ) to May 2014 and contain specific data related to mechanisms of effect of HF programmes. 10 databases were searched; grey literature was located via Proquest Dissertations and Theses, Google and publications from organisations focused on HF or self-care. Results: 33 studies ( n=3355 participants, mean age: 65 years, 35% women ) were identified ( 18 randomised controlled trials, three mixed methods studies, six pre-test post-test studies and six qualitative studies ). The main mechanisms identified in the studies were associated with increased patient understanding of HF and its links to self-care, greater involvement of other people in this self-care, increased psychosocial well-being and support from health professionals to use technology. Conclusion: Future HF disease management programmes should seek to harness the main mechanisms through which programmes actually work to improve HF self-care and outcomes, rather than simply replicating components from other programmes. The most promising mechanisms to harness are associated with increased patient understanding and self-efficacy, involvement of other caregivers and health professionals and improving psychosocial well-being and technology use.

Self-care, encompassing self-monitoring and self-management, has been widely promoted within heart failure management programmes to improve patient outcomes and reduce hospital admissions. Limited quantitative evidence describing heart failure self-care in the Scottish context led to the descriptive study reported here. The European Heart Failure Self-care Behaviour Scale was used to measure levels of self-reported self-care in a convenience sample of 39 chronic heart failure patients receiving care from a nurse-led service in the West of Scotland. The total self-care score ranged from 12 to 44 with a mean score of 25.59 from a possible range of 12 to 60; comparing favourably with similar international studies. The items ‘I exercise regularly’; ‘I weigh myself every day’ and ‘I eat a low salt diet’ had the lowest levels of agreement. While further research is warranted, we recommend that practitioners direct attention towards these self-care deficits within the identified heart failure population.

currie k. & grundy m. (2011) Journal of Nursing Management19, 933–942 Building foundations for the future: the NHS Scotland advanced practice succession planning development pathway Aim To highlight implications for managers from the implementation of a national advanced practice succession planning development pathway within Scotland. Background Internationally, advanced practice posts have often developed in an ad-hoc manner, with little organizational attention to succession planning. Evaluation of a pilot national succession planning development pathway identified mechanisms which facilitate or hamper effective planning for advanced practice roles. Methods A responsive evaluation design incorporating semi-structured questionnaires to pathway participants (n = 15) and semi-structured telephone interviews with case-site pathway participants (n = 7) and their line managers. Results Managers believed the development pathway was worthwhile; however, there was limited strategic planning to match individuals’ development to service need. Practitioners generally perceived managers as interested in their development, although levels of practical support varied. There is concern from both managers and practitioners regarding ongoing funding for advanced practice development. Conclusion The present evaluation study reiterates the need for organizational commitment to succession planning including robust service needs analysis mechanisms and adequate funding for development processes. Implications for nursing management Nurse managers are viewed as the ‘gatekeepers’ to opportunities for developing advanced nurse practitioners; scare resources must be targeted effectively to support succession planning through the development of selected individuals for future advanced practice posts, justified by service need.

Background Older adults with dementia may have feeding difficulties for several reasons: they may experience deterioration in motor and cognitive skills making eating difficult, they may forget to eat, fail to recognise food or they may suffer from dysphagia. Food intake is often poor and malnutrition is common, leading to adverse health outcomes.This review specifically focussed on how best to promote and achieve 'normal' eating and feeding in older adults with dementia, in order that undernutrition and its consequences could be avoided.Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia.Types of Participants Adults over the age of sixty with dementia in any care setting (who were not living independently). People receiving enteral tube feeding were excluded.Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers, family or volunteers, educational interventions, changes in food service.Types of Outcomes The primary outcomes were improvement in dietary intake and/or nutritional status. Measurements included: dietary intake, anthropometry, clinical outcomes, functional indicators.Types of Studies Randomised controlled trials, controlled trials and quasi-experimental studies with a 'before and after' design.Search Strategy The search strategy aimed to find both published and unpublished studies using a three-step approach. Papers were limited to the English language and a date restriction of 1999 to 2009 was set.Critical appraisal Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review. Disagreements that arose between the reviewers were resolved through discussion.Data Extraction For quantitative studies, data was extracted using a data extraction form developed to include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. This was based on the JBI data extraction tool from MAStARI and 2 reviewers extracted data independently.Data synthesis Heterogeneity in study designs, interventions and outcomes meant meta-analysis was not possible. Findings were discussed in a narrative summary.Results The review included 11 studies. This included one RCT, 1 randomised crossover study, 3 controlled non-randomised trials, 6 quasi-experimental studies. None of the studies provided robust evidence, however there was moderate evidence (Level 3) to support a Grade B recommendation for improvements in dietary intake and/or nutritional status with the following interventions: education of healthcare staff, simple environmental manipulations such as the use of high contrast tableware or small dining rooms, the introduction of something of interest such as an aquarium or background music, or the provision of feeding assistance, provision of enhanced menus, use of a decentralised food service, enhanced nutritional screening combined with increased dietetic time.Conclusion There is moderate (Level 3) evidence to support each of the interventions appraised in this review.Implications for Practice There is moderate support that warrants consideration of the interventions listed above. Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care.Implications for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following: inclusion of reliable outcome measures, full details of interventions, randomisation of participants, inclusion of control groups, adequate sample sizes, longitudinal follow up, consideration of baseline demographics of intervention groups, and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care.

Review Questions/Objectives: The objective of this qualitative systematic review is to synthesise the best available evidence related to ‘self-care needs’ from the perspective of patients who have heart failure and that of their lay caregivers. To this end, our research questions are: 1) What is the evidence on self-care needs in heart failure from the perspective of patients who experience this condition? 2) What is the evidence on self-care needs in heart failure from the perspective of lay carers who support patients who experience this condition? 3) What is the evidence on the way in which older age is perceived by patients and lay carers to affect self-care needs in heart failure? . Inclusion Criteria: Types of Participants: For inclusion, studies should involve adults over the age of 18 years who have heart failure, irrespective of age, gender, context, treatment or severity of heart failure, in order to include the widest possible range of circumstances facing people with heart failure. Phenomena of Interest: To support consistent interpretation between the research team, we will define data or themes relevant to the phenomena of interest as being: ‘findings related to any process,phenomena or construct that pertains to meeting the self-care needs of heart failure in patients or support of self-care needs by lay caregivers.’ Context: It is well recognised that self-care needs are influenced by contextual or cultural factors such as where the patient lives and the availability of social support, as well as the type of patient education and professional support provided; evidence related to the context in which specific self care needs are expressed, and the effectiveness with which they are met, will be sought.

Grounded theory methods can help to generate a theoretical explanation of social processes in specific contexts. This paper discusses theoretical sampling to guide interview participant selection and reflects on the practical application of this procedure to outline the value and limitations of using survey data in this way.

The promotion of stakeholder partnerships features within practice development work and is intuitively appealing, but in reality meaningful partnerships can be problematic. We report the findings of four parallel Nominal group Technique Interviews undertaken with groups of professional (nurses from practice and academia) and lay stakeholder representatives during a seminar event. The group work sought to explore the mechanisms, which could facilitate meaningful practice development partnerships between nurses, academic nurses and people. The most highly ranked suggestions included creating a culture where practice development is seen as everyone's business and establishing a unified collaborative infrastructure. A range of enabling and inhibiting conditions were explored and the complexity of achieving consensus decision-making processes that would allow realization of the policy rhetoric was exposed.

This paper by David Cochrane, Janette Palmer, Grace Lindsay, Elizabeth Tolmie, Douglas Allan and Kay Currie describes a project that led to the formulation of an online educational needs assessment tool by drawing on national healthcare competencies in coronary heart disease. It discusses the merits of web-based data collection and concludes that web-based survey systems offer distinct advantages providing researchers proceed with care.

This paper presents findings from a recent PhD grounded theory study exploring the practice development role of graduate specialist practitioners. A key finding within this theory is the influence of learning and confidence on the practitioner journey. The concept of confidence emerged repeatedly throughout the analysis and can be characterized as a motivational driver, a consequence of learning and gaining respect, and a condition for graduate specialist practitioners' moving on to impact in practice development. Analysis of the concept of confidence as it influences practice is limited in existing literature. This article seeks to address this gap by illustrating the centrality of learning and confidence in the development of expert specialist practices. It is anticipated that these findings will resonate with the experiences of clinicians and faculty internationally and heightened awareness of consequences of developing confidence can be utilized to strengthen the impact of a wide range of nursing programs.

Background. Changing health care practice is commonly attempted by feedback of performance data measured by clinical audit. However, empirical evidence of the effectiveness of clinical audit in changing practice is limited. Few studies have attempted to evaluate practice development or clinical outcomes within the conceptual framework of change theory. Several published studies have used passive feedback in an attempt to promote a change in practice. Sending information to health care workers on their performance is one of the simplest ways of attempting to change performance. Aims. To evaluate the impact on infection rates of the passive feedback of surgical wound infection rate data to nurses and surgeons within an empirical rational approach to change, and the active feedback of data within a normative re-educative approach to change. Methods. A prospective cohort study over a 3-year period of all surgical patients undergoing clean elective surgery (n = 2241). Patients were monitored whilst an inpatient and up to 30 days postoperatively by an independent observer to determine surgical wound infection rates. The method employed was ‘gold standard’ surveillance, whereby patients were followed up into the community setting. Interventions. Interventions of feedback and withdrawal of feedback of infection rate data and introduction of guidelines for evidence-based surgical practice within a change theory framework were monitored by the incidence of infection during the periods of the particular intervention. Results. Although the feedback of infection rate data impacted on the subsequent infection rates, the reduction was not statistically significant. However, a significant reduction in the infection rates was achieved following the introduction of guidelines for best surgical practice (P

BACKGROUND Emerging evidence suggests that heart failure (HF) patients who have mild cognitive impairment (MCI) may experience greater difficulty with self-care. OBJECTIVE This article reports a systematic review that addressed the objective "What is the evidence for an association between MCI and self-care, measured in 1 or more of the self-care domains related to HF, in adults who have a diagnosis of chronic HF?" METHOD We adopted Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the review and synthesis of quantitative research studies that formally measured both cognitive function and self-care in HF patients and sought to describe the relationship between these factors. RESULTS Ninety-one potentially relevant studies were located; 10 studies (2006-2014) were included. Because of heterogeneity in the retrieved studies, meta-analysis was not possible. Narrative synthesis found growing evidence regarding the association between MCI and adverse effects on self-care in HF. Nine studies reported significant positive associations between MCI and self-care in HF, either specifically in relation to medication adherence or more generic measures of self-care activity. One study reported a significant, negative correlation between cognitive function and self-care, suggesting that worse cognitive function was associated with better self-care; however, this is partially explained by a small sample size and mixed methodology. CONCLUSIONS These findings have implications for clinical practice. It is known that HF patients have difficulty with self-care, and the influence of cognitive function needs to be considered when providing professional support. Further research to determine the feasibility and acceptability of cognitive assessment in routine clinical care is recommended.

Background: Self-care is at the foundation for living with a chronic condition such as heart failure (HF). Patients with HF express difficulty with translating self-care knowledge into understanding ‘‘how’’ to engage in these activities and behaviors. Understanding the strategies that patients develop to engage in self-care will help healthcare providers (HCPs) improve support for unmet self-care needs of HF patients. The purpose of this systematic review was to highlight strategies that HF patients use to accommodate self-care recommendations into the reality of their daily lives. Methods: A systematic review using qualitative meta-synthesis was carried out. Included studies had to contain a qualitative component and data pertaining to self-care of HF from adults older than 18 years and be published as full papers/theses beginning 1995. Ten databases were searched until March 19, 2012. Results: Of 1421 papers identified by the search, 47 were included. Studies involved the following: 1377 patients, 45% women, mean age of 67 years (range, 25Y98 years), 145 caregivers, and 15 HCPs. Approaches to self-care reflected both perception- and action-based strategies and were a means to effectively manage HF. Although HF patients often expressed difficulty on how to integrate self-care recommendations into their daily lives, they developed intentional, planned strategies that harnessed previous experiences. Conclusions: Healthcare providers must appreciate that patients view self-care as an ‘‘adaptation’’ that they undertake to maintain their independence and quality of life. In addition, HCPs must recognize that because self-care is a process of learning over time from experience, an individualized approach that emphasizes how to self-care must be adopted for patients to develop the necessary HF self-care skills.

Summary Background The concept of person-centred care has gained international recognition over the last decade and forms one of the key concepts of our Nursing Quality Improvement Curricular Framework. Objectives This study aimed to investigate nursing students' learning about person-centred care during the first-year of their programme. Methods Qualitative thematic analysis of a section of placement learning documents from two consecutive cohorts of students from all fields of nursing (n = 405), supplemented by three focus group discussions. Results Two conceptual categories of student approaches to learning emerged. Firstly, ‘stepping back’, or learning from a distance about how nurses provide care, often through reading case notes and care plans; second, ‘stepping in’, learning about the patient as a person by direct interaction with service users. Evidence of reflection on the patient's experience of care was limited. These results have resonance with existing pedagogical theories around preferences for active or passive styles of learning. The potential for clinical mentors to build student confidence and encourage direct engagement with patients was highlighted. Conclusions Students are aware of the concepts, principles and professional values of person-centred care from early in their programme; however, the majority tend to be preoccupied by learning about what nurses ‘do’, rather than ‘how patients experience care’. Development towards a more person-centred approach may require targeted support from mentors to help students gain confidence and begin reflecting on how patients experience care.

Effective heart failure (HF) self-care can improve clinical outcomes but is dependent on patients' undertaking a number of complex self-care behaviors. Research into the effectiveness of HF management programs demonstrates mixed results. There is a need to improve understanding of patient perspectives' of self-care need in order to enhance supportive interventions.This paper reports selected findings from a systematic review of qualitative research related to HF self-care need from the patients' perspective. The focus here is on those facets of patient-healthcare professional relationships perceived by patients to influence HF self-care.We searched multiple healthcare databases to identify studies reporting qualitative findings with extractable data related to HF self-care need. Joanna Briggs Institute systematic review methods were employed and recognized meta-synthesis techniques were applied. Critical realist theory provided analytical direction to highlight how individual and contextual factors came together in complex ways to influence behavior and outcomes.Altogether 24 studies (1999-2012) containing data on patient-healthcare professional relationships and HF self-care were included. Interaction with healthcare professionals influenced self-care strongly but was notably mixed in terms of reported quality. Effective HF self-care was more evident when patients perceived that their healthcare professional was responsive, interested in their individual needs, and shared information. Poor communication and lack of continuity presented common barriers to HF self-care.Interactions and relationships with clinicians play a substantial role in patients' capacity for HF self-care. The way healthcare professionals interact with patients strongly influences patients' understanding about their condition and self-care behaviors.

Background The aim of this work was to identify the main contextual factors and processes that influence patients' self-care of heart failure (HF). Methods and Results A systematic review was conducted with the use of qualitative meta-synthesis. Ten databases were searched up to March 19, 2012. Of the 1,421 papers identified by the systematic search, 45 studies were included in this meta-synthesis. To be included, studies had to contain a qualitative research component, data pertaining to self-care of HF from adults (≥18 y) and be published as full papers or theses since 1995. These studies involved: 1,398 patients (mean age 65.9 y), 180 caregivers, and 63 health professionals. Six main types of contextual factors were found to influence HF self-care in the studies: caregivers; social networks and social support; place; finances and financial capacity; work and occupation; and HF support groups and programs. Conclusion HF self-care is influenced by contextual elements that fall outside of traditional elements of a HF self-care program. Inclusion of these elements may help to address the current concerns about poor adherence to self-management programs.

Summary Background Reducing avoidable nursing student attrition is an international challenge. A pattern of falling attendance is recognised as a frequent precursor to withdrawal from nursing programmes. To address concerns regarding nursing student attrition, the Scottish Government implemented a pilot project for a centralised Computerised Absence Management and Monitoring System (CAMMS). The CAMMS adopted an ‘assertive outreach’ approach, contacting students every two weeks via colour coded letters to tell them whether their attendance was ‘excellent’, ‘good, but potentially causing concern’; or ‘warning; attendance concerns/contact academic staff for support’. This article reports key findings from an evaluation of CAMMS. Objectives To explore the perceived impact of CAMMS on student support and attrition, from the perspectives of academic and administrative staff and students. Design Mixed methods evaluation design. Settings Three large geographically dispersed Schools of Nursing in Scotland. Participants 83 students; 20 academic staff; and 3 lead administrators. Methods On-line cohort survey of academic staff and students; structured interviews with lead administrators. Results Findings reflected a spectrum of negative and positive views of CAMMS. Students who are attending regularly seem pleased that their commitment is recognised. Lecturers who teach larger groups report greater difficulty getting to know students individually and acknowledge the benefit of identifying potential attendance concerns at an early stage. Conversely, some students who received a ‘warning’ letter were frequently annoyed or irritated, rather than feeling supported. Increased staff workload resulted in negative perceptions and a consequent reluctance to use CAMMS. However, students who were causing concern reported subsequent improvement in attendance. Conclusions CAMMS has the potential to identify ‘at-risk’ students at an early stage; however, the system should have flexibility to tailor automatically generated letters in response to individual circumstances, to avoid student frustration. Further research on the longer term impact of CAMMS on attrition rates is warranted.

Universal screening for methicillin resistant Staphylococcus aureus (MRSA) of admissions to hospital became mandatory in England in 2010 . However, there is little data about the patient experience of MRSA screening, the impact of receiving a positive result and the confidence patients have in the care they receive.

We applied the grounded theory method to explore the post discharge concerns of older people after fall-induced hip fracture repair. It was anticipated that this understanding would increase awareness of issues that may impact on recovery and rehabilitation.Semi-structured interviews were carried out with 19 older people after discharge home. Initially, purposive sampling guided data collection and thereafter theoretical sampling was employed. Interviews were analysed using the constant comparative method.We generated a theory of how older people 'take control' after hip fracture. Conceptually, taking control was about 'balancing' and was both a process and a range of strategies. The three stages of the process that people moved through were: 'going under', 'keeping afloat' and 'gaining ground'. Nautical metaphors conceptualise the precarious and unstable conditions that older people faced as they struggled to regain their independence. Older people struggled to balance help and risk, in their attempt to manage their concerns relating to losing control of their future independence.Older people are vulnerable to losing a sense of control after a health trauma. This theory adds a new dimension to our understanding of recovery from hip fracture and highlights that older people and their families need tailored information and support to enable them to take control safely and appropriately.

Summary Background Despite limited evidence of meticillin-resistant Staphylococcus aureus (MRSA) decolonization efficacy, the practice of decolonization for both pre-admission and on-admission patients is growing. Recent research within National Health Service (NHS) Scotland revealed low rates of treatment and consequent low efficacy in home-based decolonization. As no national guidelines on home-based decolonization currently exist, practices within NHS Scotland may be variable. Aim To establish current pre-admission MRSA home-based decolonization protocols and patient advice within NHS Scotland. Similarities and differences were identified to determine possible sources of variability. Methods Cross-sectional survey distributed electronically to MRSA Screening Project Managers within each NHS geographical region in Scotland ( N = 15). Findings Thirteen out of 15 NHS regions responded; one region reported no standard protocol. From the remaining 12 regions, 100% recommended use of mupirocin and antiseptic bodywash daily for five days; this was the only consistent aspect of practice across responding regions. Variation was noted in advice regarding method of mupirocin application, bodywash product and volume of bodywash recommended. Six regions (50%) specified bodywash skin contact time, yet these times varied across regions. Mouth care was advocated by three regions (25%). Daily change of facecloths and clothes was endorsed by five regions (41.7%); four regions (33.3%) promoted daily towel changes. Only one region (8.3%) suggested daily bedroom cleaning; three regions (25%) advised changing bed linen daily. Conclusions Variation in protocols and patient advice may influence efficacy of home-based decolonization and further research may inform the development of evidence-based clinical guidelines.