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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 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.

Background\ud \ud There is growing recognition by national and international policy makers of the contribution nurses make towards antimicrobial stewardship. Although undergraduate education provides an ideal opportunity to prepare nurses for antimicrobial stewardship roles and activities, only two thirds of undergraduate nursing programmes incorporate any antimicrobial stewardship teaching and only 12% cover all the recommended antimicrobial stewardship principles. Nurses also report that they do not have a good knowledge of antibiotics, and many have not heard of the term antimicrobial stewardship.\ud Aim\ud \ud To provide international consensus on the antimicrobial stewardship competency descriptors appropriate for undergraduate nurse education.\ud Methods\ud \ud A modified Delphi approach comprising two on-line surveys delivered to an international panel of fifteen individuals reflecting expertise in prescribing and medicines management in the education and practice of nurses; and antimicrobial stewardship. Data collection took place between February and March 2019.\ud Findings\ud \ud A total of 15 participants agreed to become members of the expert panel, of whom 13 (86%) completed round one questionnaire, and 13 (100%) completed round two. Consensus was achieved, with consistent high levels of agreement across panel members, on 6 overarching competency domains and 63 descriptors, essential for antimicrobial stewardship practice.\ud Conclusion\ud \ud The competency descriptors should be used to direct undergraduate nurse education, and the AMS practices of qualified nurses (including those working in new roles such as Nursing Associates) given the high levels of agreement reached on competency descriptors.

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.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread internationally with 5 593 631 cases reported globally including 353 334 deaths [ 1 ] . Its rapid emergence and dissemination have highlighted multiple areas in which competencies in antimicrobial stewardship (AMS) (the safe and effective use of antimicrobials), specifically by nurses, can support response efforts. There have been calls for nurses to be recognised as legitimate contributors to AMS team efforts [ 2 , 3 , 4 , 5 ].Unfortunately, nurse’s role in these efforts, have received minimal mention in international and national policy [ 4 , 6 , 7 , 8 , 9 , 10 ]. It is reported that nurses’ knowledge of antibiotics is poor [ 11 , 12 ], and that AMS taught in nurse undergraduate programmes is disparate or lacking [ 13 ]. To address this gap, AMS consensus based international competency statements have been developed, focussed on six domains (Infection prevention and control, antimicrobials and antimicrobial resistance, the diagnosis of infection and use of antibiotics, antimicrobial prescribing practice, person centred care, interprofessional collaborative practice), which are (seen as) priorities/minimum requirements for nurses [ 14 , 15 ].

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.

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.

This article discusses the importance of the role of the health visitor in the containment of antimicrobial resistance, focusing on three key areas of practice. Antimicrobial resistance is a serious public health problem and all health professionals should be engaged in preserving antibiotics for future generations. The focus of this article is on the health visitor role in infection prevention and control, antibiotic stewardship and prescribing, and improving public engagement and professional development in antibiotic stewardship and infection control.

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.

Summary 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.

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.

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.

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.

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.

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 methods 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.

Summary 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.

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.

Background Fasting before general anaesthesia aims to reduce the volume and acidity of stomach contents during surgery, thus reducing the risk of regurgitation/aspiration. Recent guidelines have recommended a shift in fasting policy from the standard 'nil by mouth from midnight' approach to more relaxed policies which permit a period of restricted fluid intake up to a few hours before surgery. The evidence underpinning these guidelines however, was scattered across a range of journals, in a variety of languages, used a variety of outcome measures and methodologies to evaluate fasting regimens that differed in duration and the type and volume of intake permitted during a restricted fasting period. Practice has been slow to change. Objectives To systematically review the effect of different preoperative fasting regimens (duration, type and volume of permitted intake) on perioperative complications and patient wellbeing (including aspiration, regurgitation and related morbidity, thirst, hunger, pain, nausea, vomiting, anxiety) in different adult populations. Search methods Electronic databases, conference proceedings and reference lists from relevant articles were searched for studies of preoperative fasting in August 2003 and experts in the area were consulted. Selection criteria Randomised controlled trials which compared the effect on postoperative complications of different preoperative fasting regimens on adults were included. Data collection and analysis Details of the eligible studies were independently extracted by two reviewers and where relevant information was unavailable from the text attempts were made to contact the authors. Main results Thirty eight randomised controlled comparisons (made within 22 trials) were identified. Most were based on 'healthy' adult participants who were not considered to be at increased risk of regurgitation or aspiration during anaesthesia. Few trials reported the incidence of aspiration/regurgitation or related morbidity but relied on indirect measures of patient safety i.e. intra-operative gastric volume and pH. There was no evidence that the volume or pH of participants' gastric contents differed significantly depending on whether the groups were permitted a shortened preoperative fluid fast or continued a standard fast. Fluids evaluated included water, coffee, fruit juice, clear fluids and other drinks (e.g. isotonic drink, carbohydrate drink). Participants given a drink of water preoperatively were found to have a significantly lower volume of gastric contents than the groups that followed a standard fasting regimen. This difference was modest and clinically insignificant. There was no indication that the volume of fluid permitted during the preoperative period (i.e. low or high) resulted in a difference in outcomes from those participants that followed a standard fast. Few trials specifically investigated the preoperative fasting regimen for patient populations considered to be at increased risk during anaesthesia of regurgitation/aspiration and related morbidity. Authors' conclusions There was no evidence to suggest a shortened fluid fast results in an increased risk of aspiration, regurgitation or related morbidity compared with the standard 'nil by mouth from midnight' fasting policy. Permitting patients to drink water preoperatively resulted in significantly lower gastric volumes. Clinicians should be encouraged to appraise this evidence for themselves and when necessary adjust any remaining standard fasting policies (nil-by-mouth from midnight) for patients that are not considered 'at-risk' during anaesthesia.

When writing at degree level, nurses need to demonstrate an understanding of evidence by summarising its key elements and comparing and contrasting authors' views. Critical analysis is an important nursing skill in writing and in practice. With the advent of an all-degree profession, understanding how to develop this skill is crucial. This article examines how students can develop critical analysis skills to write at undergraduate degree level. It highlights some of the common errors when writing at this academic level and provides advice on how to avoid such mistakes.