IBriS study: intervention supporting breastfeeding in substance dependency.

Introduction: Breastfeeding offers the substance exposed mother and child potential short and long-term health benefits, with breast milk shown to alleviate the severity of Neonatal Abstinence Syndrome. Substance dependent women, however, have limited success establishing breastfeeding with physical, psychological and institutional factors cited as barriers. This study aimed to develop and test the feasibility of an evidence informed and theory based intervention to support continued breastfeeding for this group. Methods: The research was a two-phase feasibility study. Phase 1 informed intervention development using a mixed methodology approach which included (a) a comprehensive systematic literature review of breastfeeding support for women from disadvantaged groups (b) expert advisory group recommendations and (c) think aloud verbal protocols with opioid dependent women. Phase 2 underpinned the evidence with the theoretical constructs of behaviour change, prior to testing the acceptability and implementation fidelity of the intervention in a feasibility study with an embedded small-scale randomised controlled trial. Results: Phase 1 identified the barriers to breastfeeding continuation as low maternal self-efficacy; neonatal feeding difficulties associated with withdrawal and unsupportive healthcare practices. Evidence and theory synthesis resulted in an integrated breastfeeding support model founded on practical, informational, psychological, person-centred and environmental components. Phase 2 demonstrated that the intervention was feasible to implement and acceptable to participants. The randomised controlled trial reported higher rates of continued breastfeeding and a greater level of maternal confidence in breastfeeding ability in the intervention group compared to the control group. Breastfed infants were less likely to require pharmacological management and had corresponding shorter durations of hospitalisation than formula fed infants. Conclusion: The research provided an original contribution to the development of a complex healthcare intervention which is meaningful to both existing research and clinical practice. The findings highlighted the potential of the intervention to support breastfeeding for the substance exposed mother and baby, which has wide ranging implications for the improved health and social equalities of this group

Consultation in out-of-hours practice: a clinical review of Lyme disease

In recent times, telephone triage and virtual consultation have been expedited in the out-of-hours urgent primary care setting. This brings challenges concerning gaining a comprehensive history and building a therapeutic relationship between nurse prescriber and patient. This article presents a clinical review of Lyme disease to explore consultation models and how implementing a hybrid consultation approach may support the practitioner to develop safe prescribing practices and optimise patient expectations. This review of Lyme disease management highlights the sparse, low-quality evidence available, with national guidance indicating antimicrobial treatment for those who present with an erythema migrans rash prior to laboratory testing confirmation. This reinforces the importance of reaching a shared decision with the patient understanding of the perceived risk and benefits of treatment. The factors discussed include Lyme disease prevention and how the practitioner ensures safety netting in the out-of-hours setting

Non-medical prescribing considerations in emergency mental health services

The emergency mental health practitioner's job involves providing immediate care to patients who are suffering a mental health crisis. Independent nurse prescribing supports this service through timely access to pharmacological and non-pharmacological measures or cognitive behavioural strategies. This case study involves a service user diagnosed with bipolar type II disorder who presents with suicidal ideation, and outlines the prescribing options available for short-term crises and long-term risk management. There is a complex balance of appraising physical and mental health including capacity, assessment of risk of self-harm and harm to others, and working in consultation to optimise adherence and concordance. The authors highlight the importance of using a person-centred approach, which includes family, carers and their wider support network, to develop a therapeutic relationship which promotes positive outcomes. This is further supported by utilising the most recent and up-to-date policy, guidelines and legislation, including local and national policies

Prescribing within clinical toxicology

In 2020, the first clinical toxicology advanced nurse practitioner and independent prescriber post was introduced in the United Kingdom. This article discusses the remit of clinical toxicology and the integration of nurse prescribing into this service by following a patient journey from admission to discharge. The case study describes an acute paracetamol poisoning presentation following intentional self-harm. Paracetamol is widely available and safe in therapeutic dosages; however, it is the drug most commonly taken in intentional overdose and the toxic effect can result in hepatic failure and fatality. The nurse prescriber conducted a holistic consultation, assessed pharmacological management and instigated timely treatment. Current research on the benefits and disadvantages of paracetamol antidote regimes are discussed. Long-term physical and mental wellbeing following intentional overdose require interprofessional liaison with access to psychological support, arranged prior to patient discharge

Narrative review of closed loop automated oxygen systems

Preterm infants frequently require respiratory support with supplemental oxygen but excess and fluctuation of oxygen levels can have adverse effects. Oxygen saturation levels are maintained within narrow target ranges as a manual titration process. Closed loop automated oxygen systems hypothesis that automatic titration of inspired oxygen will reduce time spent out of desired oxygen target range compared with current manual control.Aimscomparison of automated versus manual oxygen control for preterm neonates undergoing non-invasive ventilation plus supplemental oxygen.MethodsFour electronic databases (CINAHL, Cochrane Library, Medline and PubMed) were searched with narrative review of findings.ResultsFour studies were included and all reported neonates spent more time in the oxygen target range with automated versus manual control with a wide variation in improvement from 8.8% to 30%.ConclusionsAutomated oxygen systems with non-invasive respiratory modalities can minimise time spent out with oxygen target range. Long term impact of automated control on incidence of oxidative stress injury remains undetermined

Characteristics of prescribing activity within primary care in Scotland 2013–2022 of general practitioners, nurse, pharmacist and allied health prescribers: A retrospective cross-sectional study

BackgroundIndependent prescribing by nurses, pharmacists and allied health professionals is diversifying into a variety of healthcare settings as pressures mount on existing resources. Primary care was an early adopter of prescribing by non-medical professionals with resulting improvements in accessibility and flexibility of services but also noted barriers. Exploring existing prescribing activity within primary care can support future initiatives that are cognisant of the needs of this specific population and targeted in the use of finite resources.AimTo explore the characteristics of prescribing activity of common drugs dispensed by community pharmacies in Scotland by prescribing groups of general practitioners, nurses, pharmacist and allied health professionals. Specifically, to compare overall drug prescribing frequency by prescriber group and identify emergent prescribing patterns of individual drugs.DesignA cross-sectional study.MethodsThe data from Public Health Scotland on frequency of the ten most common drugs prescribed and dispensed from community pharmacies between 2013 and 2022 by prescriber group were examined, applying descriptive statistics using secondary data analysis.ResultsPrescribing activity in non-medical prescribing groups accounted for 2%–3% of overall prescribing activity in primary care. There is a growing interprofessional approach to prescribing in chronic disease. Proton pump inhibitors were the most commonly prescribed medication overall with a 4-fold increase in nurse prescribing. The decline in prescribing frequency caused by COVID 19 restrictions has since returned to pre-pandemic levels.ConclusionThere is a growing contribution of nurse independent prescriber activity within primary care although still a relatively small proportion compared to medical practitioners. The pattern of increased prescribing of medications for long term and chronic conditions such as proton pump inhibitors by all prescribers is suggestive of multi-disciplinary professionals supporting increased patient demand. This study provides a baseline to evaluate current service provision in further research and enable professional, service and policy development

Breastfeeding Support and Opiate Dependence: A Think Aloud Study

Objective: international guidelines recommend the promotion and protection of breastfeeding for the substance exposed mother and baby. Yet few studies have explored the facilitators, moderators and barriers to successful breastfeeding for women enrolled on opiate maintenance treatment, or suggested targeted support strategies. The aim of this study was to explore the views of women with opiate dependence on proposed elements for inclusion in a breastfeeding support intervention.Design: a qualitative study using think aloud technique.Setting: tertiary maternity hospital in the North-East of Scotland. Interviews conducted between November 2013 and March 2014.Participants: 6 opiate dependent women within 6 months of giving birth. Participants were enrolled on opiate medication treatment during their pregnancy, had initiated breastfeeding and accessed in-hospital breastfeeding support.Findings: an intervention founded on practical, informational and environmental elements was endorsed as supportive of continued breastfeeding of an infant at risk of Neonatal Abstinence Syndrome. Opiate dependent women were more receptive to strategies promoting a person-centered approach that were specific to their individualized infant feeding needs and delivered within an emotionally supportive environment. Barriers to the acceptability of breastfeeding advice included discouraging, prescriptive and judgemental healthcare actions and attitudes.Key conclusions: there are distinct facilitators, modifiers and barriers to breastfeeding within the context of opiate exposure. Using this awareness to underpin the key features of the design should enhance maternal receptiveness, acceptability and usability of the support intervention.Implications for practice: additional and tailored support interventions are required to meet the specific needs of breastfeeding an infant experiencing opiate withdrawal. The elimination of disempowering institutional actions and attitudes is imperative if a conducive environment in which opiate dependent women feel supportedis to be achieved

Optimising the continuity experiences of student midwives: an integrative review

Background: In several countries, midwifery students undertake continuity of care experiences as part of their pre-registration education. This is thought to enable the development of a woman-centred approach, as well as providing students with the skills to work in continuity models. A comprehensive overview of factors that may promote optimal learning within continuity experiences is lacking.Aim: To identify barriers and facilitators to optimal learning within continuity experiences, in order to provide a holistic overview of factors that may impact on, modify and determine learning within this educational model.Methods: An integrative literature review was undertaken using a five-step framework which established the search strategy, screening and eligibility assessment, and data evaluation processes. Quality of included literature was critically appraised and extracted data were analysed thematically.Findings: Three key themes were identified. A central theme was relationships, which are instrumental in learning within continuity experiences. Conflict or coherence represents the different models of care in which the continuity experience is situated, which may conflict with or cohere to the intentions of this educational model. The final theme is setting the standards, which emerged from the lack of evidence and guidance to inform the implementation of student placements within continuity experiences.Conclusion: The learning from continuity experiences must be optimised to prepare students to be confident, competent and enthusiastic to work in continuity models, ultimately at the point of graduation. This will require an evidence-based approach to inform clear guidance around the intent, implementation, documentation and assessment of continuity experiences