School Nurses' perspectives on the role of the school nurse in health education and health promotion in England: a qualitative study.

BACKGROUND: The role of the school nurse is complex with many possible elements identified by previous research. The aim of this study is to understand perceptions of the role of the school nurse in order to support school nurses in the delivery of health education. METHODS: The study used an inductive, qualitative research design involving semi-structured interviews and focus groups. Participants were recruited from four NHS trusts across England and final sample size was thirty one school nurses. Three focus groups and two interviews took place in person, and three interviews were over the phone. Data was thematically analysed. RESULTS: School nurses described six main themes. Four themes directly related to the school nurse role: the main roles of a school nurse, school nurses' role in health education, prioritisation of workload and activities, and community work. A further two other themes related to the delivery of health education: the school nursing system and educational resources. CONCLUSIONS: The role of the school nurse in England is very diverse and the school nurse role in health education is primarily to advise and support schools, rather than to directly deliver education. The study identified that tailored public health educational resources are needed to support school nurses

Tools to overcome potential barriers to chlamydia screening in general practice: Qualitative evaluation of the implementation of a complex intervention

Background: Chlamydia trachomatis remains a significant public health problem. We used a complex intervention, with general practice staff, consisting of practice based workshops, posters, computer prompts and testing feedback and feedback to increase routine chlamydia screening tests in under 25 year olds in South West England. We aimed to evaluate how intervention components were received by staff and to understand what determined their implementation into ongoing practice. Methods: We used face-to-face and telephone individual interviews with 29 general practice staff analysed thematically within a Normalisation Process Theory Framework which explores: 1. Coherence (if participants understand the purpose of the intervention); 2. Cognitive participation (engagement with and implementation of the intervention); 3. Collective action (work actually undertaken that drives the intervention forwards); 4. Reflexive monitoring (assessment of the impact of the intervention). Results: Our results showed coherence as all staff including receptionists understood the purpose of the training was to make them aware of the value of chlamydia screening tests and how to increase this in their general practice. The training was described by nearly all staff as being of high quality and responsible for creating a shared understanding between staff of how to undertake routine chlamydia screening. Cognitive participation in many general practice staff teams was demonstrated through their engagement by meeting after the training to discuss implementation, which confirmed the role of each staff member and the use of materials. However several participants still felt unable to discuss chlamydia in many consultations or described sexual health as low priority among colleagues. National targets were considered so high for some general practice staff that they didn’t engage with the screening intervention. Collective action work undertaken to drive the intervention included use of computer prompts which helped staff remember to make the offer, testing rate feedback and having a designated lead. Ensuring patients collected samples when still in the general practice was not attained in most general practices. Reflexive monitoring showed positive feedback from patients and other staff about the value of screening, and feedback about the general practices testing rates helped sustain activity. Conclusions: A complex intervention including interactive workshops, materials to help implementation and feedback can help chlamydia screening testing increase in general practices

Treatment of infections caused by multidrug-resistant Gram-negative bacteria: report of the British Society for Antimicrobial Chemotherapy/Healthcare Infection Society/British Infection Association Joint Working Party

The Working Party makes more than 100 tabulated recommendations in antimicrobial prescribing for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB) and suggest further research, and algorithms for hospital and community antimicrobial usage in urinary infection. The international definition of MDR is complex, unsatisfactory and hinders the setting and monitoring of improvement programmes. We give a new definition of multiresistance. The background information on the mechanisms, global spread and UK prevalence of antibiotic prescribing and resistance has been systematically reviewed. The treatment options available in hospitals using intravenous antibiotics and in primary care using oral agents have been reviewed, ending with a consideration of antibiotic stewardship and recommendations. The guidance has been derived from current peer-reviewed publications and expert opinion with open consultation. Methods for systematic review were NICE compliant and in accordance with the SIGN 50 Handbook; critical appraisal was applied using AGREE II. Published guidelines were used as part of the evidence base and to support expert consensus. The guidance includes recommendations for stakeholders (including prescribers) and antibiotic-specific recommendations. The clinical efficacy of different agents is critically reviewed. We found there are very few good-quality comparative randomized clinical trials to support treatment regimens, particularly for licensed older agents. Susceptibility testing of MDR GNB causing infection to guide treatment needs critical enhancements. Meropenem- or imipenem-resistant Enterobacteriaceae should have their carbapenem MICs tested urgently, and any carbapenemase class should be identified: mandatory reporting of these isolates from all anatomical sites and specimens would improve risk assessments. Broth microdilution methods should be adopted for colistin susceptibility testing. Antimicrobial stewardship programmes should be instituted in all care settings, based on resistance rates and audit of compliance with guidelines, but should be augmented by improved surveillance of outcome in Gram-negative bacteraemia, and feedback to prescribers. Local and national surveillance of antibiotic use, resistance and outcomes should be supported and antibiotic prescribing guidelines should be informed by these data. The diagnosis and treatment of both presumptive and confirmed cases of infection by GNB should be improved. This guidance, with infection control to arrest increases in MDR, should be used to improve the outcome of infections with such strains. Anticipated users include medical, scientific, nursing, antimicrobial pharmacy and paramedical staff where they can be adapted for local use

Feasibility of a community pharmacy antimicrobial stewardship intervention (PAMSI): an innovative approach to improve patients’ understanding of their antibiotics

Background Community pharmacy staff have an opportunity to play a pivotal role in antimicrobial stewardship (AMS) due to their expertise in medicines and accessibility to patients. Objectives To develop and test the feasibility of a pharmacy AMS intervention (PAMSI) to increase community pharmacy staff’s capability, opportunity and motivation to check antibiotic appropriateness and provide self-care and adherence advice when dispensing antibiotics. Methods The PAMSI was centred around an Antibiotic Checklist, completed by patients and pharmacy staff, to facilitate personalized advice to the patient, based on their reported knowledge. An educational webinar for staff and patient-facing materials were also developed. Staff and patients completing Antibiotic Checklists were invited to provide feedback via questionnaires. Results In February 2019, 12 community pharmacies in England trialled the intervention. Forty-three pharmacy staff evaluated the educational webinar and reported increases in their understanding, confidence, commitment and intention to use the tools provided to give adherence and self-care advice. Over 4 weeks, 931 Antibiotic Checklists were completed. Staff reported being more focused on giving advice and able to address patients’ knowledge gaps (mainly: likely symptom duration; alcohol and food consumption advice; possible side effects from antibiotics; returning unused antibiotics to the pharmacy), resulting in increased self-reported effective and meaningful conversations. Conclusions Implementation of a PAMSI is feasible and effectively promotes AMS. Pharmacy staff and commissioners should consider this within their AMS plans. An optional digital format of the Antibiotic Checklist should be explored, for patients who are not collecting their antibiotic prescriptions themselves, and to save printing costs

Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies

Objective: While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions. Settings: English primary care. Interventions: AMS interventions targeting healthcare professionals’ antibiotic prescribing for respiratory tract infections. Methods: We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing. Results: We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: ‘beliefs about consequences’, ‘social influences’, ‘skills’, ‘environmental context and resources’, ‘intentions’ and ‘emotions’. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%–67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none. Conclusions: Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, ‘forming/reversing habits’, ‘reducing negative emotions’, ‘social support’). These could be incorporated into existing, or developed as new, AMS interventions

Optimising interventions for catheter-associated urinary tract infections (Cauti) in primary, secondary and care home settings

Catheter-associated urinary tract infections (CAUTI) are common yet preventable. Healthcare professional behaviours, such as reducing unnecessary catheter use, are key for preventing CAUTI. Previous research has focused on identifying gaps in the national response to CAUTI in multiple settings in England. This study aimed to identify how national interventions could be optimised. We conducted a multi-method study comprising: a rapid review of research on interventions to reduce CAUTI; a behavioural analysis of effective research interventions compared to national interventions; and a stakeholder focus group and survey to identify the most promising options for optimising interventions. We identified 37 effective research interventions, mostly conducted in United States secondary care. A behavioural analysis of these interventions identified 39 intervention components as possible ways to optimise national interventions. Seven intervention components were prioritised by stakeholders. These included: checklists for discharge/admission to wards; information for patients and relatives about the pros/cons of catheters; setting and profession specific guidelines; standardised nationwide computer-based documentation; promotion of alternatives to catheter use; CAUTI champions; and bladder scanners. By combining research evidence, behavioural analysis and stakeholder feedback, we identified how national interventions to reduce CAUTI could be improved. The seven prioritised components should be considered for future implementation

The views of general practitioners and practice nurses towards the barriers and facilitators of proactive, internet-based chlamydia screening for reaching young heterosexual men

Background: Chlamydia trachomatis is a common bacterial sexually transmitted infection (STI), which disproportionately affects young people under 25 years. Commonly, more women are offered screening than men. This study obtained the views of general practitioners and practice nurses towards Internet-based screening and assessed levels of support for the development of proactive screening targeting young heterosexual men via the Internet. Methods: Semi-structured telephone interviews with 10 general practitioners and 8 practice nurses, across Central Scotland. Topics covered: experience of screening heterosexual men for chlamydia, views on the use of the Internet as a way to reach young men for chlamydia screening, beliefs about the potential barriers and facilitators to Internet-based screening. Transcripts from audio recordings were analysed with Framework Analysis, using QSR NVivo10. Results: Experiences of chlamydia screening were almost exclusively with women, driven by the nature of consultations and ease of raising sexual health issues with female patients; few practice nurses reported seeing men during consultations. All participants spoke in favour of Internet-based screening for young men. Participants reported ease of access and convenience as potential facilitators of an Internet-based approach but anonymity and confidentiality could be potential barriers and facilitators to the success of an Internet approach to screening. Concerns over practical issues as well as those pertaining to gender and socio-cultural issues were raised. Conclusions: Awareness of key barriers and facilitators, such as confidentiality, practicality and socio-cultural influences, will inform the development of an Internet-based approach to screening. However, this approach may have its limits in terms of being able to tackle wider social and cultural barriers, along with shifts in young people's and health professionals' attitudes towards screening. Nevertheless, employing innovative efforts as part of a multi-faceted approach is required to ensure effective interventions reach the policy agenda

Social and contextual influences on antibiotic prescribing and antimicrobial stewardship: a qualitative study with clinical commissioning group and general practice professionals

Antibiotic prescribing in England varies considerably between Clinical Commissioning Groups (CCGs) and general practices. We aimed to assess social and contextual factors affecting antibiotic prescribing and engagement with antimicrobial stewardship (AMS) initiatives. Semi-structured telephone interviews were conducted with 22 CCG professionals and 19 general practice professionals. Interviews were audio-recorded, transcribed, and analyzed thematically. Social/contextual influences were grouped into the following four categories: (1) Immediate context, i.e., patients’ social characteristics (e.g., deprivation and culture), clinical factors, and practice and clinician characteristics (e.g., “struggling” with staff shortage/turnover) were linked to higher prescribing. (2) Wider context, i.e., pressures on the healthcare system, limited resources, and competing priorities were seen to reduce engagement with AMS. (3) Collaborative and whole system approaches, i.e., communication, multidisciplinary networks, leadership, and teamwork facilitated prioritizing AMS, learning, and consistency. (4) Relativity of appropriate prescribing, i.e., “high” or “appropriate” prescribing was perceived as relative, depending on comparators, and disregarding different contexts, but social norms around antibiotic use among professionals and patients seemed to be changing. Further optimization of antibiotic prescribing would benefit from addressing social/contextual factors and addressing wider health inequalities, not only targeting individual clinicians. Tailoring and adapting to local contexts and constraints, ensuring adequate time and resources for AMS, and collaborative, whole system approaches to promote consistency may help promote AMS