Protection against SARS-CoV-2 after Covid-19 Vaccination and Previous Infection.

BACKGROUND: The duration and effectiveness of immunity from infection with and vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are relevant to pandemic policy interventions, including the timing of vaccine boosters. METHODS: We investigated the duration and effectiveness of immunity in a prospective cohort of asymptomatic health care workers in the United Kingdom who underwent routine polymerase-chain-reaction (PCR) testing. Vaccine effectiveness (≤10 months after the first dose of vaccine) and infection-acquired immunity were assessed by comparing the time to PCR-confirmed infection in vaccinated persons with that in unvaccinated persons, stratified according to previous infection status. We used a Cox regression model with adjustment for previous SARS-CoV-2 infection status, vaccine type and dosing interval, demographic characteristics, and workplace exposure to SARS-CoV-2. RESULTS: Of 35,768 participants, 27% (9488) had a previous SARS-CoV-2 infection. Vaccine coverage was high: 95% of the participants had received two doses (78% had received BNT162b2 vaccine [Pfizer-BioNTech] with a long interval between doses, 9% BNT162b2 vaccine with a short interval between doses, and 8% ChAdOx1 nCoV-19 vaccine [AstraZeneca]). Between December 7, 2020, and September 21, 2021, a total of 2747 primary infections and 210 reinfections were observed. Among previously uninfected participants who received long-interval BNT162b2 vaccine, adjusted vaccine effectiveness decreased from 85% (95% confidence interval [CI], 72 to 92) 14 to 73 days after the second dose to 51% (95% CI, 22 to 69) at a median of 201 days (interquartile range, 197 to 205) after the second dose; this effectiveness did not differ significantly between the long-interval and short-interval BNT162b2 vaccine recipients. At 14 to 73 days after the second dose, adjusted vaccine effectiveness among ChAdOx1 nCoV-19 vaccine recipients was 58% (95% CI, 23 to 77) - considerably lower than that among BNT162b2 vaccine recipients. Infection-acquired immunity waned after 1 year in unvaccinated participants but remained consistently higher than 90% in those who were subsequently vaccinated, even in persons infected more than 18 months previously. CONCLUSIONS: Two doses of BNT162b2 vaccine were associated with high short-term protection against SARS-CoV-2 infection; this protection waned considerably after 6 months. Infection-acquired immunity boosted with vaccination remained high more than 1 year after infection. (Funded by the U.K. Health Security Agency and others; ISRCTN Registry number, ISRCTN11041050.).

Striving for Improved Infection Prevention and Control Practice: A Grounded Theory of Healthcare Workers' Struggles in Implementing Infection Prevention and Control Guidance in Uganda.

There is a scarcity of qualitative research focusing on the implementation of infection prevention and control (IPC) guidance in low-income countries. This study aimed to address this gap by exploring the perspectives of healthcare workers (HCWs) regarding the implementation of IPC guidance at the healthcare facility level in Uganda. The study also sought to generate a theoretical understanding of the processes involved in implementing IPC guidance in these settings. This robust qualitative research employed a design based on constructivist grounded theory methodology, conducting individual interviews with 13 frontline health workers such as doctors, nurses, nurse interns, and laboratory staff. The key findings of the study revealed that HCWs undergo a process of 'striving for improved practice' in their efforts to implement IPC guidance. This process involved four phases: recognising the importance of IPC, playing a role, encountering challenges, and overcoming challenges. However, achieving full implementation proved difficult due to various individual and organisational barriers presented by the low-income setting. HCWs employed improvisation as a means to overcome these obstacles. Additionally, the study identified enabling factors that facilitated the implementation of IPC guidance within these settings. This study is significant as it applies robust qualitative research methods to provide valuable evidence of HCWs' perspectives on an important topic in an under-researched context, with findings transferable to similar settings.

Early Warning Surveillance for SARS-CoV-2 Omicron Variants, United Kingdom, November 2021-September 2022.

Since June 2020, the SARS-CoV-2 Immunity and Reinfection Evaluation (SIREN) study has conducted routine PCR testing in UK healthcare workers and sequenced PCR-positive samples. SIREN detected increases in infections and reinfections and delected Omicron subvariant waves emergence contemporaneous with national surveillance. SIREN's sentinel surveillance methods can be used for variant surveillance.

The effectiveness of hand hygiene interventions for preventing community transmission or acquisition of novel coronavirus or influenza infections: a systematic review.

BACKGROUND: Novel coronaviruses and influenza can cause infection, epidemics, and pandemics. Improving hand hygiene (HH) of the general public is recommended for preventing these infections. This systematic review examined the effectiveness of HH interventions for preventing transmission or acquisition of such infections in the community. METHODS: PubMed, MEDLINE, CINAHL and Web of Science databases were searched (January 2002-February 2022) for empirical studies related to HH in the general public and to the acquisition or transmission of novel coronavirus infections or influenza. Studies on healthcare staff, and with outcomes of compliance or absenteeism were excluded. Study selection, data extraction and quality assessment, using the Cochrane Effective Practice and Organization of Care risk of bias criteria or Joanna Briggs Institute Critical Appraisal checklists, were conducted by one reviewer, and double-checked by another. For intervention studies, effect estimates were calculated while the remaining studies were synthesised narratively. The protocol was pre-registered (PROSPERO 2020: CRD42020196525). RESULTS: Twenty-two studies were included. Six were intervention studies evaluating the effectiveness of HH education and provision of products, or hand washing against influenza. Only two school-based interventions showed a significant protective effect (OR: 0.64; 95% CI 0.51, 0.80 and OR: 0.40; 95% CI 0.22, 0.71), with risk of bias being high (n = 1) and unclear (n = 1). Of the 16 non-intervention studies, 13 reported the protective effect of HH against influenza, SARS or COVID-19 (P < 0.05), but risk of bias was high (n = 7), unclear (n = 5) or low (n = 1). However, evidence in relation to when, and how frequently HH should be performed was inconsistent. CONCLUSIONS: To our knowledge, this is the first systematic review of effectiveness of HH for prevention of community transmission or acquisition of respiratory viruses that have caused epidemics or pandemics, including SARS-CoV-1, SARS-CoV-2 and influenza viruses. The evidence supporting the protective effect of HH was heterogeneous and limited by methodological quality; thus, insufficient to recommend changes to current HH guidelines. Future work is required to identify in what circumstances, how frequently and what product should be used when performing HH in the community and to develop effective interventions for promoting these specific behaviours in communities during epidemics.

Effectiveness of interventions to improve the public's antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review.

Background: A global antimicrobial resistance (AMR) awareness intervention targeting the general public has been prioritized. Objectives: To evaluate the effectiveness of interventions that aim to change AMR awareness and subsequent stewardship behaviours amongst the public. Methods: Five databases were searched between 2000 and 2016 for interventions to change the public's AMR awareness and/or antimicrobial stewardship behaviours. Study designs meeting the Cochrane Effective Practice and Organization of Care (EPOC) criteria, non-controlled before-and-after studies and prospective cohort studies were considered eligible. Participants recruited from healthcare settings and studies measuring stewardship behaviours of healthcare professionals were excluded. Quality of studies was assessed using EPOC risk of bias criteria. Data were extracted and synthesized narratively. Registration: PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016050343). Results: Twenty studies were included in the review with nine meeting the EPOC criteria. The overall risk of bias was high. Nineteen studies were conducted in high-income countries. Mass media interventions were most common (n = 7), followed by school-based (n = 6) and printed material interventions (n = 6). Seventeen studies demonstrated a significant effect on changing knowledge, attitudes or the public's antimicrobial stewardship behaviours. Analysis showed that interventions targeting schoolchildren and parents have notable potential, but for the general public the picture is less clear. Conclusions: Our work provides an in-depth examination of the effectiveness of AMR interventions for the public. However, the studies were heterogeneous and the quality of evidence was poor. Well-designed, experimental studies on behavioural outcomes of such interventions are required.

Influences on independent nurse prescribers' antimicrobial prescribing behaviour: a systematic review.

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.

Are theoretical perspectives useful to explain nurses' tolerance of suboptimal care?

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.

Methicillin-resistant Staphylococcus aureus screening as a patient safety initiative: using patients' experiences to improve the quality of screening practices.

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.

Building capacity for point of care alcohol-based handrub (ABHR) and hand hygiene compliance among health care workers in the rural maternity and surgical units of a hospital in Cameroon.

BACKGROUND: Hand hygiene (HH) is challenging in health care, but particularly in resource-limited settings due to a lack of training, resources, and infrastructure. This study aimed to evaluate the implementation of wall-mounted alcohol-based handrub (ABHR) at the point of care (POC) on HH compliance among health care workers in a Cameroon hospital. METHODS: It was a three-stage before and after study. The first stage involved baseline collection of ABHR utilization and HH compliance data. The second stage included the implementation of ABHR at the POC, supported by an implementation strategy involving HH training, monitoring and feedback, and HH champions. The third stage involved postimplementation data collection on ABHR use and HH compliance. RESULTS: 5,214 HH opportunities were evaluated. HH compliance significantly increased from 33.3% (baseline) to 83.1% (implementation stage) (P < .001) and to 87.2% (postimplementation stage) (P < .001). Weekly ABHR usage increased significantly during implementation (5,670 ml), compared to baseline, (1242.5 ml, P = .001), and remained high in postimplementation (7,740 ml). CONCLUSIONS: Continuous availability of ABHR at POC, supported by implementation strategy, significantly increased HH compliance and ABHR use. Learning from this study could be used to implement ABHR at POC in other facilities.

Interventions for preventing or controlling health care-associated infection among health care workers or patients within primary care facilities: A scoping review.

BACKGROUND: This review aimed to synthesize the evidence on infection prevention and control interventions for the prevention of health care-associated infection among health care workers or patients within primary care facilities. METHODS: PubMed, CINAHL, EMBASE, and CENTRAL databases were searched for quantitative studies published between 2011 and 2022. Study selection, data extraction, and quality assessment using Cochrane and Joanna Briggs tools, were conducted by independent review with additional sensitivity checking performed on study selection. RESULTS: Four studies were included. A randomized trial and a cross-sectional survey, respectively, found no statistical difference in laboratory-confirmed influenza in health care workers wearing N95 versus medical masks (P = .18) and a significant inverse association between the implementation of tuberculosis control measures and tuberculosis incidence (P = .02). For the prevention of surgical site infections following minor surgery, randomized trials found nonsterile gloves (8.7%; 95% confidence interval, 4.9%-12.6%) to be noninferior to sterile gloves (9.3%; 95% confidence interval, 7.4%-11.1%) and no significant difference between prophylactic antibiotics compared to placebo (P = .064). All studies had a high risk of bias. CONCLUSIONS: Evidence for infection prevention and control interventions for the prevention of health care-associated infection in primary care is very limited and insufficient to make practice recommendations. Nevertheless, the findings highlight the need for future research.

Effectiveness of BNT162b2 mRNA vaccine third doses and previous infection in protecting against SARS-CoV-2 infections during the Delta and Omicron variant waves; the UK SIREN cohort study September 2021 to February 2022.

Third doses of COVID-19 vaccines were widely deployed following the primary vaccine course waning and the emergence of the Omicron-variant. We investigated protection from third-dose vaccines and previous infection against SARS-CoV-2 infection during Delta-variant and Omicron-variant (BA.1 & BA.2) waves in our frequently PCR-tested cohort of healthcare-workers. Relative effectiveness of BNT162b2 third doses and infection-acquired immunity was assessed by comparing the time to PCR-confirmed infection in boosted participants with those with waned dose-2 protection (≥254 days after dose-2), by primary series vaccination type. Follow-up time was divided by dominant circulating variant: Delta 07 September 2021 to 30 November 2021, Omicron 13 December 2021t o 28 February 2022. We used a Cox regression model with adjustment/stratification for demographic characteristics and staff-type. We explored protection associated with vaccination, infection and both. We included 19,614 participants, 29% previously infected. There were 278 primary infections (4 per 10,000 person-days of follow-up) and 85 reinfections (0.8/10,000 person-days) during the Delta period and 2467 primary infections (43/10,000 person-days) and 881 reinfections (33/10,000) during the Omicron period. Relative Vaccine Effectiveness (VE) 0-2 months post-3rd dose (3rd dose) (3-doses BNT162b2) in the previously uninfected cohort against Delta infections was 63% (95% Confidence Interval (CI) 40%-77%) and was lower (35%) against Omicron infection (95% CI 21%-47%). The relative VE of 3rd dose (heterologous BNT162b2) was greater for primary course ChAdOX1 recipients, with VE 0-2 months post-3rd dose over ≥68% higher for both variants. Third-dose protection waned rapidly against Omicron, with no significant difference between two and three BNT162b2 doses observed after 4-months. Previous infection continued to provide additional protection against Omicron (67% (CI 56%-75%) 3-6 months post-infection), but this waned to about 25% after 9-months, approximately three times lower than against Delta. Infection rates surged with Omicron emergence. Third doses of BNT162b2 vaccine provided short-term protection, with rapid waning against Omicron infections. Protection associated with infections incurred before Omicron was markedly diminished against the Omicron wave. Our findings demonstrate the complexity of an evolving pandemic with the potential emergence of immune-escape variants and the importance of continued monitoring.

Designing an optimal infection prevention service: Part 2.

Background: The importance of infection prevention and control (IPC) services to prevent threats from healthcare-associated infections and improve the quality of healthcare delivery is undeniable. However, IPC services across the UK and Ireland have substantial variability in terms of team structures and delivery models. Aim: The aim of this study was to define an optimal IPC service in different contexts and settings within the United Kingdom and Ireland. Methods: This mixed methods study adopted discussion huddles with IPC teams to explore various components of IPC programmes and services. A Nominal Group technique was then undertaken to achieve a group consensus of what an optimal infection prevention service should look like. Results: Five discussion huddles were conducted which included 53 participants in total. Key themes arising were IPC Service Priorities, IPC Service Enablers for Success, and Necessary Skills and Expertise Required for Delivering an Effective IPC Service. For the nominal technique, 45 responses were identified which were determining the key priorities for an effective IPC service and 69 responses for establishing key enablers for success. Discussion: These findings supported the development of a conceptual model for designing an optimal infection prevention service, which can be used to develop IPC services at an international, national, regional and local level. A focus is required around implementation of these highlighted enablers, so are effectively embedded into infection prevention and control services, and wider healthcare settings.

Effectiveness of national and subnational interventions for prevention and control of health-care-associated infections in acute hospitals in high-income and upper-middle-income counties: a systematic review update.

This systematic review, commissioned and funded by WHO, aimed to update a review of infection prevention and control (IPC) interventions at a national level to inform a review of their IPC Core Components guidelines (PROSPERO CRD42021297376). CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS were searched for studies meeting Cochrane's Effective Practice and Organisation of Care (EPOC) design criteria, published from April 19, 2017, to Oct 14, 2021. Primary research studies examining national IPC interventions in acute hospitals in any country with outcomes related to rates of health-care-associated infections were included. Two independent reviewers extracted data and assessed quality using the EPOC risk of bias criteria. 36 studies were categorised per intervention type and synthesised narratively: care bundles (n=2), care bundles with implementation strategies (n=9), IPC programmes (n=16), and regulations (n=9). Designs included 21 interrupted time-series, nine controlled before-and-after studies, four cluster-randomised trials, and two non-randomised trials. Evidence supports the effectiveness of care bundles with implementation strategies. However, evidence for IPC programmes and regulations was inconclusive as studies were heterogeneous regarding populations, interventions, and outcomes. The overall risk of bias was high. Recommendations include the involvement of implementation strategies in care bundles and for further research on national IPC interventions with robust study designs and in low-income and middle-income settings.

Systematic review on factors influencing the effectiveness of alcohol-based hand rubbing in healthcare.

BACKGROUND: The effectiveness of hand rubbing with alcohol-based handrub (ABHR) is impacted by several factors. To investigate these, World Health Organization (WHO) commissioned a systematic review. AIM: To evaluate the impact of ABHR volume, application time, rubbing friction and hand size on microbiological load reduction, hand surface coverage or drying time. METHODS: Medline, CINAHL, Web of Science and ScienceDirect databases were searched for healthcare or laboratory-based primary studies, published in English, (1980- February 2021), investigating the impact of ABHR volume, application time, rubbing friction or hand size on bacterial load reduction, hand coverage or drying time. Two reviewers independently performed data extraction and quality assessment. The results are presented narratively. FINDINGS: Twenty studies were included in the review. Categories included: ABHR volume, application time and rubbing friction. Sub-categories: bacterial load reduction, hand size, drying time or hand surface coverage. All used experimental or quasi-experimental designs. Findings showed as ABHR volume increased, bacterial load reduced, and drying times increased. Furthermore, one study showed that the application of sprayed ABHR without hand rubbing resulted in significantly lower bacterial load reduction than poured or sprayed ABHR with hand rubbing (- 0.70; 95%CI: - 1.13 to - 0.28). Evidence was heterogeneous in application time, volume, technique, and product. All studies were assessed as high risk of bias. CONCLUSIONS: There is insufficient evidence to change WHO recommendation of a palmful of ABHR in a cupped hand applied for 20-30 s or manufacturer-recommended volume applied for about 20 s (Centers for Disease Control and Prevention). Future hand hygiene research should standardise volume, application time, and consider hand size.

Comparing the effectiveness of hand hygiene techniques in reducing the microbial load and covering hand surfaces in healthcare workers: Updated systematic review.

BACKGROUND: This review, commissioned by the World Health Organization (WHO), examined the effectiveness of the WHO 6-step hand hygiene (HH) technique in reducing microbial load on hands and covering hand surfaces, and compared its effectiveness to other techniques. METHODS: Medline, CINAHL, ProQuest, Web of Science, Mednar, and Google Scholar were searched for primary studies, published in English (1978-February 2021), evaluating the microbiological effectiveness or hand surface coverage of HH techniques in healthcare workers. Reviewers independently performed quality assessment using Cochrane tools. The protocol for the narrative review was registered (PROSPERO 2021: CRD42021236138). RESULTS: Nine studies were included. Evidence demonstrated that the WHO technique reduced microbial load on hands. One study found the WHO technique more effective than the 3-step technique (P = .02), while another found no difference between these 2 techniques (P = .08). An adapted 3-step technique was more effective than the WHO technique in laboratory settings (P = .021), but not in clinical practice (P = .629). One study demonstrated that an adapted 6-step technique was more effective than the WHO technique (P = .001). Evidence was heterogeneous in application time, product, and volume. All studies were high risk of bias. CONCLUSIONS: Eight studies found that the WHO 6-step technique reduced microbial load on healthcare workers' hands; but the studies were heterogeneous and further research is required to identify the most effective, yet feasible technique.

The Consolidated Framework for Implementation Research: a reflection on researchers' experiences of its benefits and challenges and the lessons learnt from using it.

BACKGROUND: In healthcare implementation research, there is little discussion of researchers' experiences of using frameworks, including the Consolidated Framework for Implementation Research (CFIR). AIM: To identify and discuss the benefits and challenges encountered and the lessons learnt from researchers' experiences of using the CFIR in different contexts and phases of research. DISCUSSION: This article synthesises the reflections of nursing and public health researchers on their experiences of using the CFIR across four separate healthcare-associated infection prevention and control implementation studies. The CFIR's benefits and challenges, the resolutions to these challenges and the lessons learnt from the application of the framework were discussed. CONCLUSIONS: Identified benefits included the framework's adaptability and flexibility, and its provision of structure and shared language for research. Translation to another language and differentiating between domains and constructs were challenges. IMPLICATIONS FOR PRACTICE: Nurse researchers may find this article useful when considering use of the CFIR, or to anticipate and prepare to overcome the challenges highlighted when using the framework.

The Consolidated Framework for Implementation Research: a reflection on researchers' experiences of its benefits and challenges and the lessons learnt from using it.

BACKGROUND: In healthcare implementation research, there is little discussion of researchers' experiences of using frameworks, including the Consolidated Framework for Implementation Research (CFIR). AIM: To identify and discuss the benefits and challenges encountered and the lessons learnt from researchers' experiences of using the CFIR in different contexts and phases of research. DISCUSSION: This article synthesises the reflections of nursing and public health researchers on their experiences of using the CFIR across four separate healthcare-associated infection prevention and control implementation studies. The CFIR's benefits and challenges, the resolutions to these challenges and the lessons learnt from the application of the framework were discussed. CONCLUSIONS: Identified benefits included the framework's adaptability and flexibility, and its provision of structure and shared language for research. Translation to another language and differentiating between domains and constructs were challenges. IMPLICATIONS FOR PRACTICE: Nurse researchers may find this article useful when considering use of the CFIR, or to anticipate and prepare to overcome the challenges highlighted when using the framework.

Supporting and mentoring nursing students in practice.

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.

A visual affective analysis of mass media interventions to increase antimicrobial stewardship amongst the public.

OBJECTIVES: In an innovative approach to improve the contribution of health psychology to public health we have analysed the presence and nature of affect within the visual materials deployed in antimicrobial stewardship interventions targeting the public identified through systematic review. DESIGN: A qualitative analysis focused on the affective content of visual materials garnered from a systematic review of antibiotic stewardship (k = 20). METHODS: A novel method was devised drawing on concepts from semiotics to analyse the affective elements within intervention materials. RESULTS: Whilst all studies examined tacitly rely on affect, only one sought to explicitly deploy affect. Three thematic categories of affect are identified within the materials in which specific ideological machinery is deployed: (1) monsters, bugs, and superheroes; (2) responsibility, threat, and the misuse/abuse of antibiotics; (3) the figure of the child. CONCLUSIONS: The study demonstrates how affect is a present but tacit communication strategy of antimicrobial stewardship interventions but has not - to date - been adequately theorized or explicitly considered in the intervention design process. Certain affective features were explored in relation to the effectiveness of antimicrobial resistance interventions and warrant further investigation. We argue that further research is needed to systematically illuminate and capitalize upon the use of affect to effect behaviour change concerning antimicrobial stewardship. Statement of contribution What is already known on this subject? The (mis)use of antibiotics and consequent risk of antimicrobial resistance is a critical public health problem. If sufficient action is not taken, global society will face the 'post-antibiotic' era, in which common infections will lead to death for many millions. Key desirable behavioural changes are decreased patient demands for antibiotics, use of them for targeted purposes alone, and compliance with prescribed dosing. There is a growth of interest in the role of affect in mass media interventions designed to engage publics and produce health-related behavioural change. What does this study add? This article presents a novel analytic approach to understanding and intervening within behaviour change in public health that may complement other types of analysis. We present findings specifically from an 'affective' analysis based on semiotics in which we critically interrogated the visual imagery being deployed in mass media public health interventions concerning antimicrobial stewardship. Three thematic categories of affect are identified within the materials in which specific ideological machinery is deployed and that demonstrate some association with intervention effectiveness worthy of further investigation and testing.

The effect of fake tan on hand hygiene practice.

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.