Nurse prescriber's understanding of their antimicrobial stewardship role: a qualitative study.

Introduction Antimicrobial resistance is an infectious disease threat to public health globally, and antimicrobial stewardship among healthcare professionals is one key way to address this potential problem. Registered nurse designated prescribers are the newest group of health professionals to gain prescribing authority in Aotearoa New Zealand, yet little is known about their understanding of their antimicrobial stewardship role. Aim The aim of this study was to explore registered nurse designated prescribers' understanding of their antimicrobial stewardship role through their prescribing practices and approaches to clinical reasoning. Methods This exploratory descriptive qualitative study used individual semi-structured interviews with six registered nurse designated prescribers. Thematic analysis was used to analyse the interviews. Results Four themes were identified: antibiotic prescribing practices and antimicrobial resistance; clinical indicators for prescribing antibiotics, with the sub-themes of history taking, presence of infection and bacterial versus viral infection; patient education; and safety and monitoring. These themes provide insight into registered nurse designated prescribers' understanding of their antimicrobial stewardship role and prescribing of antibiotics. Discussion This research found that the registered nurse designated prescribers had an awareness of the importance of their antimicrobial stewardship role in relation to antibiotic prescribing and reducing antimicrobial resistance. Education about antimicrobial resistance and antimicrobial stewardship for this professional group can be effective, but further research is needed to understand their ongoing educational needs.

Linguistic Validation of Genomic Nursing Concept Inventory to Finnish Applying Mandysova's Decision Tree Algorithm.

Background and Purpose: Currently, there is no available Finnish version of the Genomic Nursing Concept Inventory tool (GNCI). This study tested the validity, reliability, and clinical usability of a Finnish translation. Methods: A decision tree algorithm was used to guide the translation, as per International Society for Pharmacoeconomics and Outcomes Research guidelines. Item-Content Validity Index (I-CVI), modified kappa (k*) statistics, and Cronbach's alpha were calculated. Results: The I-CVI and k* values were "good" to "excellent" (I-CVI = 0.63-1.00, k* = 0.52-1.00), and Cronbach's alpha value was "good" (α = 0.816; 95% confidence interval: 0.567-0.956). Conclusion: The Mandysova's decision tree algorithm provided clear and rigorous direction for the translation and validity of the Finnish GNCI.

Assessing antibiotic prescribing in nurse practitioners: Applied cognitive task analysis.

Background: Prescribing antibiotics is a demanding and complex task where decision-making skills are of critical importance to minimize the risk of antimicrobial resistance. Despite its importance, little is known about the decision-making skills and cognitive strategies new Nurse Practitioners (NPs) use when prescribing antibiotics. Objective: To identify the cognitive demands of antibiotic prescribing complexity and to explore the cognitive strategies that new NPs in New Zealand use when prescribing antibiotics. Design: A qualitative approach using Applied Cognitive Task Analysis (ACTA) methodology. Participants: A purposive sample was recruited consisting of five NPs who had been registered within the last five years and were prescribing antibiotics as part of their scope of practice. Methods: In-depth face-to-face interviews consisting of a task diagram interview and a knowledge audit were conducted and analyzed following the ACTA protocol. Results: Four cognitive elements were identified from the data which showed the cognitive demands of prescribing antibiotics, and the cues and strategies NPs use for safe practice. These were: 1 prescribing in the face of uncertainty (complex patients and diagnostic uncertainty); 2 making clinical decisions with insufficient/poor guidance (lack of guidelines, conflicting information); 3 producing an individualized treatment plan in view of clinical and non-clinical patient factors (patient demand/expectation, inadequate patient education, risks versus benefits of antibiotic treatment); 4 ensuring treatment efficacy and continuity of care (ineffective treatment, patient care follow up). Conclusion: The ACTA framework has given insight into the current antibiotic prescribing practice of new NPs, identifying areas where professional development courses and treatment resources can be targeted to support antibiotic prescribing. NPs are likely to benefit from resources that are freely available and reflect national or local antimicrobial data. Further work is also warranted to determine whether targeted education resources and clinical pathways will help with diagnostic uncertainty, and how this could be embedded into existing curricula.

Using Technology as a Novel Method to Develop Students' Clinical Reasoning Skills Through Virtual Collaborative Learning in Scriptwriting.

One of the most important skills students need to learn in applying pharmacotherapeutics is clinical reasoning. This study aimed to evaluate the impact of virtual collaboration in scriptwriting as a teaching approach to develop clinical reasoning skills. Data was from student feedback (n=102). Discussing conceptual questions in a collaborative learning environment with peers proved to support the development of clinical reasoning skills as the activity increased interactivity, improved understanding and retention. Findings show that the development of clinical reasoning skills were enhanced with the use of scriptwriting as a virtual collaborative activity.

Potentially inappropriate medicines for older adults with intellectual disability: Clinical implications from a medication audit.

OBJECTIVE: To investigate medications that have the potential to be inappropriately prescribed for people with intellectual disability (ID) and to explore possible issues surrounding the potential harm that can result from the use of groups of medicines for people with ID who are ageing and living longer. METHODS: An audit of medical case records of 350 patients under the care of an organisation in New Zealand was undertaken to examine existing medication profiles. RESULTS: Of the 350 patients, 95% were prescribed at least five or more medicines, with 7% of patients have 10 or more medicines. Increasing prescriptions are evident for those 56 years old and above. CONCLUSION: Medicines that may have been appropriate for people with intellectual disability when they were younger may have the potential to cause harm when they age. It is therefore important that monitoring and evaluation of medications for ageing individuals with intellectual disability are regularly undertaken.

Randomized controlled trial on the effectiveness of web-based Genomics Nursing Education Intervention for undergraduate nursing students: a study protocol.

AIM: To describe a randomized controlled trial protocol that will evaluate the effectiveness of two web-based genomic nursing education interventions. BACKGROUND: Preparing future nurses to be competent in genetic and genomic concepts is fundamental to ensure appropriate clinical application. However, genetics-genomics concepts are still new in the field of nursing. Little is known about what type and kind of web-based nursing education is effective in improving the knowledge of nursing students. To address these knowledge gaps, a web-based 'Genomic Nursing Education Intervention' will be developed and compared with an existing online education programme. DESIGN: A randomized controlled trial of two groups with pre-test and repeated posttesting. METHODS: The Genomic Nursing Concept Inventory, a validated tool, will be used to assess the genetics-genomics knowledge of nursing students. Participants will be randomly allocated to either a control or an intervention group. The control group will receive the standard web-based nursing education, while the intervention group will receive a newly developed web-based education intervention. Outcome measures include the students' knowledge level of nursing genetics-genomics concepts. Participants will be retested at 3 and 6 months. CONCLUSION: Current evidence shows that ensuring nurses have adequate education in genetic-genomic concepts is challenging. This study will demonstrate which of two web-based nursing education methods is more effective in teaching genetic-genomic concepts. This research project will better prepare the nursing profession in their careers for the emerging advance technologies in genetics-genomics and personalized health care. IMPACT: Current evidence shows major challenges in ensuring that nurses have adequate education in genetics-genomics concepts. Less is known about what approaches to web-based education are effective to improve the knowledge gaps of nursing students in genetics-genomics concepts. This study will determine which type of web-based nursing education is effective in improving the genetics-genomics knowledge of nursing students. This research project will help better prepare nurses in dealing with advances in genetics-genomics in their careers. TRIAL REGISTRATION:  This study is registered in ClinicalTrials.gov (ID number NCT03963687) https://clinicaltrials.gov/show/NCT03963687.

A Personalised Dietary Approach-A Way Forward to Manage Nutrient Deficiency, Effects of the Western Diet, and Food Intolerances in Inflammatory Bowel Disease.

This review discusses the personalised dietary approach with respect to inflammatory bowel disease (IBD). It identifies gene-nutrient interactions associated with the nutritional deficiencies that people with IBD commonly experience, and the role of the Western diet in influencing these. It also discusses food intolerances and how particular genotypes can affect these. It is well established that with respect to food there is no "one size fits all" diet for those with IBD. Gene-nutrient interactions may help explain this variability in response to food that is associated with IBD. Nutrigenomic research, which examines the effects of food and its constituents on gene expression, shows that-like a number of pharmaceutical products-food can have beneficial effects or have adverse (side) effects depending on a person's genotype. Pharmacogenetic research is identifying gene variants with adverse reactions to drugs, and this is modifying clinical practice and allowing individualised treatment. Nutrigenomic research could enable individualised treatment in persons with IBD and enable more accurate tailoring of food intake, to avoid exacerbating malnutrition and to counter some of the adverse effects of the Western diet. It may also help to establish the dietary pattern that is most protective against IBD.

Does self-compassion mitigate the relationship between burnout and barriers to compassion? A cross-sectional quantitative study of 799 nurses.

BACKGROUND: Burnout has numerous negative consequences for nurses, potentially impairing their ability to deliver compassionate patient care. However, the association between burnout and compassion and, more specifically, barriers to compassion in medicine is unclear. This article evaluates the associations between burnout and barriers to compassion and examines whether dispositional self-compassion might mitigate this association. HYPOTHESIS: Consistent with prior work, the authors expected greater burnout to predict greater barriers to compassion. We also expected self-compassion - the ability to be kind to the self during times of distress - to weaken the association between burnout and barriers to compassion among nurses. METHODS: Registered nurses working in New Zealand medical contexts were recruited using non-random convenience sampling. Following consent, 799 valid participants completed a cross-sectional survey including the Copenhagen Burnout Inventory, the Barriers to Physician Compassion scale, and a measure of dispositional self-compassion. RESULTS: As expected, greater burnout predicted greater barriers to compassion while self-compassion predicted fewer barriers. However, self-compassion mitigated the association between burnout and burnout related barriers to compassion (but not other barriers). The interaction suggested that suggested that the association was stronger (rather than weaker) among those with greater self-compassion. DISCUSSION: Understanding the lack of compassion and the effects of burnout in patient care are priorities in health. This report extends evidence on the association between burnout and compassion-fatigue to show that burnout also predicts the experience of specific barriers to compassion. While self-compassion predicted lower burnout and barriers, it may not necessarily reduce the extent to which burnout contributes to the experience of barriers to compassion in medicine. Implications for understanding how burnout manifests in barriers to clinical compassion, interventions and professional training, and future directions in nursing are discussed.

Prevalence and management of intrathecal morphine-induced pruritus in New Zealand Maori healthcare recipients.

AIMS AND OBJECTIVES: The aim of this article was to determine whether the incidence of intrathecal morphine-induced pruritus (ITMI) was influenced by ethnicity, age or gender in relation to orthopaedic versus caesarean surgeries. BACKGROUND: The use of intrathecal morphine for patients undergoing total hip and knee joint replacements and for lower segment caesarean sections (LSCS) has gained popularity worldwide since its introduction over 30 years ago. Several international studies show that morphine delivered via the intrathecal route is an effective and safe method of pain relief. However, while the beneficial effects of intrathecal morphine have been clearly documented in many studies, so also have the adverse effects, predominantly being nausea and vomiting, pruritus and respiratory depression. Pruritus is described as one of the most common adverse effects, with a reported incidence of 30-100%. DESIGN: A retrospective study was conducted using data collected over a 21-month period on post-operative patients who had received intrathecal morphine as their post-operative pain management. METHODS: A two-phased approach was undertaken. The study was conducted to determine the incidence of ITMI pruritus among two patient groups, New Zealand Maori and New Zealand European, 96 subjects in total, and if treatment was received. RESULTS: The findings revealed significant ethnic disparities whereas New Zealand Maori had a significantly higher rate of ITMI pruritus than New Zealand European, New Zealand Maori experienced the pruritus with more intensity and are less likely to be treated for it. CONCLUSION: Increased international knowledge and awareness for health professionals around the diversities of ethnicity and associated pharmacogenetics playing a significant role in patient response to opioid therapy can lead to improved overall care and patient satisfaction.

Beginners in prescribing practice: Experiences and perceptions of nurses and doctors.

AIMS AND OBJECTIVES: To investigate and compare the experiences and perceptions of nurses and doctors in becoming prescribers. BACKGROUND: The development of core skills, knowledge and attitudes as a prescriber is among the present foci of current medical education, and the requirements for ongoing mentorship, support and education for novice medical prescribers have been identified as important training components. However, little is known of the prescribing practices of other health professionals who are also new to prescribing, for example, nurse prescribers. DESIGN: This qualitative study was guided by a constructivist narrative approach using a multiple case narrative strategy. METHODS: A purposive sampling approach was used, with a view to selecting participants to best illuminate the experiences of beginning to prescribe. Individual interviews were conducted, 26 in total, lasting approximately one hour each and were audio-recorded. RESULTS: Common themes were found across prescribing groups: fear and anxiety when taking on prescribing responsibility; the strategy of using a personal list of medicines to support safe practice; how this list was expanded over time; referring to senior colleagues in prescribing decision-making. CONCLUSIONS: This study shows that the journeys are similar for nurses and doctors as beginning prescribers. The effort required for a novice prescriber to select the most appropriate medication and write prescriptions can be extensive as development of expertise takes time and occurs over months or years. RELEVANCE TO CLINICAL PRACTICE: Medical and nurse prescribers differ in term of educational preparation, their journeys as beginner prescribers share common behaviour and practices. Clinical experience and mentorship important to enhance skill development in prescribing and should be advocated for all prescribers. Beginner prescribers require ongoing education and support when prescribing for high risk patients or when prescribing new drugs.

Navigating professional and prescribing boundaries: Implementing nurse prescribing in New Zealand.

Non-medical prescribing is now well established in a number of countries. Because prescribing has traditionally been viewed as a medical role, there are inevitable interprofessional boundary tensions when non-medical prescribing is introduced. In New Zealand, enabling legislation has allowed nurse practitioners to apply for prescriptive authority after undertaking appropriate educational preparation. This study explored the experiences and perspectives of one of the first cohorts of nurse prescribers and their strategies in establishing the role and negotiating the associated professional boundaries. Semi-structured interviews were undertaken with ten newly registered nurse-prescribers. Two broad categories, each comprising three themes, were identified: 'shifting professional boundaries' and 'navigating boundaries of practice'. Participants described how they were faced with the challenge of an unprepared environment as they began to prescribe and how they built trust in their prescribing practice among their colleagues and patients. They also related how they determined their personal prescribing boundaries in this new environment. They described the new professional relationship between nurse prescribers and doctors as collaborative, but with the crucial difference of it being interdependent, not dependent. The study offers insights into the challenges associated with the establishment of new professional roles such as prescribing.

Nurse prescribing: the New Zealand context.

The purpose of this study was to examine the introduction of nurse prescribing in New Zealand, especially with respect to the basis of concerns related to level of knowledge and skills required of practitioners for safe prescribing; and further to compare experiences in New Zealand with those in other countries where nurses are authorised to prescribe. It is argued that prescribing rights previously extended to Nurse Practitioners and now being extended to other groups of nurses, and also to other health professions, is a matter provoking concern with respect to patient safety and adequacy of educational preparation. Unlike in the UK where extending prescribing rights to nurses did not involve rigorous educational preparation, Nurse Practitioners in New Zealand now undergo a stringent process involving Masters degree preparation in biological sciences and pharmacology (similar to USA). However, despite differences between policy environments, in New Zealand, criticisms grouped into concern about knowledge, patient safety and the impacts on team work and the health system echoed that voiced in the UK. The view that the educational model to prepare medical practitioners to prescribe is the 'gold standard' is critiqued and alternative models supported for extending prescribing rights to nurses and other professions. The expectation now is that extended prescribing rights are unlikely to be reversed. As the first two professions to be granted prescriptive authority in New Zealand, experiences in preparing both midwives and nurses educationally are expected to influence the models of educational preparation for other professions. The focus of the debate needs to shift from arguing against extending prescribing authority (especially to nurses), to consideration of how practitioners can be best prepared for and supported in the role.

New Zealand newly graduated nurses medication management: results of a survey.

BACKGROUND: Nurses play a crucial role in medication management in in-patient settings where their knowledge and skills can detect adverse drug effects and prevent errors. Yet newly graduated nurses are new to practice and have little experience. OBJECTIVES: This exploratory study sought to understand how these new nurses applied their pharmacology knowledge to medication management. METHOD: A survey was distributed to all registered nurses working in one large urban New Zealand hospital who had graduated within the previous 24 months. FINDINGS: Over 70% of nurses who participated in this study indicated strength in applying some principles; resources, formulation, correct dosage, why the drug was given, monitoring and when a drug was not given safely. Two pharmacological principles; understanding the mechanism of action of drugs and drug clearance were applied less well. Whilst previous studies have reported nurses have a lack of pharmacology knowledge, this study does not support this, but rather identifies strengths and areas for improvement. CONCLUSION: Recommendations from this study are that orientations for new nurses include commonly used drugs in that setting, extra education for new drugs and continuing education to support new graduates to continue to consolidate their knowledge and skills.

Experiences of nurses as postgraduate students of pharmacology and therapeutics: a multiple case narrative study.

BACKGROUND: Pharmacology and therapeutics are essential components of educational programmes in prescribing, yet little is known about students' experiences in studying these subjects for a prescribing role. OBJECTIVE: To investigate the views and experiences of nurses as postgraduate students who were studying pharmacology and therapeutics in preparation for a prescribing role. DESIGN: Qualitative study using a multiple case narrative approach. SETTINGS: The participants were undertaking or had recently completed a Master's degree programme; they worked in a range of clinical areas and services in the Auckland region. PARTICIPANTS: Twenty nurses, with advanced clinical backgrounds and experience engaged in postgraduate studies in pharmacology and therapeutics. METHODS: A semi-structured interview of approximately 1h was undertaken with each participant. Transcripts were analysed within and across cases using Narralizer software to support thematic analysis. RESULTS: There were four broad thematic areas. In the first, 'prescribing in the context of advanced nursing practice', participants reflected on why prescribing authority was important to them. In the second theme, 'adequacy of prior pharmacology knowledge' they discussed the relative lack of pharmacology in their undergraduate programmes and in nursing practice. In the third, 'drawing on clinical experience in acquiring pharmacology knowledge', participants discussed how, as they grappled with new pharmacological science, they drew on clinical experience which facilitated their learning. In the fourth theme, 'benefits of increased pharmacology knowledge' they discussed how their studies improved their interactions with patients, medical colleagues and as members of multi-disciplinary teams. CONCLUSIONS: All nurses viewed their studies in pharmacology as fundamental to their roles as prescribers, through knowledge development and an increase in confidence. Although pharmacology theory was new to many participants, their learning was facilitated because they were able to reflect on previous clinical experience and apply this to theory.

Creating teaching objects: a case study of delivering recorded narrations in nursing education.

This article evaluates the use of PowerPoint presentations and recorded narrations (developed and saved as Flash content using software called Articulate Presenter) as a tool to help postgraduate nursing students taking a pharmacology course to learn key pharmacological and pharmacotherapeutic concepts. Students found that the teaching objects, provided as additional resources to assist students in learning about difficult concepts, supported them in their learning. Additionally, students reported that while they appreciated the provision of the teaching objects, the objects lacked an interactive component and did not replace interaction with the teacher. Articulate Presenter, as a tool to create a recorded narration, was easy for the teacher to use and promoted teacher independence in the creation of teaching objects.

Creating teaching objects: a case study of delivering recorded narrations in nursing education.

This article evaluates the use of PowerPoint presentations and recorded narrations (developed and saved as Flash content using software called Articulate Presenter) as a tool to help postgraduate nursing students taking a pharmacology course to learn key pharmacological and pharmacotherapeutic concepts. Students found that the teaching objects, provided as additional resources to assist students in learning about difficult concepts, supported them in their learning. Additionally, students reported that while they appreciated the provision of the teaching objects, the objects lacked an interactive component and did not replace interaction with the teacher. Articulate Presenter, as a tool to create a recorded narration, was easy for the teacher to use and promoted teacher independence in the creation of teaching objects.

Application of pharmacology knowledge in medication management by final year undergraduate nursing students.

The purpose of this qualitative descriptive study was to explore final year undergraduate nursing student's perception of clinical practice situations where they applied, or were not able to apply, their pharmacology knowledge in medication management. Pharmacology knowledge is integrated into practice during medication administration, formulation, dosing and client education. A key finding is that the majority of students do use their pharmacology knowledge in the clinical setting. Despite these encouraging results lack of opportunities and preceptor direction in the clinical context are still barriers to fuller integration and consolidation of pharmacology knowledge. Moreover, students' perception of lack of pharmacology knowledge and the need for more knowledge as it applies to medication management remains an area for concern. Suggestions for improvement include a student workbook that would draw on both clinical and theoretical activities as different aspects of pharmacology knowledge are applied, as well as increasing preceptor involvement.

Framework for teaching pharmacology to prepare graduate nurse for prescribing in New Zealand.

The place of nurse prescribing and the preparation for this role is an educational challenge that has been heavily debated in New Zealand and overseas for the past 10 years. Nurse prescribing is relatively new in New Zealand and is related to the expanding roles and opportunities for nurses in health care. Opposition to nurse prescribing in New Zealand has been marked and often this has been linked to concerns over patient safety with the implication that nurses could not be adequately prepared for safe prescribing. The educational framework used to teach pharmacology to nurses by one university in New Zealand is presented, along with early findings on the effectiveness of this approach. Further research is required to confirm that nurse prescribers in New Zealand are well prepared and able to utilise effective decision-making processes for safe prescribing.

Integrated undergraduate nursing curriculum for pharmacology.

Undergraduate pharmacology education for nurses has tended to follow one of two broad approaches, either specific courses in pharmacology or an integrated approach, where the pharmacology content is blended with other content. The School of Nursing at the University of Auckland selected an integrated approach to pharmacology education for nurses aligned with constructivist learning theory. The weaving of pharmacology through the three-year undergraduate curriculum is described, showing the development of a pharmacology curricula thread. The significance of supporting curricula content in areas such as communication skills, law and ethics, as well as sound biological science and physiology knowledge are highlighted. A sound understanding of pharmacology knowledge does not develop in isolation. Rather pharmacology education in the undergraduate nurse is the beginning of developing pharmacological reasoning and providing the skills for life-long learning in this ever changing subject.