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Developing an Antibiotic Prescribingonline training resourcefor Foundation Year Doctors
A Summary Report
BackgroundAntibiotic stewardship is central to the Scottish Action Plan on Antimicrobial Resistance
(SEHD, 2002). The Scottish Medicines Consortium (SMC) and Scottish Executive have
also highlighted prudent prescribing of antibiotics as a key area to be addressed in
clinical practice and in training for prescribers (SEHD 2005; Nathwani, 2006).
The Scottish Executive’s HAI taskforce has commissioned NHS Education for Scotland
(NES) to develop educational solutions aimed at improving clinical practice and reducing
the impact of HAI in healthcare in Scotland.
We describe the development of an online training resource on Antibiotic Prescribing
for Foundation Year Doctors in Scotland and discuss the potential application for other
clinical practitioners.
The project outlineInitial discussions between NES and subject experts focussed on the content, mode of
delivery and target group for the materials. The development of the materials involved
the following processes:
• Identification of project team and curriculum advisory group
• Identification of target group
• Content development
• Assessment
• Review process
• Identification of VLE provider
• Consultation
• Launch
• Ongoing development
The project team and advisory groupA project team was identified by NES. The team included subject experts, external
consultants on graphic design, content development and IT support. The work of the
project team was overseen by a Curriculum Advisory Group (CAG) which met on a
regular basis throughout the project and was involved in review of materials at key
stages. The CAG included representation from the Foundation Year Doctors curriculum
development team, subject experts, other prescribing groups and educational advisors
(see Appendix 1).
1
The target groupThe target group identified for the first phase of the project was Foundation Year
Doctors. There were a number of benefits in selecting this group for the initial
development of materials: Foundation Year Doctors are engaged in postgraduate
training through the Foundation Year Curriculum and access other online training
programmes via the Doctors Online Training System (DOTS); concentrating on a single
practitioner group gave a clear focus to the development process for the first phase of
the project. In addition, junior doctors have been highlighted as a group requiring further
training in the area of antibiotic prescribing, particularly in the application of
undergraduate learning in the clinical context (Nathwani, 2006).
Antibiotic stewardship links with two competencies currently described in the foundation
year curriculum: “prescribing” and “control of infection”. The CAG and project team
worked with the Foundation Year Curriculum representatives to ensure that the Antibiotic
Prescribing training programme would be allocated space in the current Foundation Year
curriculum. One hour of online training time was allocated. Unfortunately, there was no
scope to allocate any ‘off-line’ training time to the project.
Representatives from other prescribing groups were involved in the development and
review of the materials as it is planned to extend the application of the training materials
to other clinical practitioner groups in later phases of the project.
Content developmentA curriculum advisory group (Appendix 1) chaired by Professor Dilip Nathwani was set up
by NES to oversee the development of the materials for Foundation Year Doctors.
A workshop with Educational Supervisors, Foundation Year Doctors and representation
from other clinical groups was held to get feedback from potential users. The materials
were in part developed and adapted from an earlier project for undergraduate training,
Appropriate Prescribing for Tomorrow's Doctors, which was conducted on behalf of the
British Society of Antimicrobial Chemotherapy (BSAC) and the Scottish Executive Health
Department. Members of the CAG also contributed to writing and reviewing new materials.
2
ContentWe presented background information on areas relevant to antibiotic prescribing,
including diagnosis and assessment, investigations and interpretation, clinical
management, infection control and public health. This information was followed
by four case-based vignettes which highlighted key points in relation to clinical
management and antibiotic stewardship. The vignettes were scored to allow
assessment of learning. Throughout the vignettes, supporting text was provided
as questions were answered. This gave the opportunity to address key points
in the context of clinically based scenarios.
AssessmentThe vignettes provided a means of online assessment of learning. All Foundation Year
Doctors taking part in the course had to pass a minimum of 3 of the 4 vignettes
presented. The pass mark was set at 60%. If any of the doctors failed a vignette they
were given the chance to resit the vignette. A record of learning was available to print
off after completion of each of the vignettes.
Competencies relating to antibiotic prescribing for Foundation Year Doctors were
proposed (Table 1) and we detailed how each of these competencies related to the
content presented in the vignettes (Table 2). Both of these were available through the
training programme for printing as a pdf file. We felt it was not possible to evidence the
competencies solely from the online training materials. The online materials could be
complemented by inclusion of some offline assessment, clinical supervision or reflective
practice exercises.
Graphic designA graphic design template was developed for the programme to be consistent with the
overall look and feel of NES’s HAI virtual learning environment (VLE).
Review processThe CAG contributed to the review of the materials throughout their development.
Regular meetings were held and materials circulated for discussion and presented
to the group at appropriate points. Once materials were available online and before
launching to the Foundation Year Doctors, the CAG were given the opportunity to
review the online programme. This approach allowed peer review at key stages in the
development of the materials.
3
VLE provisionAs part of the HAI initiative, NES issued an invitation to tender for the provision of a virtual
learning environment (VLE) on which to host a range of materials relevant to HAI. The
Knowledge Business (Appendix 2) was successful in securing the tender and currently
provides NES with a VLE licenced for use by healthcare workers in Scotland and the
Higher Education Sector.
The content was uploaded onto the VLE using the Knowledge Business content
management software. A direct link was created from the DOTS website to the Antibiotic
Prescribing for Foundation Year Doctors materials hosted on the VLE. Assessment
details were also sent to the DOTS system to update the Foundation Year Doctors’
individual training records.
4
ConsultationIn addition to consultation with the CAG, feedback on the materials and the development
process was also invited from external representatives from a number of key groups
including Foundation Year Educational Supervisors, Foundation Year Doctors, Specialist
Registrars, Consultant Physicians, General Practice, DOTS project staff, Pharmacists
and Nurse prescribers. Comments from national groups such as the British Society for
Antimicrobial Chemotherapy (BSAC) were also sought.
As part of this consultation process we hosted a workshop and invited participants from
the groups listed above. A sample vignette and the competency list was circulated to
participants in advance of the workshop. The workshop was well attended. The project
group presented a brief background to the project and hosted four discussion groups:
e-Learning; Competencies; Content; Methods of Assessment. Delegates were allocated
to a group and participated in each of the discussion topics. The facilitators reported
back at the end of the session and comments informed the ongoing development of the
materials. The feedback was positive with general comments supporting the proposed
content and competencies. There was a general agreement that case-based
assessments provided a useful tool. Some of the Foundation Year Doctors felt that it
would be useful to review the casework with their Educational Supervisors but
representatives from the Educational Supervisors in the groups felt that the schedule
was already at capacity and there would be little extra time to devote to additional
topics. Comments from the e-Learning group focussed on technical requirements and
the general perception was to aim for the minimum expected hardware and software
specification for computers available for training within the NHS.
Once the materials had been agreed by the CAG and uploaded onto the VLE, guest
passwords were issued to invited reviewers before the materials were made available
to the Foundation Year Doctors.
LaunchFollowing the consultation and development process described, the materials were
launched to Foundation Year Doctors in January 2007 through a direct link via the
Doctors Online Training System (DOTS) www.nhsdots.org. This link allowed the
Foundation Year Doctors to access the materials when they logged into the learning
zone in DOTS.
5
EvaluationAll users were asked to complete an online evaluation form to provide feedback on the
training materials. We asked for feedback on the training materials presented,
assessment of competency, online training in general and relevance to clinical practice.
The response rate was good with 301 responses (at 31 May 2007), of these, 88% (266)
were Foundation Year 1 Doctors and 10% were Foundation Year 2 Doctors, the other
2% were made up of Educational Supervisors, Specialist Registrar and ‘other’. The
results are summarised below:
Training materialsThe response to the training materials was positive with >80% rating content, method of
delivery, ease of use (core materials) and ease of use (vignettes) as good or excellent:
AssessmentThe majority (95%) felt that the level the vignettes were set at was “About right”.
Although this training programme was offered solely online, 88% of respondents
felt that assessment of clinical competence in this area should be a “mixture of
workplace and online”.
6
Online learningThe majority (93%) of respondents had used other online training programmes
and most (94%) rated this method of learning as “OK” or “like a lot”.
Antibiotic prescribingMost respondents felt training in antibiotic prescribing was “very relevant to
clinical practice” for foundation level doctors (99%) and other prescribers (89%).
A small number (9%) felt that training in this area would be “of interest only” to
other prescribers.
Most respondents (90%) said that they would be interested in additional training
in this area.
As these results show, the general feedback to the materials has been very positive. We
will continue to use this evaluation tool to obtain user feedback.
Ongoing developmentAn editorial board will be set up to review the materials to ensure that currency and
accuracy are maintained. It is planned to extend the materials to other prescribing
groups. This may require some revision of the materials, but where possible the content
will remain the same. Input from representatives from other prescribing groups and
training providers will be crucial to the next stage of development.
SummaryWe have described the development process for an online training resource on antibiotic
prescribing for Foundation Year Doctors. Appointing a curriculum advisory group at the
start of the project allowed appropriate peer review during the content development
process. Additional consultation provided feedback both on the content and the delivery
of the materials from a wider group. This involvement throughout the development
process led to the production of materials that gained a positive review from the target
audience. Ongoing involvement of representatives from professional groups should
ensure successful development of materials relevant to other prescribing groups.
This training resource promotes appropriate use of antibiotics in the clinical setting with
a general aim of improving antibiotic stewardship among Foundation Year Doctors.
Extension of this resource to other professional groups will be a valuable next step in
promoting prudent use of antibiotics.
7
References
SEHD (2002)
avaliable online at: www.scotland.gov.uk/library5/health/arsap-00.asp
SEHD (2005)
avaliable online at: www.scotland.gov.uk/Publications/2005/09/02132609/26119
Nathwani (2006)
avaliable online at: http://jac.oxfordjournals.org/cgi/content/abstract/dkl137v1
8
Apendix 1
9
Dr Anne Boyter
Lecturer in Clinical Practice
University of Strathclyde
Mr Rodney Mountain
Associate Postgraduate Dean
NHS Education for Scotland
Mrs Arlene Brailey
Assistant Director, Pharmacy
NHS Education for Scotland
Professor Dilip Nathwani
Consultant Physician
Ninewells Hospital and Medical School
NHS Tayside
Dr Margaret Brown
HAI Project Leader
NHS Education for Scotland
Dr Martin Pucci
GP
NHS Grampian Primary Care
Dr Stephanie Dancer
Consultant Microbiologist
Southern General Hospital
NHS Greater Glasgow
Dr Andrew Seaton
Infectious Diseases Consultant
Gartnavel Royal Hospital
NHS Greater Glasgow
Professor Peter Davey
Director, Health Informatics Centre
University of Dundee
Dr Hazel Scott
Director of Medical Education
Wishaw General Hospital
NHS Lanarkshire
Professor Curtis Gemmell
University of Glasgow
Dr Fiona Strachan
Independent Consultant
Mrs Liz Gillies
Director, HAI
NHS Education for Scotland
Mr Andy Hyde
Independent Consultant
Dr Jean Ker
Director, Clinical Skills Centre
University of Dundee
Ms Julie McDonald
Centre for Medical Education
University of Dundee
Dr A R Mackenzie
Infectious Diseases Consultant
Aberdeen Royal Infirmary
NHS Grampian
Apendix 2
The Knowledge Business
Research Park North
Riccarton
Edinburgh
EH14 4AP
Tel: 0771 252 6866
www.the-knowledge-business.com
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Competencies for foundation year doctorsThe foundation level doctor will apply up to date clinical, microbiological, pharmaceutical
and public health knowledge to recognise, diagnose and assess the severity of a
bacterial infection and then initiate antibiotic therapy where appropriate. The doctor
should appreciate the basic principles related to prudent antibiotic prescribing, recognise
some unique risks or adverse reactions related to antibiotic prescribing and recognise
effective monitoring of treatment.
Competencies have been divided into:Application: skills that the Foundation Level doctor should apply regularly in their work
and be able to carry out with minimal supervision.
Awareness: skills that the Foundation Level doctor would not be expected to have
acquired but should be sufficiently aware to seek help.
Shading indicates competencies that are generic and not specific to antimicrobial
prescribing
Table One
The foundation level doctor will:
11
How the Competencies relate to the vignettesThe vignettes that form the online assessment for Antibiotic Prescribing for Foundation
Year Doctors cover areas relevant to the competencies described. The following list can
be used with your results from the vignettes to provide a record of the areas covered
by completion of the vignettes. This list does not provide evidence of achieved
competencies, as this would require some offline assessment and supervision.
Table Two
The foundation level doctor will:
13