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).

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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.

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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.

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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.

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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.

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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”.

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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.

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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

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Apendix 1

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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:

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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:

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