Exploring the Implementation Process of Technology Adoption In Long-term care Nursing Facilities.

There is little understanding of how long-term care settings implement and adopt technology. The study purpose was to set forth a model that integrates implementation science and technology adoption frameworks and to explore the process of EHR technology implementation leading to adoption. Research questions investigated key stakeholders’ experiences with the implementation, if adoption occurred, and what themes mapped to the new model. There were three components of the dissertation. Based on a critical analysis of the literature, a model was set forth that integrates implementation science and technology adoption frameworks. Next, the experiences of 30 key stakeholders in three nursing homes were explored to understand implementation strategies. The third was one in-depth case study to explore EHR implementation and adoption. The first study was an exploratory qualitative study using grounded theory methods with focus groups (nurses and certified nurse aides) and individual interviews (Directors of Nursing) conducted at three Midwestern nursing homes with various numbers of beds (99-200), locations, and stages of implementation. A stratified random sample was used for focus groups (nurses and certified nurse aides). Data analysis included constant comparison of data. The second study an in-depth case study at a 124 bed, inner-city nursing home. Data sources were interviews of nurses and nurse aides (15), observation sessions of key care events (15), and leadership meetings. Data analysis included using constant comparison of themes and descriptive statistics (activity frequencies and percentages). Integration of data occurred to illustrate the dynamics of implementing and adopting the EHR. Five major themes emerged which included: motivation and EHR adoption, factors that influence the implementation, audit and bi-directional feedback, benefits, and opportunities to improve the EHR. The studies supported the new model with the workflow concept broadened to work processes. The importance of this dissertation is that it added to the knowledge of individual’s and system’s perspectives about implementation and adoption of an EHR in LTC facilities. The study supported the new Integrated Technology Implementation model concepts. Future research that is designed prospectively using this new model is needed. Other types of users should be studied such as administrators, physicians, and residents.PhDNursingUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/113622/1/rhondas_1.pd

Design and introduction of a quality of life assessment and practice support system: perspectives from palliative care settings

Background: Quality of life (QOL) assessment instruments, including patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs), are increasingly promoted as a means of enabling clinicians to enhance person-centered care. However, integration of these instruments into palliative care clinical practice has been inconsistent. This study focused on the design of an electronic Quality of Life and Practice Support System (QPSS) prototype and its initial use in palliative inpatient and home care settings. Our objectives were to ascertain desired features of a QPSS prototype and the experiences of clinicians, patients, and family caregivers in regard to the initial introduction of a QPSS in palliative care, interpreting them in context. Methods: We applied an integrated knowledge translation approach in two stages by engaging a total of 71 clinicians, 18 patients, and 17 family caregivers in palliative inpatient and home care settings. Data for Stage I were collected via 12 focus groups with clinicians to ascertain desirable features of a QPSS. Stage II involved 5 focus groups and 24 interviews with clinicians and 35 interviews with patients or family caregivers during initial implementation of a QPSS. The focus groups and interviews were recorded, transcribed, and analyzed using the qualitative methodology of interpretive description. Results: Desirable features focused on hardware (lightweight, durable, and easy to disinfect), software (simple, user-friendly interface, multi-linguistic, integration with e-health systems), and choice of assessment instruments that would facilitate a holistic assessment. Although patient and family caregiver participants were predominantly enthusiastic, clinicians expressed a mixture of enthusiasm, receptivity, and concern regarding the use of a QPSS. The analyses revealed important contextual considerations, including: (a) logistical, technical, and aesthetic considerations regarding the QPSS as a technology, (b) diversity in knowledge, skills, and attitudes of clinicians, patients, and family caregivers regarding the integration of electronic QOL assessments in care, and (c) the need to understand organizational context and priorities in using QOL assessment data. Conclusion: The process of designing and integrating a QPSS in palliative care for patients with life-limiting conditions and their family caregivers is complex and requires extensive consultation with clinicians, administrators, patients, and family caregivers to inform successful implementation

Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training.

Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes' implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation

Joining Forces: Enriching RN to BSN Education with Veteran-Centered Learning

This article highlights the commitment of the American Association of Colleges of Nursing to engage nursing schools to support the Joining Forces initiative by enhancing the education and preparation of the nation’s nurses to care for veterans, service members, and their families. The progress toward meeting the Joining Forces pledge and integrating veteran-centered learning in an online RN to BSN program is described

Nursing Students\u27 Self-Efficacy and Attitude: Examining the Influence ofthe Omaha System In Nurse Managed Centers

Self-efficacy, or confidence, as an outcome behavior has been identified as influencing nursing job satisfaction and retention. Clinical learning environments and teaching strategies that build and support perceived self-efficacy are critical aspects of preparing new nurses for their entry and continuing role as professional nurses in today\u27s information-intensive data-management healthcare environment. The purpose of this pre-test post-test study is to measure, using the C-scale (Grundy, 1992), nursing students\u27 self-efficacy to perform patient assessment in Nurse Managed Centers (NMC) after one semester of using the Omaha System documentation framework. Nursing students\u27 attitudes of preparation for using Standardized Nursing Languages (SNL) in the future was also examined. Bandura\u27s (1977, 19986) theoretical model of self-efficacy provided the conceptual framework. Students\u27 overall self-efficacy scores increased significantly over the 12 week study. Use of the Omaha System \u27prepared a little\u27 to \u27very prepared\u27 90% of student nurses for future use of SNL. Continued use of the Omaha System documentation framework in Nurse Managed Center clinicals as a tool for understanding SNL is recommended.

Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Relational use of an electronic quality of life and practice support system in hospital palliative consult care: a pilot study

Objectives: This study is part of an overarching research initiative on the development and integration of an electronic Quality of Life and Practice Support System (QPSS) that uses patient-reported outcome and experience measures in clinical practice. The current study focused on palliative nurse consultants trialing the QPSS with older hospitalized adults receiving acute care. The primary aim of the study was to better understand consultants’ and patients’ experiences and perspectives of use. Method: The project involved two nurse specialists within a larger palliative outreach consult team (POCT) and consenting older adult patients (age 55+) in a large tertiary acute care hospital in western Canada. User-centered design of the QPSS was informed by three focus groups with the entire POCT team, and implementation was evaluated by direct observation as well as interviews with the POCT nurses and three patients. Thematic analysis of interviews and field notes was informed by theoretical perspectives from social sciences. Result: Over 9 weeks, the POCT nurses used the QPSS at least once with 20 patients, for a total of 47 administrations. The nurses most often assisted patients in using the QPSS. Participants referenced three primary benefits of relational use: enhanced communication, strengthened therapeutic relations, and cocreation of new insights about quality of life and care experiences. The nurses also reported increased visibility of quality of life concerns and positive development as relational care providers. Significance of results: Participants expressed that QPSS use positively influenced relations of care and enhanced practices consistent with person-centered care. Results also indicate that electronic assessment systems may, in some instances, function as actor-objects enabling new knowledge and relations of care rather than merely as a neutral technological platform. This is the first study to examine hospital palliative consult clinicians’ use of a tablet-based system for routine collection of patient-reported outcome and experience measures

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The production and deployment of an on-line video learning bank in a skills training environment

This paper describes the introduction of videos as aids in clinical skills teaching. Although the process explored focuses on a nursing clinical skills environment it is relevant to many other disciplines. With the introduction of the pre-registration degree in nursing in Ireland in 2002, the formerly hospital-based schools of nursing amalgamated into larger programmes with their affiliated higher education institutes (HEIs). The result was a considerable increase in class sizes. The current average annual cohort in the School of Nursing, Dublin City University (DCU) is 240 students. This has resulted in a need to review the way we teach clinical skills on campus. These skills form a large part of the programme and are taught to students in the school-based simulated nursing environment to prepare them for their practical experience in the clinical environment. Until 2006 the skills had been taught to groups of 25-30 students using a demonstration and practice technique. This teaching method has posed a number of problems: •Learning experiences vary depending on the mix of demonstration and practice in each session. •It can be difficult for students to absorb all of the information presented in a single demonstration. •It is highly resource intensive. It was decided that video technology incorporating a large scale deployment of skills videos over a video web server, in conjunction with a shift in emphasis in the teaching contact sessions could offer a useful tool to aid the teaching process. This paper will discuss the production process, the implementation of the project in the teaching environment and the evaluation findings