TY - JOUR AU - Huang, Huanhuan AU - Chen, Zhiyu AU - Chen, Lijuan AU - Du, Xingyao AU - Huang, Qi AU - Jia, Wenbi AU - Zhao, Qinghua PY - 2025/7/2 TI - Nurses? Experience Regarding Barriers to Providing Internet Plus Continuous Nursing: Mixed Methods Study JO - JMIR Med Inform SP - e65445 VL - 13 KW - transitional care KW - digital governance KW - influencing factors KW - barrier KW - nursing KW - mixed methods study KW - internet KW - digitalization KW - China KW - digital health KW - self-made questionnaire KW - interview KW - Chinese nurses KW - health care delivery KW - policymakers KW - communication KW - care quality KW - patient satisfaction N2 - Background: The novel medical model of ?Internet Plus continuous nursing? has received much attention under the dual background of aging and digitalization in China. However, there is a scarcity of studies that report on the potential barriers and challenges associated with the implementation of this practice. Objective: This study aimed to investigate and understand nurses? experience regarding barriers to providing Internet Plus continuous nursing. Methods: A sequential mixed methods design was adopted. In the first phase, a self-made questionnaire was used to quantify the barriers and challenges into 3 domains: management, relational, and information continuity. In the second phase, nurses who participated in the Internet Plus continuous nursing program were invited to attend semistructured interviews to further explore, explain, and understand the complexities behind these data, obtaining more detailed information on participants? experiences, perspectives, and meanings. Results: A total of 4638 participants from 312 hospitals were selected for the final analysis; the adjusted mean score of the survey was 3.49 (SD 0.83). Among the 3 domains, management continuity had the lowest score (mean 3.32, SD 0.97), followed by relational continuity (mean 3.44, SD 0.9) and information continuity (mean 3.62, SD 0.92). The results of the multivariable analysis showed that age, education level, and a greater number of working years were predictors of continuity for Internet Plus continuous nursing (P<.001). Following the qualitive study, 8 subthemes emerged from 72 initial codes and were grouped into 3 themes: organizational changes, practice changes, and future directions. Conclusions: This mixed methods study revealed that Chinese nurses may have differential challenges when providing Internet Plus continuous nursing, particularly in management continuity. To better benefit patients and improve health care delivery, health care organizations and policymakers should implement strategies to improve interdisciplinary relationships, establish and perfect organizational management, and enhance communication. UR - https://medinform.jmir.org/2025/1/e65445 UR - http://dx.doi.org/10.2196/65445 ID - info:doi/10.2196/65445 ER - TY - JOUR AU - Stevens, R. Elizabeth AU - Alfaro Arias, Veronica AU - Luu, Son AU - Lawrence, Katharine AU - Groom, Lisa PY - 2025/6/16 TI - Technology Integration to Support Nurses in an ?Inpatient Room of the Future?: Qualitative Analysis JO - J Med Internet Res SP - e68689 VL - 27 KW - nursing clinical workflows KW - patient room design KW - user-centered design KW - health information technology KW - digital health KW - built environment KW - technology integration KW - human-centered design N2 - Background: The design and integration of technology within inpatient hospital rooms has a critical role in supporting nursing workflows, enhancing provider experience, and improving patient care. As health care technology evolves, there is a need to design ?future-proofed? physical environments that integrate technology in ways that support workflows and maintain clinical performance. Assessing how current technologies affect nursing workflows can help inform the development of these future environments. Objective: We assessed the current challenges nursing staff face in inpatient rooms, gather insights on technology, and build environment interactions to envision the design of a technology-integrated ?Inpatient Room of the Future.? Methods: A qualitative study was conducted involving semistructured interviews, shadowing, and focus groups among nursing staff in the inpatient setting. Methods including horizon scanning, scenario analysis, technology assessment, and backcasting facilitated a comprehensive qualitative analysis of current technology use and needs in inpatient nursing workflows to inform exploratory design considerations for technology-integrated envisioned futures solutions. Results: In total, 26 nursing staff across 4 inpatient hospital units participated in this study. Analysis identified four major themes considered central to designing a technology-integrated inpatient room that enhances nursing workflow and experience: (1) the need for seamless integration of technologies advocating for a unified system that minimizes fragmented technology use and enhances efficiency; (2) the potential for technology to reduce cognitive load, alleviate mental strain, and streamline complex workflows; (3) a focus on enhancing interpersonal communication with specific emphasis on tools that facilitate clear and efficient communication among clinicians and with patients; and (4) the importance of improved staff well-being with design considerations aimed at promoting both physical and mental health for health care workers in the inpatient setting. Envisioned future solutions included enhanced patient monitoring with automated measurements and actions through computer vision and data triangulation, a smart electronic health record?integrated supply management system using computer vision to detect supply shortages and auto-delivery of needed supplies, and a personal tech smart assistant capable of real-time patient monitoring and escalation, task prioritization, and hands-free clinical documentation and communication. Conclusions: While current technologies address specific tasks, there are significant opportunities for better technology integration, reducing cognitive load, enhancing communication, and promoting the physical and mental well-being of nursing staff. Future research should focus on seamless technology integration aligned with clinical workflows and implementing supportive technologies that do not interfere with clinician judgment and critical thinking. Policy recommendations include oversight mechanisms for evaluating artificial intelligence?enabled devices, safeguarding patient information, and ensuring nurses are actively involved at every stage of technology development and implementation. Future inpatient unit designs should actively engage input from both nursing professionals and technologists in developing future-proofed clinical spaces to ensure the creation of integrated systems that foster a cohesive and harmonious user experience. UR - https://www.jmir.org/2025/1/e68689 UR - http://dx.doi.org/10.2196/68689 UR - http://www.ncbi.nlm.nih.gov/pubmed/40522717 ID - info:doi/10.2196/68689 ER - TY - JOUR AU - Han, Xuefeng AU - Liu, Hairong AU - Zhang, Tingchong AU - Fan, Guangxin PY - 2025/6/10 TI - Analysis of Risk Factors and Nursing Strategies for Unplanned Extubation in Children: Retrospective Cohort Study JO - JMIR Nursing SP - e71307 VL - 8 KW - unplanned extubation KW - nursing strategies KW - prevention KW - risk factor KW - pediatric care N2 - Background: Unplanned extubation (UEX) is a critical indicator of nursing care quality. Existing research primarily focuses on pediatric intensive care units (PICUs), with limited data available from general pediatric surgery. Currently, most studies on this topic are mainly focused on PICUs, and there is a lack of research data regarding general pediatric surgery. Therefore, further research should be conducted based on this consideration. Objective: This study aimed to analyze the high-risk factors for UEX in children and implement appropriate nursing strategies to reduce its incidence, ensuring clinical safety of pediatric patients. Methods: A retrospective study (January 2018 - December 2023) included pediatric patients with indwelling catheters in general surgery. Exclusion criteria included mental disorders or abnormal Glasgow Coma Scale scores. Data on catheter days, UEX incidents, and risk factors were analyzed. Results: A total of 1977 catheter days were recorded during the perioperative period, comprising 1079 days with urinary catheters, 768 days with postoperative wound drainage tubes, 68 days with gastric tubes, 46 days with peripheral central venous catheters, and 8 days with central venous catheters. During this period, 13 incidents of UEX occurred, yielding an overall UEX rate of 6.58 per 1000 catheter days. Urinary catheters accounted for the highest proportion of UEX incidents (8/13, 61.5%), followed by gastric tubes (3/13, 21.3%) and postoperative wound drainage tubes (2/13, 15.4%). The reintubation rate following UEX was 15.38% (2/13). Further analysis identified significant risk factors associated with UEX: (1) patient characteristics: age ?3 years (8/13, 61.5%) and male sex (10/13, 76.9%); (2) clinical management: absence of physical restraints (10/13, 76.9%); and (3) temporal factors: incidents occurring during holidays (9/13, 69.2%). Multivariate analysis revealed that UEX risk was influenced by inter-related factors, including pediatric physiological characteristics (eg, limited self-regulation capacity), suboptimal catheter fixation methods, positional discomfort during patient movement, and variations in nursing interventions (eg, frequency of rounds and caregiver education). Conclusions: Unplanned extubation in pediatric inpatients represents a critical clinical complication that may compromise treatment efficacy and prolong hospitalization. Our findings highlight the multifactorial etiology of UEX events, with risk determinants spanning patient characteristics, care protocols, and environmental factors. To mitigate these risks, we propose implementing evidence-based multidisciplinary preventive strategies, including standardized risk assessment protocols for high-risk subgroups (eg, male patients aged ?3 years), enhanced staff training on age-appropriate restraint techniques and securement device utilization, and dynamic adjustment of nursing surveillance frequency during peak risk periods (eg, holidays or postural changes). This systematic approach demonstrates potential to reduce UEX-associated adverse events by 42%?68%, according to benchmark studies, ultimately improving pediatric care quality. UR - https://nursing.jmir.org/2025/1/e71307 UR - http://dx.doi.org/10.2196/71307 ID - info:doi/10.2196/71307 ER - TY - JOUR AU - Rubyan, Michael AU - Gouseinov, Yana AU - Morgan, Mikayla AU - Rubyan, Deborah AU - Jahagirdar, Divya AU - Choberka, David AU - Boyd, J. Carol AU - Shuman, Clayton PY - 2025/5/8 TI - Evaluating the Usability, Acceptability, User Experience, and Design of an Interactive Responsive Platform to Improve Perinatal Nurses? Stigmatizing Attitudes Toward Substance Use in Pregnancy: Mixed Methods Study JO - JMIR Hum Factors SP - e67685 VL - 12 KW - digital platform KW - nurse training KW - usability KW - user experience KW - user interface KW - mixed methods KW - theatre testing KW - stigma KW - perinatal substance use KW - art intervention KW - acceptability KW - perinatal KW - substance use KW - pregnancy KW - perinatal nurse KW - feasibility KW - interactive responsive platform N2 - Background: Perinatal nurses are increasingly encountering patients who have engaged in perinatal substance use (PSU). Despite growing evidence demonstrating the need to reduce nurses? stigmatizing attitudes toward PSU, limited interventions are available to target these attitudes and support behavior change, especially those reflecting the overwhelming evidence that education alone is insufficient to change practice behavior. Arts-based interventions are associated with increasing nursing empathy, changing patient attitudes, improving reflective practice, and decreasing stigma. We adapted ArtSpective for PSU?a previously evaluated, in-person, arts-based intervention to reduce stigma toward PSU among perinatal nurses?into an interactive, digital, and responsive platform that facilitates intervention delivery asynchronously. Objective: This study aimed to evaluate the usability, acceptability, and feasibility of the interactive, responsive platform version of ArtSpective for PSU. Our goal was to elicit the strengths and weaknesses of the responsive platform by evaluating the user experience to identify strategies to overcome them. Methods: This study used a mixed methods approach to explore the platform?s usability, user experience, and acceptability as an intervention to address stigma and implicit bias related to PSU. Theatre testing was used to qualitatively assess usability and acceptability perspectives with nurses and experts; a modified version of the previously validated 8-item Abbreviated Acceptability Rating Profile was used for quantitative assessment. Quantitative data for acceptability and satisfaction were analyzed using descriptive statistics. All qualitative data were analyzed iteratively using an inductive framework analysis approach. Results: Overall, 21 nurses and 4 experts in stigma, implicit bias, and instructional design completed theatre-testing sessions. The mean duration of interviews was 31.92 (SD 11.32) minutes for nurses and 40.73 (SD 8.57) minutes for experts. All participants indicated that they found the digital adaptation of the intervention to be highly acceptable, with mean acceptability items ranging from 5.0 (SD 1.0) to 5.5 (SD 0.6) on a 1-6 agreement scale. Nurses reported high satisfaction with the platform, with mean satisfaction items ranging from 5.14 (SD 0.56) to 5.29 (SD 0.63) on a 1-6 agreement scale. In total, 1797 interview segments were coded from the theatre-testing sessions with 4 major themes: appearance, navigation, characterization, and overall platform, and 16 subthemes were identified. Consistent with the quantitative findings, the results were positive overall, with participants expressing high satisfaction related to the platform?s appearance, the ease with which they could navigate the various modules, engagement, clarity of the presentation, and feasibility of being completed asynchronously. Conclusions: Developing and evaluating the usability of a digital adaptation of ArtSpective for PSU resulted in strong support for the usability, acceptability, and satisfaction of the program. It also provided insight into key aspects related to acceptability and usability that should be considered when designing a digital adaptation of an arts-based intervention for health care providers. UR - https://humanfactors.jmir.org/2025/1/e67685 UR - http://dx.doi.org/10.2196/67685 UR - http://www.ncbi.nlm.nih.gov/pubmed/40146964 ID - info:doi/10.2196/67685 ER - TY - JOUR AU - Nabelsi, Veronique AU - Plouffe, V�ronique AU - Leclerc, Chantal Marie PY - 2025/5/7 TI - Barriers to and Facilitators of Implementing Overnight Nursing Teleconsultation in Small, Rural Long-Term Care Facilities: Qualitative Interview Study JO - JMIR Aging SP - e71950 VL - 8 KW - teleconsultation KW - long-term facilities KW - nursing KW - barriers and facilitators KW - rural KW - telehealth KW - qualitative KW - pilot study KW - Quebec N2 - Background: Teleconsultation has expanded rapidly in recent years, especially during the COVID-19 pandemic, and has become standard practice among physicians. The benefits of teleconsultation, namely, improving access to care, ensuring continuity and quality of care, increasing patient satisfaction, and reducing costs and wait times, are well documented. However, its use in nursing practice, especially in long-term care settings, remains underresearched despite its significant transformative potential, particularly in resource-limited and rural settings, where it could address major challenges such as nursing shortages and access to care. Objective: This study aimed to identify barriers to and facilitators of implementing overnight nursing teleconsultation in rural residential and long-term care centers in Quebec, Canada (centres d?h�bergement et de soins de longue dur�e [CHSLDs]), with ?50 beds. Methods: A 6-month pilot project was rolled out sequentially in 3 rural CHSLDs in 2 administrative regions of Quebec between July 2022 and March 2023. A total of 38 semistructured interviews were conducted with managers (n=27, 71%), nursing staff members (n=9, 24%), and resident committee presidents (n=2, 5%) between February 2023 and July 2023. Results: The study identified several barriers to the implementation of teleconsultation. The main barriers reported included union opposition (managers: 23/27, 85%), network instability (resident committee presidents: 2/2, 100%), limited technology skills (nursing staff members: 7/9, 78%), a perceived increase in workload (nursing staff members: 8/9, 89%; resident committee presidents: 2/2, 100%), and a low volume of teleconsultations (nursing staff members: 8/9, 89%). Despite the barriers, participants also identified key facilitators. These included the care setting (nursing staff members: 9/9, 100%; managers: 21/27, 78%), buy-in from senior management and managers (managers: 27/27, 100%; resident committee presidents: 2/2, 100%), collaboration between the departments (nursing staff members: 9/9, 100%), nursing staff motivation (nursing staff members: 9/9, 100%), and improvements in professional practices (nursing staff members: 8/9, 89%). Finally, the relative benefits of teleconsultation, such as enhanced mutual vision, faster assessment of clinical situations, improved resident care management quality, and greater flexibility and safety, were unanimously recognized (38/38, 100%) as contributing to its acceptability and potential for success. Conclusions: This study provides an in-depth understanding of the barriers to and facilitators of implementing overnight nursing teleconsultation in small rural CHSLDs. This constitutes a sound basis for developing tailored strategies aimed at overcoming identified barriers and optimizing facilitators. The results also provide practical guidelines for decision makers, highlighting the need to adapt implementation approaches to the unique context of each facility. Furthermore, this study highlights the importance of further research to broaden our knowledge on the dissemination and scale-up of health care innovations. This includes the development of learning health systems capable of responding in an agile and effective way to the needs of rural and vulnerable populations both in Quebec and elsewhere. UR - https://aging.jmir.org/2025/1/e71950 UR - http://dx.doi.org/10.2196/71950 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/71950 ER - TY - JOUR AU - Ma, Cong AU - Fang, Yifan AU - Zhang, Hui AU - Zheng, Ying AU - Zhang, Ying AU - Zhao, Wanchen AU - Yan, Ge AU - Zeng, Yaoxin AU - Zhang, Yanwu AU - Ning, Xiaohong AU - Jia, Zhimeng AU - Guo, Na PY - 2025/5/5 TI - Nurse-Delivered Telehealth in Home-Based Palliative Care: Integrative Systematic Review JO - J Med Internet Res SP - e73024 VL - 27 KW - nurse KW - homecare services KW - palliative care KW - systematic review KW - telehealth KW - telemedicine KW - technology KW - implementation science N2 - Background: Telehealth technologies can enhance patients? and their families? access to high-quality resources in home-based palliative care. Nurses are deeply involved in delivering telehealth in home-based palliative care. However, no previous integrative systematic reviews have synthesized evidence on nurses? roles, facilitators, and barriers to implementing nurse-delivered telehealth in home-based palliative care. Objective: This integrative systematic review aimed to provide a comprehensive understanding of the roles of nurses and the multilevel facilitators and barriers to implementing nurse-delivered telehealth in home-based palliative care, which could inform future policy development, research, and clinical practice. Methods: This integrative systematic review was conducted using Joanna Briggs Institute methodological guidance. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. We systematically searched articles published from January 1, 2014, to May 2024 in PubMed, Embase, Web of Science, CINAHL, and Cochrane Library. We included English-language; peer-reviewed; original; and qualitative, quantitative, and mixed methods studies that centered on nurse-delivered telehealth in home-based palliative care. We used the Mixed Methods Appraisal Tool to assess the quality of the included articles. Furthermore, 3 authors independently assessed eligibility, extracted data, and assessed the quality of articles. The entities to extract were identified by research questions of interest regardless of the type of study. We applied a convergent synthesis approach to integrate quantitative and qualitative data. Guided by the updated Consolidated Framework for Implementation Research (CFIR) 2.0, we synthesized the facilitators and barriers to implementing nurse-delivered telehealth in home-based palliative care. Results: This integrative systematic review identified 4819 unique articles, including 34 papers encompassing 29 unique primary research studies. Innovations were mainly delivered by nurses (n=8) and nurse-involved multiprofessional teams (n=18). The roles of nurses in telehealth home-based palliative care involve palliative care nurses, community nurses, nurse coordinators, nurse coaches or nurse navigators, and nurse case managers. Guided by CFIR 2.0, facilitators and barriers to implementing nurse-delivered, telehealth, home-based palliative care were identified to 6 implementation levels and 20 constructs. The key facilitators included the COVID-19 pandemic, cost avoidance to the health care system, engagement of patients and their family caregivers, and so on. The barriers included a lack of reimbursement and payment mechanisms, technical problems, insufficiently trained health care providers, and so on. Conclusions: This integrative systematic review synthesizes evidence on nurses? evolving roles in telehealth home-based palliative care and identifies multilevel facilitators and barriers to nurse-delivered, home-based palliative care implementation. With the empowerment of telehealth technologies, nurses could establish a stronger professional identity and develop leadership in home-based palliative care. Nurses should leverage influence to promote nursing practice, clinical management, and policy support in the implementation of telehealth home-based palliative care. Trial Registration: PROSPERO CRD42024541038; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024541038 UR - https://www.jmir.org/2025/1/e73024 UR - http://dx.doi.org/10.2196/73024 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/73024 ER - TY - JOUR AU - El Arab, Adel Rabie AU - Al Moosa, Abdulaziz Omayma AU - Abuadas, H. Fuad AU - Somerville, Joel PY - 2025/4/4 TI - The Role of AI in Nursing Education and Practice: Umbrella Review JO - J Med Internet Res SP - e69881 VL - 27 KW - artificial intelligence KW - nursing practice KW - nursing education KW - ethical implications KW - social implications KW - AI integration KW - AI literacy KW - ethical frameworks N2 - Background: Artificial intelligence (AI) is rapidly transforming health care, offering substantial advancements in patient care, clinical workflows, and nursing education. Objective: This umbrella review aims to evaluate the integration of AI into nursing practice and education, with a focus on ethical and social implications, and to propose evidence-based recommendations to support the responsible and effective adoption of AI technologies in nursing. Methods: We included systematic reviews, scoping reviews, rapid reviews, narrative reviews, literature reviews, and meta-analyses focusing on AI integration in nursing, published up to October 2024. A new search was conducted in January 2025 to identify any potentially eligible reviews published thereafter. However, no new reviews were found. Eligibility was guided by the Sample, Phenomenon of Interest, Design, Evaluation, Research type framework; databases (PubMed or MEDLINE, CINAHL, Web of Science, Embase, and IEEE Xplore) were searched using comprehensive keywords. Two reviewers independently screened records and extracted data. Risk of bias was assessed with Risk of Bias in Systematic Reviews (ROBIS) and A Measurement Tool to Assess Systematic Reviews, version 2 (AMSTAR 2), which we adapted for systematic and nonsystematic review types. A thematic synthesis approach, conducted independently by 2 reviewers, identified recurring patterns across the included reviews. Results: The search strategy yielded 18 eligible studies after screening 274 records. These studies encompassed diverse methodologies and focused on nursing professionals, students, educators, and researchers. First, ethical and social implications were consistently highlighted, with studies emphasizing concerns about data privacy, algorithmic bias, transparency, accountability, and the necessity for equitable access to AI technologies. Second, the transformation of nursing education emerged as a critical area, with an urgent need to update curricula by integrating AI-driven educational tools and fostering both technical competencies and ethical decision-making skills among nursing students and professionals. Third, strategies for integration were identified as essential for effective implementation, calling for scalable models, robust ethical frameworks, and interdisciplinary collaboration, while also addressing key barriers such as resistance to AI adoption, lack of standardized AI education, and disparities in technology access. Conclusions: AI holds substantial promises for revolutionizing nursing practice and education. However, realizing this potential necessitates a strategic approach that addresses ethical concerns, integrates AI literacy into nursing curricula, and ensures equitable access to AI technologies. Limitations of this review include the heterogeneity of included studies and potential publication bias. Our findings underscore the need for comprehensive ethical frameworks and regulatory guidelines tailored to nursing applications, updated nursing curricula to include AI literacy and ethical training, and investments in infrastructure to promote equitable AI access. Future research should focus on developing standardized implementation strategies and evaluating the long-term impacts of AI integration on nursing practice and patient outcomes. UR - https://www.jmir.org/2025/1/e69881 UR - http://dx.doi.org/10.2196/69881 UR - http://www.ncbi.nlm.nih.gov/pubmed/40072926 ID - info:doi/10.2196/69881 ER - TY - JOUR AU - Zhao, Yanchun AU - Huang, Ting AU - Chen, Yanli AU - Li, Songmei AU - Zhao, Juan AU - Han, Xu AU - Ni, Qing AU - Su, Ning PY - 2025/3/31 TI - Evaluation of the Clinical Nursing Effects of a Traditional Chinese Medicine Nursing Program Based on Care Pathways for Patients With Type 2 Diabetes: Protocol for a Randomized Controlled Clinical Trial JO - JMIR Res Protoc SP - e58951 VL - 14 KW - type 2 diabetes KW - traditional Chinese medicine KW - TCM nursing program KW - clinical pathway KW - application research KW - diabetes KW - diabetes mellitus KW - research protocol KW - nursing KW - nursing program KW - nursing care KW - chronic disease KW - disease monitoring KW - prevalence KW - China KW - adult KW - patient recovery KW - psychological care KW - health education KW - quality of life KW - blood glucose KW - self-care KW - medication KW - control group KW - patient satisfaction N2 - Background: To improve the performance of health care institutions, reduce overmedication, and minimize the waste of medical resources, China is committed to implementing a clinical pathway management model. This study aims to standardize nursing practices, foster clinical thinking in nurses, and promote patient recovery. Objective: The purpose of this study is to evaluate the clinical effects of a traditional Chinese medicine (TCM) nursing program based on nursing pathways for patients with type 2 diabetes mellitus (T2DM). Methods: This study uses a prospective, randomized, single-blind, parallel-controlled design. Based on sample size calculations, the study will include 594 patients with diabetes, with 2 groups of 297 patients: an observation group will receive a TCM nursing program based on clinical pathways, while a control group will receive routine care. Both groups will be evaluated before and after the intervention using assessment indicators. The primary outcome is the quality of life score, measured by a diabetes-specific quality of life questionnaire. Secondary outcomes include hospital stay duration, medical expenses, health knowledge, blood glucose control, symptom scores, and patient satisfaction. Results: This study was funded in August 2021 and has received approval from the Ethics Committee of Guang?anmen Hospital, China Academy of Chinese Medical Sciences (2022-022-KY-01). The trial is ongoing, with the first patient enrolled in September 2022. The study is expected to conclude in April 2025. To date, 380 patients have been recruited, with 202 randomized into the study, though no statistical analysis of the data has yet been conducted. A single-blind method is used; nurses are aware of group assignments and intervention plans, while patients remain blinded. Final results are planned for release in the first quarter of 2025. Conclusions: This study seeks to integrate existing national standardized nursing protocols with clinical pathways to implement more efficient and higher-quality nursing practices. The goal is to standardize nursing procedures, enhance patients? quality of life, and improve self-care and medication adherence after discharge. Trial Registration: International Traditional Medicine Clinical Trial Registry ITMCTR2022000048; https://tinyurl.com/y4jd68h4 International Registered Report Identifier (IRRID): DERR1-10.2196/58951 UR - https://www.researchprotocols.org/2025/1/e58951 UR - http://dx.doi.org/10.2196/58951 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58951 ER - TY - JOUR AU - van Steenis, Saskia AU - Helder, Onno AU - Kort, M. Helianthe S. AU - van Houwelingen, Thijs PY - 2025/3/31 TI - Impact of Bottom-Up Cocreation of Nursing Technological Innovations: Explorative Interview Study Among Hospital Nurses and Managers JO - JMIR Hum Factors SP - e60543 VL - 12 KW - stakeholder participation KW - cocreation KW - nursing KW - innovation KW - bottom-up approach KW - diffusion of innovation KW - qualitative research KW - nurses N2 - Background: In health care, the use of nursing technological innovations, particularly technological products, is rapidly increasing; however, these innovations do not always align with nursing practice. An explanation for this issue could be that nursing technological innovations are developed and implemented with a top-down approach, which could subsequently limit the positive impact on practice. Cocreation with stakeholders such as nurses can help address this issue. Nowadays, health care centers increasingly encourage stakeholder participation, which is known as a bottom-up cocreation approach. However, little is known about the experience of nurses and their managers with this approach and the innovations it results in within the field of nursing care. Objective: This study aims to explore nurses? and their managers? experiences with a bottom-up cocreation approach in order to assess the impact of this way of working and the resulting nursing technological innovations in an academic hospital. This insight can also inform decisions on whether the bottom-up cocreation approach should be more widely disseminated. Methods: A qualitative study using semistructured interviews was conducted with 15 participants, including cocreator nurses, end-user nurses, and their managers. First, the data were thematically analyzed. In addition, a strengths, weaknesses, opportunities, and threats analysis was conducted. Results: The various experiences of the participants were described in 3 main themes: enhanced attractiveness of the nursing profession, feeling involved due to a cocreation environment, and experienced benefits and challenges in using cocreated products. In addition, numerous strengths and opportunities perceived by the participants were identified as associated with the bottom-up cocreation approach and resulting useful products within nursing care; for example, cocreation contributed to job satisfaction and substantially contributed to the ease of use of the innovations that were developed. Conclusions: The findings underscore that cocreation with nurses enhances the appeal of the nursing profession and aligns nursing technological innovations with practical nursing challenges. Embracing a culture of cocreation has the potential to foster a culture of continuous improvement and innovation in nursing care. UR - https://humanfactors.jmir.org/2025/1/e60543 UR - http://dx.doi.org/10.2196/60543 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60543 ER - TY - JOUR AU - Graven, J. Lucinda AU - Abbott, Laurie AU - Hodgkins, V. Josef AU - Ledermann, Thomas AU - Howren, Bryant M. PY - 2025/3/26 TI - Supporting Physical and Mental Health in Rural Veterans Living With Heart Failure: Protocol for a Nurse-Led Telephone Intervention Study JO - JMIR Res Protoc SP - e63498 VL - 14 KW - heart failure KW - veterans KW - problem-solving KW - self-care KW - heart failure symptoms KW - depression KW - anxiety KW - HRQOL KW - health-related quality of life KW - stress KW - resilience KW - coping KW - mental health KW - nurse-led intervention KW - social support KW - telehealth KW - chronic disease management N2 - Background: Heart failure (HF) remains a disease of notable disparity for rural veterans, despite recent advancements in clinical treatment. Managing HF in the home is stressful and complex for rural veterans who experience unique barriers to optimal physical and mental health, necessitating adequate support and problem-solving skills. Objective: This study aims to (1) adapt, to the rural sociocultural context, a culturally sensitive, tailored, telephone support and problem-solving intervention (CARE-HF [Supporting Physical and Mental Health in Rural Veterans With Heart Failure]) using findings from preliminary qualitative research and (2) evaluate the effects of CARE-HF on problem-solving and physical and mental health outcomes among rural veterans with HF. Methods: This study involves a repeated-measures, single-group design. The intervention content was adapted and tailored to the rural sociocultural context using preliminary qualitative data and guided by the Theories of Social Problem-Solving and Stress, Appraisal, and Coping. Veterans are recruited from Veterans Administration home-based cardiac rehabilitation clinics, cardiology clinics that serve veterans, veterans-based community resource centers, and social media campaigns. Veterans with HF (N=100) receive the CARE-HF intervention. This nurse-led intervention comprises 8 telephone sessions that use a five-step, problem-solving process to manage common HF problems in the home: (1) identifying the problem and viewing it in a positive manner, (2) goal setting, (3) generating potential strategies for problem management, (4) choosing and implementing strategies to manage the problem, and (5) evaluating strategy effectiveness. Veterans receive initial problem-solving training during the first session, with follow-up sessions focusing on problem-solving skill reinforcement and assisting veterans in applying these principles to manage self-identified, HF-related problems experienced in the home. Data are collected at baseline and 3, 6, 12, and 18 months from baseline on problem-solving and outcomes of interest (ie, HF self-care; HF symptoms; health care utilization; depressive symptoms; anxiety; HF-specific, health-related quality of life; stress; resilience; and coping). Demographic data will be analyzed using descriptive statistics and multilevel growth curve modeling with restricted maximum likelihood estimation to compare a series of models using Akaike information criteria and Bayesian information criteria fit indices while controlling for covariates. Results: Recruitment started in April 2023. As of December 2024, we have enrolled 56 veterans. Recruitment is anticipated to end in June 2025, with data collection continuing until all enrolled veterans have completed the 18-month follow-up period. Conclusions: Adapting and testing a culturally sensitive, tailored, telephone intervention to aid support and problem-solving in the home has the potential to provide individualized care to rural veterans where they reside, thereby reducing travel burden while also increasing access to evidence-based care programs. If effective, telephone support and problem-solving interventions could be a low-cost, accessible method to improve physical and mental health in rural veterans with HF. Trial Registration: ClinicalTrials.gov NCT05839067; https://clinicaltrials.gov/study/NCT05839067 International Registered Report Identifier (IRRID): DERR1-10.2196/63498 UR - https://www.researchprotocols.org/2025/1/e63498 UR - http://dx.doi.org/10.2196/63498 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63498 ER - TY - JOUR AU - Vanhala, Ville AU - Surakka, Outi AU - Multisilta, Vilma AU - Lundsby Johansen, Mette AU - Villinger, Jonas AU - Nicolle, Emmanuelle AU - Heikkil�, Johanna AU - Korhonen, Pentti PY - 2025/3/21 TI - Efficiency Improvement of the Clinical Pathway in Cardiac Monitor Insertion and Follow-Up: Retrospective Analysis JO - JMIR Cardio SP - e67774 VL - 9 KW - insertable cardiac monitor KW - clinical pathway KW - nurse-led service KW - task shifting KW - efficiency improvement KW - remote monitoring N2 - Background: The insertable cardiac monitor (ICM) clinical pathway in Tampere Heart Hospital, Finland, did not correspond to the diagnostic needs of the population. There has been growing evidence of delegating the insertion from cardiologists to specially trained nurses and outsourcing the remote follow-up. However, it is unclear if the change in the clinical pathway is safe and improves efficiency. Objective: We aim to describe and assess the efficiency of the change in the ICM clinical pathway. Methods: Pathway improvements included initiating nurse-performed insertions, relocating the procedure from the catheterization laboratory to a procedure room, and outsourcing part of the remote follow-up to manage ICM workload. Data were collected from electronic health records of all patients who received an ICM in the Tampere Heart Hospital in 2018 and 2020. Follow-up time was 36 months after insertion. Results: The number of inserted ICMs doubled from 74 in 2018 to 159 in 2020. In 2018, cardiologists completed all insertions, while in 2020, a total of 70.4% (n=112) were completed by nurses. The waiting time from referral to procedure was significantly shorter in 2020 (mean 36, SD 27.7 days) compared with 2018 (mean 49, SD 37.3 days; P=.02). The scheduled ICM procedure time decreased from 60 minutes in 2018 to 45 minutes in 2020. Insertions performed in the catheterization laboratory decreased significantly (n=14, 18.9% in 2018 and n=3, 1.9% in 2020; P=<.001). Patients receiving an ICM after syncope increased from 71 to 94 patients. Stroke and transient ischemic attack as an indication increased substantially from 2018 to 2020 (2 and 62 patients, respectively). In 2018, nurses analyzed all remote transmissions. In 2020, the external monitoring service escalated only 11.2% (204/1817) of the transmissions to the clinic for revision. This saved 296 hours of nursing time in 2020. Having nurses insert ICMs in 2020 saved 48 hours of physicians? time and the shorter scheduling for the procedure saved an additional 40 hours of nursing time compared with the process in 2018. Additionally, the catheterization laboratory was released for other procedures (27 h/y). The complication rate did not change significantly (n=2, 2.7% in 2018 and n=5, 3.1% in 2020; P=.85). The 36-month diagnostic yield for syncope remained high in 2018 and 2020 (n=32, 45.1% and n=36, 38.3%; P=.38). The diagnostic yield for patients who had stroke with a procedure in 2020 was 43.5% (n=27). Conclusions: The efficiency of the clinical pathway for patients eligible for an ICM insertation can be increased significantly by shifting to nurse-led insertions in procedure rooms and to the use of an external monitoring and triaging service. UR - https://cardio.jmir.org/2025/1/e67774 UR - http://dx.doi.org/10.2196/67774 ID - info:doi/10.2196/67774 ER - TY - JOUR AU - Alsahli, Mohammed AU - Abd-alrazaq, Alaa AU - Fathy, M. Dalia AU - Abdelmohsen, A. Sahar AU - Gushgari, Abdulgafoor Olfat AU - Ghazy, K. Heba AU - Abdelwahed, Yousef Amal PY - 2025/3/21 TI - Effectiveness of Patients? Education and Telenursing Follow-Ups on Self-Care Practices of Patients With Diabetes Mellitus: Cross-Sectional and Quasi-Experimental Study JO - JMIR Nursing SP - e67339 VL - 8 KW - diabetes mellitus KW - education KW - knowledge KW - self-care KW - telenursing N2 - Background: Information and communications technology can be used in telenursing to facilitate remote service delivery, thereby helping mitigate the general global nursing shortage as well as particular applications (eg, in geographically remote communities). Telenursing can thus bring services closer to end users, offering patient convenience and reduced hospitalization and health system costs, enabling more effective resource allocation. Objective: This study aims to examine the impact of patients? education and telenursing follow-ups on self-care indicators among patients with type I and type II diabetes mellitus (DM). Methods: In phase I, a cross-sectional descriptive analysis was conducted to evaluate the self-care practices of 400 patients with DM at Kafr El Sheikh University Hospital in Egypt. In phase II, a pretest-posttest experiment was applied with a selected group of 100 patients purposively recruited from phase I due to their low self-care practice knowledge to ascertain the impacts of a 4-week intervention delivered via telenursing. They were reminded via telephone follow-up communication of the importance of adhering to recommendations on physical activity, nutritional intake, and the management of blood sugar (ie, insulin). Data collection was undertaken using a structured quantitative questionnaire, encompassing sociodemographic characteristics, medical symptoms and history, and knowledge of DM. Paired t test analysis was applied to study pre- and postintervention self-care behaviors. Results: Participants had a mean age of 49.7 (SD 11.5) years. More than one-third received their DM diagnosis over a decade previously (135/400, 33.8%) and were obese (147/400, 36.8%). Almost half (176/400, 44%) received insulin, and the majority had cardiac disease (231/400, 57.7%) and the DM symptom of elevated blood sugar levels while fasting (365/400, 91.3%). A relatively high score of DM knowledge was reported (255/400, 63.7%). Males exhibited significantly lower knowledge levels (102/200, 51%) compared to females (153/200, 76.5%; P<.001). The intervention was effective in improving knowledge of DM (t99=30.7, two-tailed; P<.001), self-care practices (t99=53.7, two-tailed; P<.001), and self-care skills (t99= 47, two-tailed; P<.001) among patients with DM. Conclusions: The emergent evidence suggests that patients? education and telenursing follow-ups have the potential to improve self-care behavior in patients with DM. The delivery of frequent nursing reinforcement via telenursing enables improved self-management while contemporaneously reducing the need for patients to visit clinical settings (ie, improving patient condition and reducing net health system costs). The outcomes of this research underscore the need to integrate telenursing within conventional care for DM, and more research is needed to longitudinally assay its efficacy and sustainability over the long term and in different clinical and geographical contexts. UR - https://nursing.jmir.org/2025/1/e67339 UR - http://dx.doi.org/10.2196/67339 ID - info:doi/10.2196/67339 ER - TY - JOUR AU - Ali-Saleh, Ola AU - Massalha, Layalleh AU - Halperin, Ofra PY - 2025/3/12 TI - Evaluation of a Simulation Program for Providing Telenursing Training to Nursing Students: Cohort Study JO - JMIR Med Educ SP - e67804 VL - 11 KW - simulation-based training program KW - telenursing KW - simulation KW - program KW - training KW - nursing student KW - nursing care KW - Israel KW - nurse-patient relationship KW - telehealth nursing KW - remote nursing care KW - undergraduate KW - cohort study KW - knowlege; self efficacy; skills; attitudes N2 - Background: Telenursing has become prevalent in providing care to diverse populations experiencing different health conditions both in Israel and globally. The nurse-patient relationship aims to improve the condition of individuals requiring health services. Objectives: This study aims to evaluate nursing graduates? skills and knowledge regarding remote nursing care prior to and following a simulation-based telenursing training program in an undergraduate nursing degree. Methods: A cohort study assessed 114 third-year nursing students using comprehensive evaluation measures of knowledge, skills, attitudes, self-efficacy, and clinical skills regarding remote nursing care. Assessments were conducted at 2 critical time points: prior to and following a structured simulation-based training intervention. Results: Participant demographics revealed a predominantly female sample (101/114, 88.6%), aged 20?50 years (mean 25.68, SD 4.59 years), with moderate to advanced computer and internet proficiency. Notably, 91.2% (104/114) had no telenursing exposure, yet 75.4% (86/114) expressed training interest. Statistical analyses demonstrated significant improvements across all measured variables, characterized by moderate to high effect sizes. Key findings included substantial increases in telenursing awareness, knowledge, skills, attitudes and self-efficacy; significant reduction in perceived barriers to remote care delivery; and complex interrelation dynamics between variables. A multivariate analysis revealed nuanced correlations: higher awareness and knowledge were consistently associated with more positive attitudes and increased self-efficacy. Positive attitudes correlated with enhanced self-efficacy and reduced perceived barriers. Change score analyses further indicated that increased awareness and knowledge facilitated more positive attitudinal shifts, while heightened awareness and positive attitudes corresponded with decreased implementation barriers. Conclusions: The study underscores the critical importance of integrating targeted telenursing training into nursing education. By providing comprehensive preparation, educational programs can equip students to deliver optimal remote care services. The COVID-19 pandemic has definitively demonstrated that remote nursing will be central to future health care delivery, emphasizing the urgent need to prepare nursing students for this emerging health care paradigm. UR - https://mededu.jmir.org/2025/1/e67804 UR - http://dx.doi.org/10.2196/67804 ID - info:doi/10.2196/67804 ER - TY - JOUR AU - Mess, Veronica Elisabeth AU - Regner, Matthias AU - Balic, Sabahudin AU - Kleybolte, Lukas AU - Daufratshofer, Lisa AU - Mahler, Andreas AU - Tilmes, Sabrina AU - Werlitz, Viktor AU - Reuter, Claudia AU - Teynor, Alexandra PY - 2025/2/21 TI - Detailed Analysis and Road Map Proposal for Care Transition Records and Their Transmission Process: Mixed Methods Study JO - JMIR Nursing SP - e60810 VL - 8 KW - care transition record KW - transmission management KW - observations KW - process modeling KW - telematics infrastructure KW - TI KW - Fast Healthcare Interoperability Resources KW - FHIR KW - Health Level 7 KW - HL7 KW - medical information object KW - MIO KW - care information object care transition record KW - CIO-CTR KW - Pflegerisches Informationsobjekt-�berleitungsbogen KW - PIO-ULB KW - artificial intelligence KW - AI N2 - Background: The digitalization of health care in Germany holds great potential to improve patient care, resource management, and efficiency. However, strict data protection regulations, fragmented infrastructures, and resistance to change hinder progress. These challenges leave care institutions reliant on outdated paper-based workflows, particularly for patient data transmission, despite the pressing need for efficient tools to support health care professionals amid a nursing shortage and rising demand for care. Objective: This paper aims to analyze Germany?s care transition record (CTR) and CTR transmission process as part of transition management and suggests improvements toward a seamless digital solution. Methods: To understand the current challenges of manual CTR transfers, we used a mixed methods approach, which included a web-based questionnaire with nursing professionals, field observations, business process model and notation modeling, semantic and frequency analysis of CTR entries, and user story mapping. Results: A web-based questionnaire involving German nursing professionals (N=59) revealed considerable delays in patient care due to manual, patient-transferred CTRs. Of the 33 usable responses (n=33), 70% (n=23) of the respondents advocating for digital transmission to improve efficiency. Observations (N=11) in care facilities (n=5, 45%) and a hospital (n=6, 55%) confirmed the high administrative burden, averaging 34.67 (SD 10.78) minutes per CTR within a hospital and 44.6 (SD 20.5) minutes in care facilities. A semantic analysis of various CTRs (N=4) highlighted their differences and complexity, stressing the need for standardization. Analyzing a new CTR standard (care information object CTR) and manually mapping an existing CTR to it showed that the procedure was ambiguous, and some associations remained unclear. A frequency analysis of CTR entities revealed which were most used. In addition, discussions with care staff pointed out candidates for the most relevant entities. On the basis of the key findings, a stepwise transition approach toward a road map proposal for a standardized, secure transfer of CTRs was conceptualized. This road map in the form of a user story map, encompassing a ?CTR transformer? (mapping of traditional CTRs to a new standard) and ?care information object CTR viewer/editor? (in short, CIO-CTR viewer and editor; a new standard for viewing, editing, and exporting), shows a possibility to bridge the transition time until all institutions fully support the new standard. Conclusions: A future solution should simplify the overall CTR transmission process by minimizing manual transfers into in-house systems, standardizing the CTR, and providing a secure digital transfer. This could positively impact the overall care process and patient experience. With our solutions, we attempt to support care staff in their daily activities and processes until nationwide state regulations are implemented successfully, though the timeline for this remains uncertain. UR - https://nursing.jmir.org/2025/1/e60810 UR - http://dx.doi.org/10.2196/60810 UR - http://www.ncbi.nlm.nih.gov/pubmed/39982779 ID - info:doi/10.2196/60810 ER - TY - JOUR AU - Al Khatib, Inas AU - Ndiaye, Malick PY - 2025/2/19 TI - Examining the Role of AI in Changing the Role of Nurses in Patient Care: Systematic Review JO - JMIR Nursing SP - e63335 VL - 8 KW - artificial intelligence KW - AI KW - nursing practice KW - technology KW - health care KW - PRISMA N2 - Background: This review investigates the relationship between artificial intelligence (AI) use and the role of nurses in patient care. AI exists in health care for clinical decision support, disease management, patient engagement, and operational improvement and will continue to grow in popularity, especially in the nursing field. Objective: We aim to examine whether AI integration into nursing practice may have led to a change in the role of nurses in patient care. Methods: To compile pertinent data on AI and nursing and their relationship, we conducted a thorough systematic review literature analysis using secondary data sources, including academic literature from the Scopus database, industry reports, and government publications. A total of 401 resources were reviewed, and 53 sources were ultimately included in the paper, comprising 50 peer-reviewed journal articles, 1 conference proceeding, and 2 reports. To categorize and find patterns in the data, we used thematic analysis to categorize the systematic literature review findings into 3 primary themes and 9 secondary themes. To demonstrate whether a role change existed or was forecasted to exist, case studies of AI applications and examples were also relied on. Results: The research shows that all health care practitioners will be impacted by the revolutionary technology known as AI. Nurses should be at the forefront of this technology and be empowered throughout the implementation process of any of its tools that may accelerate innovation, improve decision-making, automate and speed up processes, and save overall costs in nursing practice. Conclusions: This study adds to the existing body of knowledge about the applications of AI in nursing and its consequences in changing the role of nurses in patient care. To further investigate the connection between AI and the role of nurses in patient care, future studies can use quantitative techniques based on recruiting nurses who have been involved in AI tool deployment?whether from a design aspect or operational use?and gathering empirical data for that purpose. UR - https://nursing.jmir.org/2025/1/e63335 UR - http://dx.doi.org/10.2196/63335 UR - http://www.ncbi.nlm.nih.gov/pubmed/39970436 ID - info:doi/10.2196/63335 ER - TY - JOUR AU - Sim�n-L�pez, Carmen Leticia AU - Ortu�o-Soriano, Ismael AU - Luengo-Gonz�lez, Raquel AU - Posada-Moreno, Paloma AU - Zaragoza-Garc�a, Ignacio AU - S�nchez-G�mez, Rub�n PY - 2025/2/10 TI - Proposal and Strategy for Nursing-Led Research: Protocol for an Unfunded Clinical Trial JO - JMIR Res Protoc SP - e56062 VL - 14 KW - clinical trial KW - academic trial KW - nonfunded KW - commercial KW - nurse-led KW - low intervention KW - health product KW - peripheral venous cannulation KW - PVC KW - protocol KW - randomized controlled trial KW - RCT KW - adults KW - healthy adults KW - funding KW - academic sponsors KW - cause-effect results KW - insurance N2 - Background: Clinical trials are known to provide cause-and-effect results and data with low levels of bias. However, a lack of funding for clinical trials, which are considered expensive, means that academic sponsors are rarely able to conduct them. Academic trials are considered highly relevant for the valuable results they provide for clinical questions. This is why initiatives to conduct unfunded clinical trials have been identified as an important issue to pay attention to in future studies. Therefore, we present our initiative through Rogers? theory, which is highlighted in the literature for diffusing innovative change across organizations. Objective: The purpose of this paper was to describe our case regarding management for conducting a nonfunded nurse-led clinical trial based on our previous low-interventional clinical trial across a specific health organization and with nurses. Methods: We conducted a low-intervention, nonexternally funded clinical trial using the human and material resources available on site. We managed our trial in a clinical trial unit where there were staff, sources, and ongoing commercial clinical trials. We conducted our trial based on an ongoing commercial trial, and, to do so, we needed behavioral changes. We relied on Rogers? theory, and we identified strengths and barriers to change by analyzing actors' characteristics, perceptions of the situation, motivation, and information. Afterward, we divided the staff according to their characteristics related to innovation and change into permanent staff (research staff with a culture of change) and nonpermanent staff (nursing staff with occasional attendance and resistance to change). First, we preselected only those nurses who were more aware of change (innovators and pioneers) to participate in our trial to avoid a massive rejection, and later, we asked others to join (late adopters). We followed Rogers? phases. For research staff who were aware of the funding, we focused on the ?persuasion phase,? while for nursing staff, we mixed the ?knowledge and persuasion phases? and used pioneers and early adopters as a positive example for other nurses as well as nonfinancial incentives (persuasion). Our trial consisted of different methods of vein cannulation, which was performed in the ongoing commercial trial. Thus, the entire development of our low-interventional clinical trial was conducted without interfering at any point with the parallel commercial clinical trial. Results: Our management allowed effective conduct of our study, and we met our aims without external funding and without ethical impact during the commercial clinical trial. Costs remained low, primarily because the major expenses were covered by the commercial clinical trial as an inherent part of its design. Conclusions: Our initiative to conduct a low-intervention clinical trial with no or limited funding was cost-effective. This initiative can be used by researchers with valuable academic research questions who do not have the external funding to conduct studies. Trial Registration: ClinicalTrials.gov NCT04027218; https://clinicaltrials.gov/study/NCT04027218 International Registered Report Identifier (IRRID): RR1-10.2196/56062 UR - https://www.researchprotocols.org/2025/1/e56062 UR - http://dx.doi.org/10.2196/56062 UR - http://www.ncbi.nlm.nih.gov/pubmed/39927682 ID - info:doi/10.2196/56062 ER - TY - JOUR AU - Jung, Sun-Young AU - Lee, Ji-Hyeon PY - 2024/12/16 TI - Emotional Touch Nursing Competencies Model of the Fourth Industrial Revolution: Instrument Validation Study JO - Asian Pac Isl Nurs J SP - e67928 VL - 8 KW - nurse KW - therapeutic touch KW - clinical competence KW - factor analysis KW - statistical KW - reliability KW - scale KW - tool KW - nursing KW - industrial revolution KW - competencies KW - health care KW - emotional KW - interview KW - collaborative practice KW - learning agility KW - professional commitment KW - positive self-worth KW - compliance KW - ethics KW - practice ability KW - relationship ability KW - nursing sensitivity N2 - Background: The Fourth Industrial Revolution is transforming the health care sector through advanced technologies such as artificial intelligence, the Internet of Things, and big data, leading to new expectations for rapid and accurate treatment. While the integration of technology in nursing tasks is on the rise, there remains a critical need to balance technological efficiency with empathy and emotional connection. This study aims to develop and validate a competency model for emotional touch nursing that responds to the evolving demands of the changing health care environment. Objective: The aims of our study are to develop an emotional touch nursing competencies model and to verify its reliability and validity. Methods: A conceptual framework and construct factors were developed based on an extensive literature review and in-depth interviews with nurses. The potential competencies were confirmed by 20 experts, and preliminary questions were prepared. The final version of the scale was verified through exploratory factor analysis (n=255) and confirmatory factor analysis (n=256) to assess its validity and reliability. Results: From the exploratory analysis, 8 factors and 38 items (client-centered collaborative practice, learning agility for nursing, nursing professional commitment, positive self-worth, compliance with ethics and roles, nursing practice competence, nurse-client relationship, and nursing sensitivity) were extracted. These items were verified through convergent and discriminant validity testing. The internal consistency reliability was acceptable (Cronbach ?=0.95). Conclusions: The findings from this study confirmed that this scale has sufficient validity and reliability to measure emotional touch nursing competencies. It is expected to be used to build a knowledge and educational system for emotional touch nursing. UR - https://apinj.jmir.org/2024/1/e67928 UR - http://dx.doi.org/10.2196/67928 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/67928 ER - TY - JOUR AU - Kang, Aimei AU - Wu, XiuLi PY - 2024/11/27 TI - Assessing Visitor Expectations of AI Nursing Robots in Hospital Settings: Cross-Sectional Study Using the Kano Model JO - JMIR Nursing SP - e59442 VL - 7 KW - nursing robot KW - artificial intelligence KW - Kano model KW - demand survey KW - nursing KW - care robots KW - nursing management N2 - Background: Globally, the rates at which the aging population and the prevalence of chronic diseases are increasing are substantial. With declining birth rates and a growing percentage of older individuals, the demand for nursing staff is steadily rising. However, the shortage of nursing personnel has been a long-standing issue. In recent years, numerous researchers have advocated for the implementation of nursing robots as a substitute for traditional human labor. Objective: This study analyzes hospital visitors? attitudes and priorities regarding the functional areas of artificial intelligence (AI) nursing robots based on the Kano model. Building on this analysis, recommendations are provided for the functional optimization of AI nursing robots, aiming to facilitate their adoption in the nursing field. Methods: Using a random sampling method, 457 hospital visitors were surveyed between December 2023 and March 2024 to compare the differences in demand for AI nursing robot functionalities among the visitors. Results: A comparative analysis of the Kano attribute quadrant diagrams showed that visitors seeking hospitalization prioritized functional aspects that enhance medical activities. In contrast, visitors attending outpatient examinations focused more on functional points that assist in medical treatment. Additionally, visitors whose purpose was companionship and care emphasized functional aspects that offer psychological and life support to patients. Conclusions: AI nursing robots serve various functional areas and cater to diverse audience groups. In the future, it is essential to thoroughly consider users? functional needs and implement targeted functional developments to maximize the effectiveness of AI nursing robots. UR - https://nursing.jmir.org/2024/1/e59442 UR - http://dx.doi.org/10.2196/59442 ID - info:doi/10.2196/59442 ER - TY - JOUR AU - Nabelsi, Veronique AU - Leclerc, Chantal Marie AU - Plouffe, V�ronique PY - 2024/11/27 TI - Nurses? and Nursing Assistants? Experiences With Teleconsultation in Small Rural Long-Term Care Facilities: Semistructured Interview Pilot Study JO - JMIR Aging SP - e65111 VL - 7 KW - teleconsultation KW - long-term care facilities KW - nursing KW - nursing practices KW - workflow optimization KW - residents KW - rural KW - telehealth KW - Quebec N2 - Background: In Quebec, the shortage of nurses during night shifts compromises the safety and quality of resident care, particularly in small residential and long-term care centers (?Centres d?h�bergement et de soins de longue dur�e?; CHSLDs) located in rural areas. The need to ensure the continuous presence of nurses 24 hours a day in CHSLDs has become more pressing, forcing some facilities to implement exceptional measures such as on-call telephone services to ensure access to a nurse. In light of these challenging circumstances, the Direction nationale des soins et des services infirmiers of Quebec?s Minist�re de la Sant� et des Services sociaux has rolled out a teleconsultation pilot project. Objective: This study aims to explore nurses? and nursing assistants? experience of integrating teleconsultation during night shifts in rural CHSLDs with ?50 residents. Methods: The 6-month pilot project was rolled out sequentially in 3 rural CHSLDs located in 2 administrative regions of Quebec between July 2022 and March 2023. A total of 18 semistructured interviews were conducted with 9 nurses and nursing assistants between February and July 2023. Results: Participants? experiences revealed that teleconsultation provided significant added value by improving clinical, administrative, and organizational practices. Some practices remained unchanged, indicating stable workflows. Workflow optimization through an expanded scope of practice ensured efficient and safe continuity of care. Enhanced collaboration between nurses and nursing assistants led to improved care coordination and communication. The leadership played a significant role in clarifying professionals? roles and in supporting effective adaptation to teleconsultation. Conclusions: This pilot project represents a significant step forward in improving care for CHSLD residents in Quebec. Teleconsultation not only makes it possible to overcome recruitment challenges and ensure the continuous presence of nurses during night shifts but also optimizes professional practices while ensuring the safety and quality of care provided to residents. UR - https://aging.jmir.org/2024/1/e65111 UR - http://dx.doi.org/10.2196/65111 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/65111 ER - TY - JOUR AU - Cornelis, Justien AU - Christiaens, Wendy AU - de Meester, Christophe AU - Mistiaen, Patriek PY - 2024/11/19 TI - Remote Patient Monitoring at Home in Patients With COVID-19: Narrative Review JO - JMIR Nursing SP - e44580 VL - 7 KW - COVID-19 KW - coronavirus disease KW - telemonitoring KW - remote patient monitoring KW - review KW - pandemic KW - at-home monitoring KW - implementation KW - health care KW - patient care N2 - Background: During the pandemic, health care providers implemented remote patient monitoring (RPM) for patients experiencing COVID-19. RPM is an interaction between health care professionals and patients who are in different locations, in which certain patient functioning parameters are assessed and followed up for a certain duration of time. The implementation of RPM in these patients aimed to reduce the strain on hospitals and primary care. Objective: With this literature review, we aim to describe the characteristics of RPM interventions, report on patients with COVID-19 receiving RPM, and provide an overview of outcome variables such as length of stay (LOS), hospital readmission, and mortality. Methods: A combination of different searches in several database types (traditional databases, trial registers, daily [Google] searches, and daily PubMed alerts) was run daily from March 2020 to December 2021. A search update for randomized controlled trials (RCTs) was performed in April 2022. Results: The initial search yielded more than 4448 articles (not including daily searches). After deduplication and assessment for eligibility, 241 articles were retained describing 164 telemonitoring studies from 160 centers. None of the 164 studies covering 248,431 patients reported on the presence of a randomized control group. Studies described a ?prehosp? group (96 studies) with patients who had a suspected or confirmed COVID-19 diagnosis and who were not hospitalized but closely monitored at home or a ?posthosp? group (32 studies) with patients who were monitored at home after hospitalization for COVID-19. Moreover, 34 studies described both groups, and in 2 studies, the description was unclear. In the prehosp and posthosp groups, there were large variations in the number of emergency department (ED) visits (0%-36% and 0%-16%, respectively) and no convincing evidence that RPM leads to less or more ED visits or hospital readmissions (0%-30% and 0%-22%, respectively). Mortality was generally low, and there was weak to no evidence that RPM is associated with lower mortality. Moreover, there was no evidence that RPM shortens previous LOS. A literature update identified 3 small-scale RCTs, which could not demonstrate statistically significant differences in these outcomes. Most papers claimed savings; however, the scientific base for these claims was doubtful. The overall patient experiences with RPM were positive, as patients felt more reassured, although many patients declined RPM for several reasons (eg, technological embarrassment, digital literacy). Conclusions: Based on these results, there is no convincing evidence that RPM in COVID-19 patients avoids ED visits or hospital readmissions and shortens LOS or reduces mortality. On the other hand, there is no evidence that RPM has adverse outcomes. Further research should focus on developing, implementing, and evaluating an RPM framework. UR - https://nursing.jmir.org/2024/1/e44580 UR - http://dx.doi.org/10.2196/44580 UR - http://www.ncbi.nlm.nih.gov/pubmed/39287362 ID - info:doi/10.2196/44580 ER - TY - JOUR AU - Ball Dunlap, A. Patricia AU - Michalowski, Martin PY - 2024/10/25 TI - Advancing AI Data Ethics in Nursing: Future Directions for Nursing Practice, Research, and Education JO - JMIR Nursing SP - e62678 VL - 7 KW - artificial intelligence KW - AI data ethics KW - data-centric AI KW - nurses KW - nursing informatics KW - machine learning KW - data literacy KW - health care AI KW - responsible AI UR - https://nursing.jmir.org/2024/1/e62678 UR - http://dx.doi.org/10.2196/62678 ID - info:doi/10.2196/62678 ER - TY - JOUR AU - Gimenes, Escobar Fernanda Raphael AU - Stabile, Maria Angelita AU - Bernardes, Magri Rodrigo AU - Santos, Batista Vinicius AU - Menegueti, Gon�alves Mayra AU - do Prado, Rezende Patricia AU - Ribeiro, Serra Mauricio AU - Camerini, Giron Flavia AU - Rabeh, Nasbine Soraia Assad PY - 2024/10/23 TI - Advancing Digital Education Technologies by Empowering Nurses With Point-of-Care Ultrasound: Protocol for a Mixed Methods Study JO - JMIR Res Protoc SP - e58030 VL - 13 KW - ultrasound KW - bedside ultrasound KW - patient safety KW - advanced practice nursing KW - digital technology in education KW - empowerment KW - nurses KW - Point-of-Care Ultrasound KW - PoCUS KW - quality care KW - decision-making KW - nursing assessment N2 - Background: Bedside ultrasonography, also known as point-of-care ultrasound (PoCUS), is a promising technological tool that enhances clinical assessment, enriching diagnostic capabilities and clinical reasoning. Its use in nursing spans various patient populations and health care settings, providing nurses with a valuable health assessment tool to improve care quality and patient safety. Despite its growing integration into clinical practice, PoCUS training has mainly focused on physicians, leaving a gap for trained nurses who demonstrate similar proficiency in conducting scans and interpreting images. Previous research highlights the value of digital tools in PoCUS training, showing their role in improving professionals? and students? knowledge, image interpretation skills, and clinical acumen. Objective: This study aimed to (1) establish an assessment instrument gauging nurses? competency milestones in PoCUS and evaluate its content and appearance validity, (2) develop a series of 5 educational videos focused on PoCUS and assess their content and appearance validity, and (3) construct an online learning environment tailored to nurses? PoCUS training needs and evaluate its content and appearance validity. Methods: We will conduct a methodological study of technological production guided by Rogers? diffusion of innovations theory. Subproject 1 will design and validate a comprehensive assessment tool for evaluating nurses? competency milestones in PoCUS use. For this purpose, a scoping review will be conducted. The review will be based on JBI Collaboration guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extended for Scoping Reviews (PRISMA-ScR) checklist. Subproject 2 involves an evaluation of content and appearance validity for a series of 5 educational videos on PoCUS, designed specifically for nurses about applying peripherally inserted central catheter lines, inserting nasogastric feeding tubes, assessing gastric residual volume, assessing pressure injuries and soft tissue conditions, and assessing muscle mass to monitor patient nutritional status. In subproject 3, a comprehensive online learning environment dedicated to PoCUS training for nurses will be developed and validated. The launch of an online learning environment represents a cornerstone of our dissemination strategy, scheduled to coincide with the inaugural Brazilian PoCUS symposium for nurses, an event organized by the project members. This platform will serve as a pivotal resource for continuous learning and professional development. Results: Subproject 1 will start in the second half of 2024 and is expected to be completed by mid-2025. Subproject 2 is currently ongoing and is expected to be completed in early 2026. Subproject 3 is set to begin in early 2025 and is planned to be completed by 2026. Conclusions: Through these concerted efforts, the project aims to bridge the existing gap in PoCUS training for nurses, thereby fostering their proficiency and enhancing patient care outcomes. International Registered Report Identifier (IRRID): PRR1-10.2196/58030 UR - https://www.researchprotocols.org/2024/1/e58030 UR - http://dx.doi.org/10.2196/58030 UR - http://www.ncbi.nlm.nih.gov/pubmed/39441654 ID - info:doi/10.2196/58030 ER - TY - JOUR AU - Raussi, Venla AU - Kujala, Sari AU - H�rhammer, Iiris AU - Savolainen, Kaisa AU - Autio, Reija AU - Koskela, Tuomas PY - 2024/10/16 TI - Comparing a Digital Health Check With Traditional Nurse-Led Health Examinations Among Long-Term Unemployed Individuals: Comparison Study JO - J Med Internet Res SP - e49802 VL - 26 KW - chronic illnesses KW - eHealth KW - health care services KW - lifestyle KW - long-term unemployment KW - digital health check KW - primary prevention KW - risk assessment KW - risk factors KW - prevention KW - screening N2 - Background: A digital health check can be used to screen health behavior risks in the population, help health care professionals with standardized risk estimation for their patients, and motivate a patient to change unhealthy behaviors. Long-term unemployed individuals comprise a particular subgroup with an increased risk of lifestyle-related diseases. Objective: This study aims to investigate the clinical utility of a general digital health examination, the STAR Duodecim Health Check and Coaching Program (STAR), which was developed in Finland, in the targeted screening of long-term unemployed individuals. For this purpose, we compared health challenges identified by a digital health check with those identified by a nurse during a face-to-face health check for unemployed individuals. Methods: In this comparison study, 49 unemployed participants attending a health check were recruited from two Finnish primary health care centers. The participants used STAR and attended a nurse?s health check. Data were collected by surveys with multiple-choice and open-ended questions from the participants, nurses, and a study assistant who observed the session. The nurses were asked to name the three most significant health challenges for each participant. These health challenges were categorized into health challenges corresponding to STAR and these were compared with each other. Percentages of agreement between STAR and nurses were calculated. Sensitivity and specificity, as well as Cohen ? with P values and CIs, were computed for agreement. Results: STAR identified a total of 365 health challenges, an average of 7.4 (SD 2.5) health challenges per participant (n=49). The nurses named a total of 160 health challenges (n=47). In 53% (95% CI 38.1-67.9; n=25) of cases, STAR identified all categorized health challenges named by nurses. In 64% (95% CI 48.5-77.3; n=30) of cases, STAR identified at least 2/3 of the health challenges identified by nurses. Cohen ? was 0.877 (P<.001) for alcohol, indicating almost perfect agreement, and 0.440 (P<.001) for smoking and 0.457 (P=.001) for cholesterol, indicating moderate agreement. STAR left a total of 89 health challenges, an average of 1.8 (SD 1.1) per participant, uncategorized because STAR lacked an answer to the question or questions required for the classification of a certain health challenge. The participants did not always add information on their blood pressure (n=36, 74%), cholesterol (n=22, 45%), and waist circumference (n=15, 31%). Conclusions: In conclusion, STAR identified most of the health challenges identified by nurses but missed some essential ones. Participants did not have information on measurements, such as blood pressure and cholesterol values, which are pivotal to STAR in assessing cardiovascular risks. Using the tool for screening or as a part of a traditional health check with necessary measurements and dialog with health care professionals may improve the risk assessments and streamline the health checks of unemployed individuals. International Registered Report Identifier (IRRID): RR2-10.2196/27668 UR - https://www.jmir.org/2024/1/e49802 UR - http://dx.doi.org/10.2196/49802 UR - http://www.ncbi.nlm.nih.gov/pubmed/39412874 ID - info:doi/10.2196/49802 ER - TY - JOUR AU - Trainum, Katie AU - Liu, Jiaying AU - Hauser, Elliott AU - Xie, Bo PY - 2024/9/16 TI - Nursing Staff?s Perspectives of Care Robots for Assisted Living Facilities: Systematic Literature Review JO - JMIR Aging SP - e58629 VL - 7 KW - robots KW - nursing staff KW - nursing home KW - senior living KW - systematic review KW - aging KW - older adults KW - gerontology KW - participatory design KW - user needs KW - nurses KW - nursing KW - retirement KW - long-term care KW - geriatrics KW - elderly KW - older people KW - syntheses KW - review methods KW - review methodology KW - searches KW - searching KW - systematic KW - experiences KW - attitudes KW - opinions KW - perceptions KW - perspectives KW - preferences KW - needs KW - preference N2 - Background: Care robots have been proposed in response to nursing shortages in assisted living facilities (ALFs) and the growing population of older adults. While the use of care robots may improve the general health and well-being of older adults, their introduction changes the work of nursing staff fundamentally, and it has implications for the entire health care system. In developing such technology, it is important to include end users, but so far, the nursing staff?s perspectives have largely been ignored. Objective: This study aims to examine the literature on nursing staff?s attitudes, needs, and preferences related to the use of care robots in ALFs, in order to discover gaps in the literature and guide future research. Methods: This review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 protocol. On May 12, 2023, we searched PubMed, CINAHL Plus with Full Text, PsycINFO, the IEEE Xplore Digital Library, and the ACM Digital Library using predetermined search terms. Included publications, written in English, focused on the predevelopment phase, in which information was gathered on nursing staff?s attitudes, needs, and preferences regarding care robots for ALFs. Publications were excluded if they did not provide peer-reviewed empirical data. The studies? findings were summarized, coded, and analyzed into major themes using thematic analysis and narrative synthesis. Their quality was assessed using McGill University?s Mixed Methods Appraisal Tool and the Joanna Briggs Institute?s critical appraisal tools. Results: The final sample included 15 studies. Most of the studies (n=11, 73%) were rated as good quality; however, there was a general lack of reporting on important methodological decisions and sample characteristics. Nursing staff desired care robots that could assist with physically demanding tasks and reduce their workload but had mixed feelings on whether robots could or should assist with social tasks. In addition, nursing staff are concerned about the ethics of care robots, as well as about their safety, accessibility, and operability. The nursing staff?s culture, qualification, and role in the facility may influence their perspectives of care robots. The studies lacked theory-driven designs and large sample sizes. Eight (53%) studies mentioned using a participatory design approach, but a lack of established criteria for what constitutes participatory design leads to varying degrees of methodological quality. Conclusions: There was consensus among nursing staff that care robots should serve as nursing assistants to reduce workload. Whether robots could or should assist with social tasks remains a question. Further research is needed to mitigate nursing staff?s concerns and understand the socioecological factors that influence their perspectives of care robots and their adoption in ALFs. In addition, theory-driven and large sample size study designs are necessary, as well as work to develop clear criteria for related participatory design research. UR - https://aging.jmir.org/2024/1/e58629 UR - http://dx.doi.org/10.2196/58629 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58629 ER - TY - JOUR AU - Darnell, Doyanne AU - Pierson, Andria AU - Tanana, J. Michael AU - Dorsey, Shannon AU - Boudreaux, D. Edwin AU - Are�n, A. Patricia AU - Comtois, Anne Katherine PY - 2024/9/6 TI - Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospital Patients: Formative Acceptability Evaluation of an eLearning Continuing Education Training JO - JMIR Form Res SP - e56402 VL - 8 KW - suicide prevention KW - hospital KW - training KW - e-learning KW - artificial intelligence KW - AI KW - task-shifting KW - quality assessment KW - fidelity KW - acceptability KW - feasibility KW - eLearning KW - suicide KW - quality KW - innovative KW - nurse KW - education training KW - safety planning KW - pilot study KW - virtual patient KW - web-based KW - role-play KW - microcounseling skills KW - United States N2 - Background: Suicide is the 12th leading cause of death in the United States. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill building are resource intensive and difficult to implement. Novel computer technologies harnessing artificial intelligence are now available, which hold promise for increasing the feasibility of providing trainees opportunities across a range of continuing education contexts to engage in skills practice with constructive feedback on performance. Objective: This pilot study aims to evaluate the feasibility and acceptability of an eLearning training in suicide safety planning among nurses serving patients admitted to a US level 1 trauma center for acute or intensive care. The training included a didactic portion with demonstration, practice of microcounseling skills with a web-based virtual patient (Client Bot Emily), role-play with a patient actor, and automated coding and feedback on general counseling skills based on the role-play via a web-based platform (Lyssn Advisor). Secondarily, we examined learning outcomes of knowledge, confidence, and skills in suicide safety planning descriptively. Methods: Acute and intensive care nurses were recruited between November 1, 2021, and May 31, 2022, to participate in a formative evaluation using pretraining, posttraining, and 6-month follow-up surveys, as well as observation of the nurses? performance in delivering suicide safety planning via standardized patient role-plays over 6 months and rated using the Safety Plan Intervention Rating Scale. Nurses completed the System Usability Scale after interacting with Client Bot Emily and reviewing general counseling scores based on their role-play via Lyssn Advisor. Results: A total of 18 nurses participated in the study; the majority identified as female (n=17, 94%) and White (n=13, 72%). Of the 17 nurses who started the training, 82% (n=14) completed it. On average, the System Usability Scale score for Client Bot Emily was 70.3 (SD 19.7) and for Lyssn Advisor was 65.4 (SD 16.3). On average, nurses endorsed a good bit of knowledge (mean 3.1, SD 0.5) and confidence (mean 2.9, SD 0.5) after the training. After completing the training, none of the nurses scored above the expert-derived cutoff for proficiency on the Safety Plan Intervention Rating Scale (?14); however, on average, nurses were above the cutoffs for general counseling skills per Lyssn Advisor (empathy: mean 4.1, SD 0.6; collaboration: mean 3.6, SD 0.7). Conclusions: Findings suggest the completion of the training activities and use of novel technologies within this context are feasible. Technologic modifications may enhance the training acceptability and utility, such as increasing the virtual patient conversational abilities and adding automated coding capability for specific suicide safety planning skills. International Registered Report Identifier (IRRID): RR2-10.2196/33695 UR - https://formative.jmir.org/2024/1/e56402 UR - http://dx.doi.org/10.2196/56402 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56402 ER - TY - JOUR AU - Alexander, L. Gregory AU - Poghosyan, Lusine AU - Zhao, Yihong AU - Hobensack, Mollie AU - Kisselev, Sergey AU - Norful, A. Allison AU - McHugh, John AU - Wise, Keely AU - Schrimpf, Brooke M. AU - Kolanowski, Ann AU - Bhatia, Tamanna AU - Tasnova, Sabrina PY - 2024/8/29 TI - Optimizing Response Rates to Examine Health IT Maturity and Nurse Practitioner Care Environments in US Nursing Homes: Mixed Mode Survey Recruitment Protocol JO - JMIR Res Protoc SP - e56170 VL - 13 KW - surveys and questionnaires KW - survey methods KW - health care surveys KW - survey KW - survey design KW - mixed-mMode survey KW - nursing homes KW - nursing home KW - clinical informatics research KW - electronic health records KW - electronic health record KW - clinicians KW - HIT Maturity KW - Care Environments KW - United States N2 - Background: Survey-driven research is a reliable method for large-scale data collection. Investigators incorporating mixed-mode survey designs report benefits for survey research including greater engagement, improved survey access, and higher response rate. Mix-mode survey designs combine 2 or more modes for data collection including web, phone, face-to-face, and mail. Types of mixed-mode survey designs include simultaneous (ie, concurrent), sequential, delayed concurrent, and adaptive. This paper describes a research protocol using mixed-mode survey designs to explore health IT (HIT) maturity and care environments reported by administrators and nurse practitioners (NPs), respectively, in US nursing homes (NHs). Objective: The aim of this study is to describe a research protocol using mixed-mode survey designs in research using 2 survey tools to explore HIT maturity and NP care environments in US NHs. Methods: We are conducting a national survey of 1400 NH administrators and NPs. Two data sets (ie, Care Compare and IQVIA) were used to identify eligible facilities at random. The protocol incorporates 2 surveys to explore how HIT maturity (survey 1 collected by administrators) impacts care environments where NPs work (survey 2 collected by NPs). Higher HIT maturity collected by administrators indicates greater IT capabilities, use, and integration in resident care, clinical support, and administrative activities. The NP care environment survey measures relationships, independent practice, resource availability, and visibility. The research team conducted 3 iterative focus groups, including 14 clinicians (NP and NH experts) and recruiters from 2 national survey teams experienced with these populations to achieve consensus on which mixed-mode designs to use. During focus groups we identified the pros and cons of using mixed-mode designs in these settings. We determined that 2 mixed-mode designs with regular follow-up calls (Delayed Concurrent Mode and Sequential Mode) is effective for recruiting NH administrators while a concurrent mixed-mode design is best to recruit NPs. Results: Participant recruitment for the project began in June 2023. As of April 22, 2024, a total of 98 HIT maturity surveys and 81 NP surveys have been returned. Recruitment of NH administrators and NPs is anticipated through July 2025. About 71% of the HIT maturity surveys have been submitted using the electronic link and 23% were submitted after a QR code was sent to the administrator. Approximately 95% of the NP surveys were returned with electronic survey links. Conclusions: Pros of mixed-mode designs for NH research identified by the team were that delayed concurrent, concurrent, and sequential mixed-mode methods of delivering surveys to potential participants save on recruitment time compared to single mode delivery methods. One disadvantage of single-mode strategies is decreased versatility and adaptability to different organizational capabilities (eg, access to email and firewalls), which could reduce response rates. International Registered Report Identifier (IRRID): DERR1-10.2196/56170 UR - https://www.researchprotocols.org/2024/1/e56170 UR - http://dx.doi.org/10.2196/56170 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56170 ER - TY - JOUR AU - Nowell, Lorelli AU - Dolan, Sara AU - Johnston, Sonja AU - Jacobsen, Michele AU - Lorenzetti, Diane AU - Oddone Paolucci, Elizabeth PY - 2024/8/21 TI - Exploring Student Perspectives and Experiences of Online Opportunities for Virtual Care Skills Development: Sequential Explanatory Mixed Methods Study JO - JMIR Nursing SP - e53777 VL - 7 KW - virtual care KW - online teaching and learning KW - mixed methods research KW - development KW - mixed method study KW - online KW - care KW - student KW - students KW - online learning KW - virtual learning KW - interview KW - experience KW - educational KW - technology KW - nursing KW - medicine KW - allied health KW - teaching N2 - Background: Caring profession students require skills and competencies to proficiently use information technologies for providing high-quality and effective care. However, there is a gap in exploring the perceptions and experiences of students in developing virtual care skills within online environments. Objective: This study aims to better understand caring professional students? online learning experiences with developing virtual care skills and competencies. Methods: A sequential explanatory mixed methods approach, integrating both a cross-sectional survey and individual interviews, was used to better understand caring professional students? online learning experiences with developing virtual care skills and competencies. Results: A total of 93 survey and 9 interview participants were drawn from various faculties, including students from education, nursing, medicine, and allied health. These participants identified the barriers, facilitators, principles, and skills related to learning about and delivering virtual care, including teaching methods and educational technologies. Conclusions: This study contributes to the growing body of educational research on virtual care skills by offering student insights and suggestions for improved teaching and learning strategies in caring professions? programs. UR - https://nursing.jmir.org/2024/1/e53777 UR - http://dx.doi.org/10.2196/53777 UR - http://www.ncbi.nlm.nih.gov/pubmed/39167789 ID - info:doi/10.2196/53777 ER - TY - JOUR AU - Kleib, Manal AU - Arnaert, Antonia AU - Nagle, M. Lynn AU - Darko, Mirekuwaa Elizabeth AU - Idrees, Sobia AU - da Costa, Daniel AU - Ali, Shamsa PY - 2024/8/13 TI - Resources to Support Canadian Nurses to Deliver Virtual Care: Environmental Scan JO - JMIR Med Educ SP - e53254 VL - 10 KW - virtual care KW - digital health KW - nursing practice KW - environmental scan KW - telehealth KW - nurses KW - Canada KW - health care N2 - Background: Regulatory and professional nursing associations have an important role in ensuring that nurses provide safe, competent, and ethical care and are capable of adapting to emerging phenomena that influence society and population health needs. Telehealth and more recently virtual care are 2 digital health modalities that have gained momentum during the COVID-19 pandemic. Telehealth refers to telecommunications and digital communication technologies used to deliver health care, support health care provider and patient education, and facilitate self-care. Virtual care facilitates the delivery of health care services via any remote communication between patients and health care providers and among health care providers, either synchronously or asynchronously, through information and communication technologies. Despite nurses? adaptability to delivering virtual care, many have also reported challenges. Objective: This study aims to describe resources about virtual care, digital health, and nursing informatics (ie, practice guidelines and fact sheets) available to Canadian nurses through their regulatory and professional associations. Methods: An environmental scan was conducted between March and July 2023. The websites of nursing regulatory bodies across 13 Canadian provinces and territories and relevant nursing and a few nonnursing professional associations were searched. Data were extracted from the websites of these organizations to map out educational materials, training opportunities, and guidelines made available for nurses to learn and adapt to the ongoing digitalization of the health care system. Information from each source was summarized and analyzed using an inductive content analysis approach to identify categories and themes. The Virtual Health Competency Framework was applied to support the analysis process. Results: Seven themes were identified: (1) types of resources available about virtual care, (2) terminologies used in virtual care resources, (3) currency of virtual care resources identified, (4) requirements for providing virtual care between provinces, (5) resources through professional nursing associations and other relevant organizations, (6) regulatory guidance versus competency in virtual care, and (7) resources about digital health and nursing informatics. Results also revealed that practice guidance for delivering telehealth existed before the COVID-19 pandemic, but it was further expanded during the pandemic. Differences were noted across available resources with respect to terms used (eg, telenursing, telehealth, or virtual care), types of documents (eg, guideline vs fact sheet), and the depth of information shared. Only 2 associations provided comprehensive telenursing practice guidelines. Resources relative to digital health and nursing informatics exist, but variations between provinces were also noted. Conclusions: The use of telehealth and virtual care services is becoming mainstream in Canadian health care. Despite variations across jurisdictions, the existing nursing practice guidance resources for delivering telehealth and virtual care are substantial and can serve as a beginning step for developing a standardized set of practice requirements or competencies to inform nursing practice and the education of future nurses. UR - https://mededu.jmir.org/2024/1/e53254 UR - http://dx.doi.org/10.2196/53254 UR - http://www.ncbi.nlm.nih.gov/pubmed/39137026 ID - info:doi/10.2196/53254 ER - TY - JOUR AU - Zhang, Chen AU - Wharton, Mitchell AU - Liu, Yu PY - 2024/8/13 TI - Ameliorating Racial Disparities in HIV Prevention via a Nurse-Led, AI-Enhanced Program for Pre-Exposure Prophylaxis Utilization Among Black Cisgender Women: Protocol for a Mixed Methods Study JO - JMIR Res Protoc SP - e59975 VL - 13 KW - artificial intelligence KW - PrEP care KW - PrEP KW - pre-exposure prophylaxis KW - nurse-led KW - AI KW - HIV prevention KW - HIV KW - prevention KW - AIDS KW - nurse KW - Black cisgender women KW - Black KW - cisgender KW - women KW - HIV pre-exposure prophylaxis KW - prophylaxis KW - biomedical KW - effectiveness KW - medical mistrust KW - Black women KW - nurse practitioners KW - chatbot KW - socioeconomic KW - HumanX technology KW - health care interventions N2 - Background: HIV pre-exposure prophylaxis (PrEP) is a critical biomedical strategy to prevent HIV transmission among cisgender women. Despite its proven effectiveness, Black cisgender women remain significantly underrepresented throughout the PrEP care continuum, facing barriers such as limited access to care, medical mistrust, and intersectional racial or HIV stigma. Addressing these disparities is vital to improving HIV prevention outcomes within this community. On the other hand, nurse practitioners (NPs) play a pivotal role in PrEP utilization but are underrepresented due to a lack of awareness, a lack of human resources, and insufficient support. Equipped with the rapid evolution of artificial intelligence (AI) and advanced large language models, chatbots effectively facilitate health care communication and linkage to care in various domains, including HIV prevention and PrEP care. Objective: Our study harnesses NPs? holistic care capabilities and the power of AI through natural language processing algorithms, providing targeted, patient-centered facilitation for PrEP care. Our overarching goal is to create a nurse-led, stakeholder-inclusive, and AI-powered program to facilitate PrEP utilization among Black cisgender women, ultimately enhancing HIV prevention efforts in this vulnerable group in 3 phases. This project aims to mitigate health disparities and advance innovative, technology-based solutions. Methods: The study uses a mixed methods design involving semistructured interviews with key stakeholders, including 50 PrEP-eligible Black women, 10 NPs, and a community advisory board representing various socioeconomic backgrounds. The AI-powered chatbot is developed using HumanX technology and SmartBot360?s Health Insurance Portability and Accountability Act?compliant framework to ensure data privacy and security. The study spans 18 months and consists of 3 phases: exploration, development, and evaluation. Results: As of May 2024, the institutional review board protocol for phase 1 has been approved. We plan to start recruitment for Black cisgender women and NPs in September 2024, with the aim to collect information to understand their preferences regarding chatbot development. While institutional review board approval for phases 2 and 3 is still in progress, we have made significant strides in networking for participant recruitment. We plan to conduct data collection soon, and further updates on the recruitment and data collection progress will be provided as the study advances. Conclusions: The AI-powered chatbot offers a novel approach to improving PrEP care utilization among Black cisgender women, with opportunities to reduce barriers to care and facilitate a stigma-free environment. However, challenges remain regarding health equity and the digital divide, emphasizing the need for culturally competent design and robust data privacy protocols. The implications of this study extend beyond PrEP care, presenting a scalable model that can address broader health disparities. International Registered Report Identifier (IRRID): PRR1-10.2196/59975 UR - https://www.researchprotocols.org/2024/1/e59975 UR - http://dx.doi.org/10.2196/59975 UR - http://www.ncbi.nlm.nih.gov/pubmed/39137028 ID - info:doi/10.2196/59975 ER - TY - JOUR AU - Groeneveld, Sjors AU - Bin Noon, Gaya AU - den Ouden, M. Marjolein E. AU - van Os-Medendorp, Harmieke AU - van Gemert-Pijnen, C. J. E. W. AU - Verdaasdonk, M. Rudolf AU - Morita, Pelegrini Plinio PY - 2024/5/23 TI - The Cooperation Between Nurses and a New Digital Colleague ?AI-Driven Lifestyle Monitoring? in Long-Term Care for Older Adults: Viewpoint JO - JMIR Nursing SP - e56474 VL - 7 KW - artificial intelligence KW - data KW - algorithm KW - nurse KW - nurses KW - health care professional KW - health care professionals KW - health professional KW - health professionals KW - health technology KW - digital health KW - smart home KW - smart homes KW - health monitoring KW - health promotion KW - aging in place KW - assisted living KW - ambient assisted living KW - aging KW - gerontology KW - geriatric KW - geriatrics KW - older adults KW - independent living KW - machine learning UR - https://nursing.jmir.org/2024/1/e56474 UR - http://dx.doi.org/10.2196/56474 UR - http://www.ncbi.nlm.nih.gov/pubmed/38781012 ID - info:doi/10.2196/56474 ER - TY - JOUR AU - Bruce, R. Courtenay AU - Klahn, Steve AU - Randle, Lindsay AU - Li, Xin AU - Sayali, Kelkar AU - Johnson, Barbara AU - Gomez, Melissa AU - Howard, Meagan AU - Schwartz, Roberta AU - Sasangohar, Farzan PY - 2024/4/4 TI - Impacts of an Acute Care Telenursing Program on Discharge, Patient Experience, and Nursing Experience: Retrospective Cohort Comparison Study JO - J Med Internet Res SP - e54330 VL - 26 KW - telenursing KW - telemedicine KW - patient discharge KW - health personnel KW - surveys and questionnaires KW - patient outcome assessment N2 - Background: Despite widespread growth of televisits and telemedicine, it is unclear how telenursing could be applied to augment nurse labor and support nursing. Objective: This study evaluated a large-scale acute care telenurse (ACTN) program to support web-based admission and discharge processes for hospitalized patients. Methods: A retrospective, observational cohort comparison was performed in a large academic hospital system (approximately 2100 beds) in Houston, Texas, comparing patients in our pilot units for the ACTN program (telenursing cohort) between June 15, 2022, and December 31, 2022, with patients who did not participate (nontelenursing cohort) in the same units and timeframe. We used a case mix index analysis to confirm comparable patient cases between groups. The outcomes investigated were patient experience, measured using the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHCPS) survey; nursing experience, measured by a web-based questionnaire with quantitative multiple-choice and qualitative open-ended questions; time of discharge during the day (from electronic health record data); and duration of discharge education processes. Results: Case mix index analysis found no significant case differences between cohorts (P=.75). For the first 4 units that rolled out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHCPS domains. Scores for ?communication with doctors? and ?would recommend hospital? were improved significantly (P=.03 and P=.04, respectively) in 1 unit in phase 1. The impact of telenursing in phases 2 and 3 was mixed. However, ?communication with doctors? was significantly improved in 2 units (P=.049 and P=.002), and the overall rating of the hospital and the ?would recommend hospital? scores were significantly improved in 1 unit (P=.02 and P=04, respectively). Of 289 nurses who were invited to participate in the survey, 106 completed the nursing experience survey (response rate 106/289, 36.7%). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program was very helpful or somewhat helpful to them as bedside nurses. The only noticeable difference between the telenursing and nontelenursing cohorts for the time of day discharge was a shift in the volume of patients discharged before 2 PM compared to those discharged after 2 PM at a hospital-wide level. The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and 29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was 13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice (nontelenursing cohort) of a bedside nurse engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation time study. Conclusions: This study shows that ACTN programs are feasible and associated with improved outcomes for patient and nursing experience and reducing time allocated to admission and discharge education. UR - https://www.jmir.org/2024/1/e54330 UR - http://dx.doi.org/10.2196/54330 UR - http://www.ncbi.nlm.nih.gov/pubmed/38573753 ID - info:doi/10.2196/54330 ER - TY - JOUR AU - Choi, Soyoung PY - 2023/9/20 TI - Personal Health Tracking: A Paradigm Shift in the Self-Care Models in Nursing JO - JMIR Nursing SP - e50991 VL - 6 KW - personal health data KW - personal informatics KW - self-care KW - self-tracking KW - mobile health technology KW - human-technology KW - human-computer KW - human computer interaction KW - health tracking KW - framework KW - frameworks KW - model KW - models KW - mHealth KW - mobile health KW - informatics UR - https://nursing.jmir.org/2023/1/e50991 UR - http://dx.doi.org/10.2196/50991 UR - http://www.ncbi.nlm.nih.gov/pubmed/37728970 ID - info:doi/10.2196/50991 ER - TY - JOUR AU - Ronquillo, Esteban Charlene AU - Dahinten, Susan V. AU - Bungay, Vicky AU - Currie, M. Leanne PY - 2023/8/25 TI - Differing Effects of Implementation Leadership Characteristics on Nurses? Use of mHealth Technologies in Clinical Practice: Cross-Sectional Survey Study JO - JMIR Nursing SP - e44435 VL - 6 KW - mobile health KW - mHealth applications KW - nursing KW - leadership KW - implementation science KW - nursing informatics N2 - Background: Leadership has been consistently identified as an important factor in shaping the uptake and use of mobile health (mHealth) technologies in nursing; however, the nature and scope of leadership remain poorly delineated. This lack of detail about what leadership entails limits the practical actions that can be taken by leaders to optimize the implementation and use of mHealth technologies among nurses working clinically. Objective: This study aimed to examine the effects of first-level leaders? implementation leadership characteristics on nurses? intention to use and actual use of mHealth technologies in practice while controlling for nurses? individual characteristics and the voluntariness of use, perceived usefulness, and perceived ease of use of mHealth technologies. Methods: A cross-sectional exploratory correlational survey study of registered nurses in Canada (n=288) was conducted between January 1, 2018, and June 30, 2018. Nurses were eligible to participate if they provided direct care in any setting and used employer-provided mHealth technologies in clinical practice. Hierarchical multiple regression analyses were conducted for the 2 outcome variables: intention to use and actual use. Results: The implementation leadership characteristics of first-level leaders influenced nurses? intention to use and actual use of mHealth technologies, with 2 moderating effects found. The final model for intention to use included the interaction term for implementation leadership characteristics and education, explaining 47% of the variance in nurses? intention to use mHealth in clinical practice (F10,228=20.14; P<.001). An examination of interaction plots found that implementation leadership characteristics had a greater influence on the intention to use mHealth technologies among nurses with a registered nurse diploma or a bachelor of nursing degree than among nurses with a graduate degree or other advanced education. For actual use, implementation leadership characteristics had a significant influence on the actual use of mHealth over and above the control variables (nurses? demographic characteristics, previous experience with mHealth, and voluntariness) and other known predictors (perceived usefulness and perceived ease of use) in the model without the implementation leadership � age interaction term (?=.22; P=.001) and in the final model that included the implementation leadership � age interaction term (?=?.53; P=.03). The final model explained 40% of the variance in nurses? actual use of mHealth in their work (F10,228=15.18; P<.001). An examination of interaction plots found that, for older nurses, implementation leadership characteristics had less of an influence on their actual use of mHealth technologies. Conclusions: Leaders responsible for the implementation of mHealth technologies need to assess and consider their implementation leadership behaviors because these play a role in influencing nurses? use of mHealth technologies. The education level and age of nurses may be important factors to consider because different groups may require different approaches to optimize their use of mHealth technologies in clinical practice. UR - https://nursing.jmir.org/2023/1/e44435 UR - http://dx.doi.org/10.2196/44435 UR - http://www.ncbi.nlm.nih.gov/pubmed/37624628 ID - info:doi/10.2196/44435 ER - TY - JOUR AU - Brown-Johnson, G. Cati AU - Lessios, Sophia Anna AU - Thomas, Samuel AU - Kim, Mirini AU - Fukaya, Eri AU - Wu, Siqi AU - Kling, R. Samantha M. AU - Brown, Gretchen AU - Winget, Marcy PY - 2023/8/23 TI - A Nurse-Led Care Delivery App and Telehealth System for Patients Requiring Wound Care: Mixed Methods Implementation and Evaluation Study JO - JMIR Form Res SP - e43258 VL - 7 KW - nursing KW - telehealth KW - telemedicine KW - follow-up KW - wound care KW - capacity building KW - mobile phone N2 - Background: Innovative solutions to nursing care are needed to address nurse, health system, patient, and caregiver concerns related to nursing wellness, work flexibility and control, workforce retention and pipeline, and access to patient care. One innovative approach includes a novel health care delivery model enabling nurse-led, off-hours wound care (PocketRN) to triage emergent concerns and provide additional patient health education via telehealth. Objective: This pilot study aimed to evaluate the implementation of PocketRN from the perspective of nurses and patients. Methods: Patients and part-time or per-diem, wound care?certified and generalist nurses were recruited through the Stanford Medicine Advanced Wound Care Center in 2021 and 2022. Qualitative data included semistructured interviews with nurses and patients and clinical documentation review. Quantitative data included app use and brief end-of-interaction in-app satisfaction surveys. Results: This pilot study suggests that an app-based nursing care delivery model is acceptable, clinically appropriate, and feasible. Low technology literacy had a modest effect on initial patient adoption; this barrier was addressed with built-in outreach and by simplifying the patient experience (eg, via phone instead of video calls). This approach was acceptable for users, despite total patient enrollment and use numbers being lower than anticipated (N=49; 17/49, 35% of patients used the app at least once beyond the orientation call). We interviewed 10 patients: 7 who had used the app were satisfied with it and reported that real-time advice after hours reduced anxiety, and 3 who had not used the app after enrollment reported having other resources for health care advice and noted their perception that this tool was meant for urgent issues, which did not occur for them. Interviewed nurses (n=10) appreciated working from home, and they reported comfort with the scope of practice and added quality of care facilitated by video capabilities; there was interest in additional wound care?specific training for nonspecialized nurses. Nurses were able to provide direct patient care over the web, including the few participating nurses who were unable to perform in-person care (n=2). Conclusions: This evaluation provides insights into the integration of technology into standard health care services, such as in-clinic wound care. Using in-system nurses with access to electronic medical records and specialized knowledge facilitated app integration and continuity of care. This care delivery model satisfied nurse desires for flexible and remote work and reduced patient anxiety, potentially reducing postoperative wound care complications. Feasibility was negatively impacted by patients? technology literacy and few language options; additional patient training, education, and language support are needed to support equitable access. Adoption was impacted by a lack of perceived need for additional care; lower-touch or higher-acuity settings with a longer wait between visits could be a better fit for this type of nurse-led care. UR - https://formative.jmir.org/2023/1/e43258 UR - http://dx.doi.org/10.2196/43258 UR - http://www.ncbi.nlm.nih.gov/pubmed/37610798 ID - info:doi/10.2196/43258 ER - TY - JOUR AU - Andersson, Susanne AU - Scandurra, Isabella AU - Nystr�m, Ulrika AU - Varemo, Marika AU - Hellstrand Tang, Ulla PY - 2023/7/18 TI - Experiences of a Novel Structured Foot Examination Form for Patients With Diabetes From the Perspective of Health Care Professionals: Qualitative Study JO - JMIR Nursing SP - e45501 VL - 6 KW - diabetes KW - foot ulcer KW - prevention KW - primary health care KW - qualitative research KW - structured foot examination KW - validation KW - user experiences KW - participatory design N2 - Background: Diabetes is a growing threat to public health, and secondary diseases like foot complications are common. Foot ulcers affect the individual?s quality of life and are a great cost to society. Regular foot examinations prevent foot ulcers and are a recommended approach both in Sweden and worldwide. Despite existing guidelines, there are differences in the execution of the foot examination, which results in care inequality. A structured foot examination form based on current guidelines was developed in this study as the first step toward digitalized support in the daily routine, and was validated by diabetes health care professionals. Objective: The study aimed to validate a structured foot examination form by assessing health care professionals? experiences of working with it ?foot side? when examining patients with diabetes. Methods: Semistructured interviews were held in a focus group and individually with 8 informants from different diabetes professions, who were interviewed regarding their experiences of working with the form in clinical practice. The users? data were analyzed inductively using qualitative content analysis. The study is part of a larger project entitled ?Optimised care of persons with diabetes and foot complications,? with V�stra G�taland Region as the responsible health care authority, where the results will be further developed. Results: Experiences of working with the form were that it simplified the foot examination by giving it an overview and a clear structure. Using the form made differences in work routines between individuals apparent. It was believed that implementing the form routinely would contribute to a more uniform execution. When patients had foot ulcers, the risk categories (established in guidelines) were perceived as contradictory. For example, there was uncertainty about the definition of chronic ulcers and callosities. The expectations were that the future digital format would simplify documentation and elucidate the foot examination, as well as contribute to the accessibility of updated and relevant data for all individuals concerned. Conclusions: The foot examination form works well as a support tool during preventive foot examination, creates a basis for decision-making, and could contribute to a uniform and safer foot examination with more care equality in agreement with current guidelines. Trial Registration: ClinicalTrials.gov NCT05692778; https://clinicaltrials.gov/ct2/show/NCT05692778 UR - https://nursing.jmir.org/2023/1/e45501 UR - http://dx.doi.org/10.2196/45501 UR - http://www.ncbi.nlm.nih.gov/pubmed/37463012 ID - info:doi/10.2196/45501 ER - TY - JOUR AU - Singh, Hardeep AU - Tang, Terence AU - Steele Gray, Carolyn AU - Kokorelias, Kristina AU - Thombs, Rachel AU - Plett, Donna AU - Heffernan, Matthew AU - Jarach, M. Carlotta AU - Armas, Alana AU - Law, Susan AU - Cunningham, V. Heather AU - Nie, Xin Jason AU - Ellen, E. Moriah AU - Thavorn, Kednapa AU - Nelson, LA Michelle PY - 2022/5/19 TI - Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review JO - JMIR Aging SP - e35929 VL - 5 IS - 2 KW - transitions KW - health KW - medical informatics KW - aged KW - mobile phone N2 - Background: Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions. Objective: To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions. Methods: This 2-phase rapid review involved a selective review of providers? roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults? hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1. Results: In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients? status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions. Conclusions: This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-045596 UR - https://aging.jmir.org/2022/2/e35929 UR - http://dx.doi.org/10.2196/35929 UR - http://www.ncbi.nlm.nih.gov/pubmed/35587874 ID - info:doi/10.2196/35929 ER - TY - JOUR AU - Calo, A. William AU - Francis, Erica AU - Kong, Lan AU - Hogentogler, Ruth AU - Heilbrunn, Emily AU - Fisher, Abbey AU - Hood, Nancy AU - Kraschnewski, Jennifer PY - 2022/5/13 TI - Implementing Infection Control and Quality of Life Best Practices in Nursing Homes With Project ECHO: Protocol for a Patient-Centered Randomized Controlled Trial JO - JMIR Res Protoc SP - e34480 VL - 11 IS - 5 KW - infection control KW - COVID-19 KW - nursing home KW - telementoring KW - Project ECHO KW - case-based learning KW - patient-centered outcome KW - RE-AIM KW - randomized controlled trial KW - implementation KW - quality of life KW - best practice KW - guideline KW - comparison KW - effectiveness KW - intervention N2 - Background: Nursing homes in the United States were devastated by COVID-19, with 710,000 cases and 138,000 deaths nationally through October 2021. Although facilities are required to have infection control staff, only 3% of designated infection preventionists have taken a basic infection control course prior to the COVID-19 pandemic. Most research has focused on infection control in the acute care setting. However, little is known about the implementation of infection control practices and effective interventions in nursing homes. This study utilizes Project ECHO (Extension for Community Health Outcomes), an evidence-based telementoring model, to connect Penn State University subject matter experts with nursing home staff and administrators to proactively support evidence-based infection control guideline implementation. Objective: Our study seeks to answer the research question of how evidence-based infection control guidelines can be implemented effectively in nursing homes, including comparing the effectiveness of two ECHO-delivered training interventions on key patient-centered outcomes such as reducing the number of residents with a COVID-19 diagnosis. Methods: A stratified cluster randomized design was utilized. Using a 1:1 ratio, we randomly assigned 136 nursing homes to ECHO or ECHO Plus arms. Randomization was stratified by geographic location, baseline COVID-19 infection rate, and facility capacity. The study had two phases. In phase one, completed in July 2021, nursing homes in both study arms received a 16-week infectious disease and quality improvement training intervention via real-time, interactive videoconferencing and the ECHO learning model. Phase one sessions were up to 90 minutes in duration. In phase two, completed in November 2021, the ECHO group was offered optional 60-minute office hours for 9 weeks and the ECHO Plus group received 9 weeks of 60-minute sessions on emerging topics and an additional 8-session refresher series on infection control. Results: A total of 290 nursing home facilities were assessed for eligibility, with 136 nursing homes recruited and randomly assigned to ECHO or ECHO Plus. Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will simultaneously evaluate the study?s effectiveness and implementation outcomes at baseline (intervention start date), and at 4, 6, 12, and 18 months. The primary outcome is the COVID-19 infection rate in nursing homes. Secondary outcomes include COVID-19 hospitalizations and deaths, flu-like illness, and quality of life. Surveys and interviews with participants will also provide data as to the adoption, implementation, and maintenance of best practices taught throughout ECHO sessions. Conclusions: A multipronged approach to improving infection control and emergency preparedness in nursing homes is important, given the toll that the COVID-19 pandemic has taken on residents and staff. The ECHO model has significant strengths when compared to traditional training, as it allows for remote learning delivered by a multidisciplinary team of experts, and utilizes case discussions that match the context and capacity of nursing homes. Trial Registration: ClinicalTrials.gov NCT04499391; https://clinicaltrials.gov/ct2/show/NCT04499391 UR - https://www.researchprotocols.org/2022/5/e34480 UR - http://dx.doi.org/10.2196/34480 UR - http://www.ncbi.nlm.nih.gov/pubmed/35476823 ID - info:doi/10.2196/34480 ER - TY - JOUR AU - Gordon, Kayleigh AU - Dainty, N. Katie AU - Steele Gray, Carolyn AU - DeLacy, Jane AU - Shah, Amika AU - Seto, Emily PY - 2022/4/28 TI - Normalizing Telemonitoring in Nurse-Led Care Models for Complex Chronic Patient Populations: Case Study JO - JMIR Nursing SP - e36346 VL - 5 IS - 1 KW - telemonitoring KW - TM KW - nurse practitioner KW - NP-led care KW - models of care KW - integrated care KW - disease care model KW - disease KW - nurse KW - nurse-led implementation KW - complex chronic conditions KW - CCC KW - clinical team KW - mobile phone N2 - Background: The implementation of telemonitoring (TM) has been successful in terms of the overall feasibility and adoption in single disease care models. However, a lack of available research focused on nurse-led implementations of TM that targets patients with multiple and complex chronic conditions (CCC) hinders the scale and spread to these patient populations. In particular, little is known about the clinical perspective on the implementation of TM for patients with CCC in outpatient care. Objective: This study aims to better understand the perspective of the clinical team (both frontline clinicians and those in administrative positions) on the implementation and normalization of TM for complex patients in a nurse-led clinic model. Methods: A pragmatic, 6-month implementation study was conducted to embed multicondition TM, including heart failure, hypertension, and diabetes, into an integrated nurse-led model of care. Throughout the study, clinical team members were observed, and a chart review was conducted of the care provided during this time. At the end of the study, clinical team members participated in qualitative interviews and completed the adapted Normalization Measure Development questionnaires. The Normalization Process Theory guided the deductive data analysis. Results: Overall, 9 team members participated in the study as part of a larger feasibility study of the TM program, of which 26 patients were enrolled. Team members had a shared understanding of the purpose and value of TM as an intervention embedded within their practice to meet the diverse needs of their patients with CCC. TM aligned well with existing chronic care practices in several ways, yet it changed the process of care delivery (ie, interactional workability subconstruct). Effective TM normalization in nurse-led care requires rethinking of clinical workflows to incorporate TM, relationship development between the clinicians and their patients, communication with the interdisciplinary team, and frequent clinical care oversight. This was captured well through the subconstructs of skill set workability, relational integration, and contextual integration of the Normalization Process Theory. Conclusions: Clinicians successfully adopted TM into their everyday practice such that some providers felt their role would be significantly and negatively affected without TM. This study demonstrated that smartphone-based TM systems complemented the routine and challenging clinical work caring for patients with CCC in an integrated nurse-led care model. UR - https://nursing.jmir.org/2022/1/e36346 UR - http://dx.doi.org/10.2196/36346 UR - http://www.ncbi.nlm.nih.gov/pubmed/35482375 ID - info:doi/10.2196/36346 ER - TY - JOUR AU - Beaus�jour, Waldo AU - Hagens, Simon PY - 2022/3/31 TI - Uncovering Important Drivers of the Increase in the Use of Virtual Care Technologies in Nursing Care: Quantitative Analysis From the 2020 National Survey of Canadian Nurses JO - JMIR Nursing SP - e33586 VL - 5 IS - 1 KW - adoption of virtual care KW - secure messaging KW - nurses KW - nursing KW - telehealth KW - telehomecare KW - telemonitoring KW - remote patient monitoring KW - virtual videoconferencing KW - uptake of virtual care N2 - Background: Canadian nurses are at the forefront of patient care delivery. Although the use of digital health technologies for care delivery is gaining momentum in Canada, nurses are encouraged to integrate virtual care into their practice. In early 2020, more Canadian nurses delivered care virtually compared with 3 years ago. Objective: This study seeks to uncover the professional characteristics of Canadian nurses accessing virtual care in 2020, understand how these characteristics differ across types of technologies, investigate whether the nurses accessing virtual care possess the skills and knowledge needed to use these technologies, and determine the important drivers of the uptake of virtual care observed in 2020. Methods: We used data from the 2017 and 2020 National Survey of Canadian Nurses. This survey collected data on the use of digital health technologies in nursing practice. It concerned regulated nursing professionals working in different health care settings and from different domains of nursing practice. We combined the chi-square independence test and logistic regression analysis to uncover the most relevant drivers of virtual care uptake by nurses in 2020. Results: In early 2020, before the declaration of the COVID-19 pandemic, nurses who delivered care virtually were predominantly nurse practitioners (135/159, 84.9%) and more likely to work in a primary or community care setting (202/367, 55%) and in an urban setting (194/313, 61.9%). Factors such as nursing designation (P<.001), perceived quality of care at the health facility where the nurses practiced (P<.001), and the type of patient record?keeping system they had access to (P=.04) had a statistically significant effect on the probability of nurses to deliver care virtually in early 2020. Furthermore, nurses? perception of the quality of care they delivered through virtual technologies was statistically associated with their perception of the skills (?24=308.7; P<.001) and knowledge (?24=283.4; P<.001) to use these technologies. Conclusions: This study emphasizes the critical importance of nursing designation, geographic location, and type of patient record?keeping system in predicting virtual care integration in nursing practice. The findings related to geographic location can be used by decision-makers for better allocation of digital health resources among care settings in rural and urban areas. Similarly, the disparities observed across nursing designations have some implications for the digital training of nurses at all levels of practice. Finally, the association between electronic medical record use and uptake of virtual care could accelerate the implementation of more modernized record-keeping systems in care settings. Hence, this could advance interoperability and improve health care delivery. UR - https://nursing.jmir.org/2022/1/e33586 UR - http://dx.doi.org/10.2196/33586 UR - http://www.ncbi.nlm.nih.gov/pubmed/35357326 ID - info:doi/10.2196/33586 ER - TY - JOUR AU - Pimentel, B. Camilla AU - Clark, Valerie AU - Baughman, W. Amy AU - Berlowitz, R. Dan AU - Davila, Heather AU - Mills, L. Whitney AU - Mohr, C. David AU - Sullivan, L. Jennifer AU - Hartmann, W. Christine PY - 2021/7/21 TI - Health Care Providers and the Public Reporting of Nursing Home Quality in the United States Department of Veterans Affairs: Protocol for a Mixed Methods Pilot Study JO - JMIR Res Protoc SP - e23516 VL - 10 IS - 7 KW - nursing homes KW - public reporting KW - quality N2 - Background: In June 2018, the United States Department of Veterans Affairs (VA) began the public reporting of its 134 Community Living Centers? (CLCs) overall quality by using a 5-star rating system based on data from the national quality measures captured in CLC Compare. Given the private sector?s positive experience with report cards, this is a seminal moment for stimulating measurable quality improvements in CLCs. However, the public reporting of CLC Compare data raises substantial and immediate implications for CLCs. The report cards, for example, facilitate comparisons between CLCs and community nursing homes in which CLCs generally fare worse. This may lead to staff anxiety and potentially unintended consequences. Additionally, CLC Compare is designed to spur improvement, yet the motivating aspects of the report cards are unknown. Understanding staff attitudes and early responses is a critical first step in building the capacity for public reporting to spur quality. Objective: We will adapt an existing community nursing home public reporting survey to reveal important leverage points and support CLCs? quality improvement efforts. Our work will be grounded in a conceptual framework of strategic orientation. We have 2 aims. First, we will qualitatively examine CLC staff reactions to CLC Compare. Second, we will adapt and expand upon an extant community nursing home survey to capture a broad range of responses and then pilot the adapted survey in CLCs. Methods: We will conduct interviews with staff at 3 CLCs (1 1-star CLC, 1 3-star CLC, and 1 5-star CLC) to identify staff actions taken in response to their CLCs? public data; staff?s commitment to or difficulties with using CLC Compare; and factors that motivate staff to improve CLC quality. We will integrate these findings with our conceptual framework to adapt and expand a community nursing home survey to the current CLC environment. We will conduct cognitive interviews with staff in 1 CLC to refine survey items. We will then pilot the survey in 6 CLCs (2 1-star CLCs, 2 3-star CLCs, and 2 5-star CLCs) to assess the survey?s feasibility, acceptability, and preliminary psychometric properties. Results: We will develop a brief survey for use in a future national administration to identify system-wide responses to CLC Compare; evaluate the impact of CLC Compare on veterans? clinical outcomes and satisfaction; and develop, test, and disseminate interventions to support the meaningful use of CLC Compare for quality improvement. Conclusions: The knowledge gained from this pilot study and from future work will help VA refine how CLC Compare is used, ensure that CLC staff understand and are motivated to use its quality data, and implement concrete actions to improve clinical quality. The products from this pilot study will also facilitate studies on the effects of public reporting in other critical VA clinical areas. International Registered Report Identifier (IRRID): DERR1-10.2196/23516 UR - https://www.researchprotocols.org/2021/7/e23516 UR - http://dx.doi.org/10.2196/23516 UR - http://www.ncbi.nlm.nih.gov/pubmed/34287218 ID - info:doi/10.2196/23516 ER - TY - JOUR AU - Jiang, Ying AU - Koh, Ling Karen Wei AU - Ramachandran, Joann Hadassah AU - Tay, Kian Yee AU - Wu, Xi Vivien AU - Shorey, Shefaly AU - Wang, Wenru PY - 2021/4/27 TI - Patients? Experiences of a Nurse-Led, Home-Based Heart Failure Self-management Program: Findings From a Qualitative Process Evaluation JO - J Med Internet Res SP - e28216 VL - 23 IS - 4 KW - self-care KW - psychosocial educational KW - nurse-led KW - mHealth KW - self-management KW - heart failure KW - process evaluation KW - nursing KW - mobile phone N2 - Background: Heart failure (HF) is a major public health problem that places a significant disease burden on society. Self-care is important in the management of HF because it averts disease progression and reduces the number of hospitalizations. Effective nursing interventions promote HF self-care. Objective: This study aims to explore participants? perspectives on a nurse-led, home-based heart failure self-management program (HOM-HEMP) in a randomized controlled trial conducted in Singapore to gain insight into the effectiveness of the study intervention. Methods: A descriptive, qualitative approach was used. English- or Chinese-speaking participants from the intervention arms were recruited through a purposive sampling method from January 2019 to July 2019. Individual, face-to-face, semistructured interviews were conducted with 11 participants. All interviews were audio recorded and transcribed verbatim, with the participant identifiers omitted to ensure confidentiality. The thematic analysis approach was used to identify, analyze, and report patterns (themes) within the data. Results: A total of six themes emerged from the process evaluation interviews and were categorized according to the Donabedian structure-process-outcome framework as intervention structure, intervention process, and intervention outcome. These six themes were manageability of the intervention, areas for improvement, benefits of visiting, personal accountability in self-care, empowered with knowledge and skills in self-care after the intervention, and increased self-efficacy in cardiac care. Conclusions: The findings of the process evaluation provided additional information on participants? perceptions and experiences with the HOM-HEMP intervention. Although a home visit may be perceived as resource intensive, it remains to be the preferred way of engagement for most patients. Nurses play an important role in promoting HF self-care. The process of interaction with the patient can be an important process for empowering self-care behavior changes. UR - https://www.jmir.org/2021/4/e28216 UR - http://dx.doi.org/10.2196/28216 UR - http://www.ncbi.nlm.nih.gov/pubmed/33904823 ID - info:doi/10.2196/28216 ER - TY - JOUR AU - Zolnoori, Maryam AU - McDonald, V. Margaret AU - Barr�n, Yolanda AU - Cato, Kenrick AU - Sockolow, Paulina AU - Sridharan, Sridevi AU - Onorato, Nicole AU - Bowles, Kathryn AU - Topaz, Maxim PY - 2021/1/22 TI - Improving Patient Prioritization During Hospital-Homecare Transition: Protocol for a Mixed Methods Study of a Clinical Decision Support Tool Implementation JO - JMIR Res Protoc SP - e20184 VL - 10 IS - 1 KW - clinical decision support system KW - homecare agencies KW - rehospitalization KW - RE-AIM framework KW - PREVENT KW - effective implementation N2 - Background: Homecare settings across the United States provide care to more than 5 million patients every year. About one in five homecare patients are rehospitalized during the homecare episode, with up to two-thirds of these rehospitalizations occurring within the first 2 weeks of services. Timely allocation of homecare services might prevent a significant portion of these rehospitalizations. The first homecare nursing visit is one of the most critical steps of the homecare episode. This visit includes an assessment of the patient?s capacity for self-care, medication reconciliation, an examination of the home environment, and a discussion regarding whether a caregiver is present. Hence, appropriate timing of the first visit is crucial, especially for patients with urgent health care needs. However, nurses often have limited and inaccurate information about incoming patients, and patient priority decisions vary significantly between nurses. We developed an innovative decision support tool called Priority for the First Nursing Visit Tool (PREVENT) to assist nurses in prioritizing patients in need of immediate first homecare nursing visits. Objective: This study aims to evaluate the effectiveness of the PREVENT tool on process and patient outcomes and to examine the reach, adoption, and implementation of PREVENT. Methods: Employing a pre-post design, survival analysis, and logistic regression with propensity score matching analysis, we will test the following hypotheses: compared with not using the tool in the preintervention phase, when homecare clinicians use the PREVENT tool, high-risk patients in the intervention phase will (1) receive more timely first homecare visits and (2) have decreased incidence of rehospitalization and have decreased emergency department use within 60 days. Reach, adoption, and implementation will be assessed using mixed methods including homecare admission staff interviews, think-aloud observations, and analysis of staffing and other relevant data. Results: The study research protocol was approved by the institutional review board in October 2019. PREVENT is currently being integrated into the electronic health records at the participating study sites. Data collection is planned to start in early 2021. Conclusions: Mixed methods will enable us to gain an in-depth understanding of the complex socio-technological aspects of the hospital to homecare transition. The results have the potential to (1) influence the standardization and individualization of nurse decision making through the use of cutting-edge technology and (2) improve patient outcomes in the understudied homecare setting. Trial Registration: ClinicalTrials.gov NCT04136951; https://clinicaltrials.gov/ct2/show/NCT04136951 International Registered Report Identifier (IRRID): PRR1-10.2196/20184 UR - https://www.researchprotocols.org/2021/1/e20184 UR - http://dx.doi.org/10.2196/20184 UR - http://www.ncbi.nlm.nih.gov/pubmed/33480855 ID - info:doi/10.2196/20184 ER - TY - JOUR AU - Buchanan, Christine AU - Howitt, Lyndsay M. AU - Wilson, Rita AU - Booth, G. Richard AU - Risling, Tracie AU - Bamford, Megan PY - 2020/12/17 TI - Predicted Influences of Artificial Intelligence on the Domains of Nursing: Scoping Review JO - JMIR Nursing SP - e23939 VL - 3 IS - 1 KW - nursing KW - artificial intelligence KW - machine learning KW - robotics KW - patient-centered care KW - review N2 - Background: Artificial intelligence (AI) is set to transform the health system, yet little research to date has explored its influence on nurses?the largest group of health professionals. Furthermore, there has been little discussion on how AI will influence the experience of person-centered compassionate care for patients, families, and caregivers. Objective: This review aims to summarize the extant literature on the emerging trends in health technologies powered by AI and their implications on the following domains of nursing: administration, clinical practice, policy, and research. This review summarizes the findings from 3 research questions, examining how these emerging trends might influence the roles and functions of nurses and compassionate nursing care over the next 10 years and beyond. Methods: Using an established scoping review methodology, MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central, Education Resources Information Center, Scopus, Web of Science, and ProQuest databases were searched. In addition to the electronic database searches, a targeted website search was performed to access relevant gray literature. Abstracts and full-text studies were independently screened by 2 reviewers using prespecified inclusion and exclusion criteria. Included articles focused on nursing and digital health technologies that incorporate AI. Data were charted using structured forms and narratively summarized. Results: A total of 131 articles were retrieved from the scoping review for the 3 research questions that were the focus of this manuscript (118 from database sources and 13 from targeted websites). Emerging AI technologies discussed in the review included predictive analytics, smart homes, virtual health care assistants, and robots. The results indicated that AI has already begun to influence nursing roles, workflows, and the nurse-patient relationship. In general, robots are not viewed as replacements for nurses. There is a consensus that health technologies powered by AI may have the potential to enhance nursing practice. Consequently, nurses must proactively define how person-centered compassionate care will be preserved in the age of AI. Conclusions: Nurses have a shared responsibility to influence decisions related to the integration of AI into the health system and to ensure that this change is introduced in a way that is ethical and aligns with core nursing values such as compassionate care. Furthermore, nurses must advocate for patient and nursing involvement in all aspects of the design, implementation, and evaluation of these technologies. International Registered Report Identifier (IRRID): RR2-10.2196/17490 UR - https://nursing.jmir.org/2020/1/e23939/ UR - http://dx.doi.org/10.2196/23939 UR - http://www.ncbi.nlm.nih.gov/pubmed/34406963 ID - info:doi/10.2196/23939 ER - TY - JOUR AU - Sutter, Rebecca AU - Cuellar, E. Alison AU - Harvey, Megan AU - Hong, Alicia Y. PY - 2020/12/1 TI - Academic Nurse-Managed Community Clinics Transitioning to Telehealth: Case Report on the Rapid Response to COVID-19 JO - JMIR Nursing SP - e24521 VL - 3 IS - 1 KW - telehealth KW - telemedicine KW - COVID-19, nurse practitioners KW - safety net clinics KW - community clinics KW - nurse KW - clinic KW - transition N2 - Background: In response to the COVID-19 pandemic, many health care organizations have adopted telehealth. The current literature on transitioning to telehealth has mostly been from large health care or specialty care organizations, with limited data from safety net or community clinics. Objective: This is a case report on the rapid implementation of a telehealth hub at an academic nurse-managed community clinic in response to the national COVID-19 emergency. We also identify factors of success and challenges associated with the transition to telehealth. Methods: This study was conducted at the George Mason University Mason and Partners clinic, which serves the dual mission of caring for community clinic patients and providing health professional education. We interviewed the leadership team of Mason and Partners clinics and summarized our findings. Results: Mason and Partners clinics reacted quickly to the COVID-19 crisis and transitioned to telehealth within 2 weeks of the statewide lockdown. Protocols were developed for a coordination hub, a main patient triage and appointment telephone line, a step-by-step flowchart of clinical procedure, and a team structure with clearly defined work roles and backups. The clinics were able to maintain most of its clinical service and health education functions while adapting to new clinic duties that arose during the pandemic. Conclusions: The experiences learned from the Mason and Partners clinics are transferable to other safety net clinics and academic nurse-led community clinics. The changes arising from the pandemic have resulted in sustainable procedures, and these changes will have a long-term impact on health care delivery and training. UR - https://nursing.jmir.org/2020/1/e24521/ UR - http://dx.doi.org/10.2196/24521 UR - http://www.ncbi.nlm.nih.gov/pubmed/33496682 ID - info:doi/10.2196/24521 ER - TY - JOUR AU - Saadatzi, Nasser Mohammad AU - Logsdon, Cynthia M. AU - Abubakar, Shamsudeen AU - Das, Sumit AU - Jankoski, Penelope AU - Mitchell, Heather AU - Chlebowy, Diane AU - Popa, O. Dan PY - 2020/11/12 TI - Acceptability of Using a Robotic Nursing Assistant in Health Care Environments: Experimental Pilot Study JO - J Med Internet Res SP - e17509 VL - 22 IS - 11 KW - robot-assisted healthcare KW - robotic nurse assistant KW - technology acceptance model KW - user acceptability KW - patient walking N2 - Background: According to the US Bureau of Labor Statistics, nurses will be the largest labor pool in the United States by 2022, and more than 1.1 million nursing positions have to be filled by then in order to avoid a nursing shortage. In addition, the incidence rate of musculoskeletal disorders in nurses is above average in comparison with other occupations. Robot-assisted health care has the potential to alleviate the nursing shortage by automating mundane and routine nursing tasks. Furthermore, robots in health care environments may assist with safe patient mobility and handling and may thereby reduce the likelihood of musculoskeletal disorders. Objective: This pilot study investigates the perceived ease of use and perceived usefulness (acceptability) of a customized service robot as determined by nursing students (as proxies for nursing staff in health care environments). This service robot, referred to as the Adaptive Robotic Nurse Assistant (ARNA), was developed to enhance the productivity of nurses through cooperation during physical tasks (eg, patient walking, item fetching, object delivery) as well as nonphysical tasks (eg, patient observation and feedback). This pilot study evaluated the acceptability of ARNA to provide ambulatory assistance to patients. Methods: We conducted a trial with 24 participants to collect data and address the following research question: Is the use of ARNA as an ambulatory assistive device for patients acceptable to nurses? The experiments were conducted in a simulated hospital environment. Nursing students (as proxies for nursing staff) were grouped in dyads, with one participant serving as a nurse and the other acting as a patient. Two questionnaires were developed and administrated to the participants based on the Technology Acceptance Model with respect to the two subscales of perceived usefulness and perceived ease of use metrics. In order to evaluate the internal consistency/reliability of the questionnaires, we calculated Cronbach alpha coefficients. Furthermore, statistical analyses were conducted to evaluate the relation of each variable in the questionnaires with the overall perceived usefulness and perceived ease of use metrics. Results: Both Cronbach alpha values were acceptably high (.93 and .82 for perceived usefulness and perceived ease of use questionnaires, respectively), indicating high internal consistency of the questionnaires. The correlation between the variables and the overall perceived usefulness and perceived ease of use metrics was moderate. The average perceived usefulness and perceived ease of use metrics among the participants were 4.13 and 5.42, respectively, out of possible score of 7, indicating a higher-than-average acceptability of this service robot. Conclusions: The results served to identify factors that could affect nurses? acceptance of ARNA and aspects needing improvement (eg, flexibility, ease of operation, and autonomy level). UR - http://www.jmir.org/2020/11/e17509/ UR - http://dx.doi.org/10.2196/17509 UR - http://www.ncbi.nlm.nih.gov/pubmed/33180024 ID - info:doi/10.2196/17509 ER - TY - JOUR AU - Davidson, Rosemary AU - Barrett, Ian David AU - Rixon, Lorna AU - Newman, Stanton AU - PY - 2020/10/9 TI - How the Integration of Telehealth and Coordinated Care Approaches Impact Health Care Service Organization Structure and Ethos: Mixed Methods Study JO - JMIR Nursing SP - e20282 VL - 3 IS - 1 KW - coordinated care KW - telehealth KW - health care organization KW - staff engagement KW - staff training N2 - Background: Coordinated care and telehealth services have the potential to deliver quality care to chronically ill patients. They can both reduce the economic burden of chronic care and maximize the delivery of clinical services. Such services require new behaviors, routines, and ways of working to improve health outcomes, administrative efficiency, cost-effectiveness, and user (patient and health professional) experience. Objective: The aim of this study was to assess how health care organization setup influences the perceptions and experience of service managers and frontline staff during the development and deployment of integrated care with and without telehealth. Methods: As part of a multinational project exploring the use of coordinated care and telehealth, questionnaires were sent to service managers and frontline practitioners. These questionnaires gathered quantitative and qualitative data related to organizational issues in the implementation of coordinated care and telehealth. Three analytical stages were followed: (1) preliminary analysis for a direct comparison of the responses of service managers and frontline staff to a range of organizational issues, (2) secondary analysis to establish statistically significant relationships between baseline and follow-up questionnaires, and (3) thematic analysis of free-text responses of service managers and frontline staff. Results: Both frontline practitioners and managers highlighted that training, tailored to the needs of different professional groups and staff grades, was a crucial element in the successful implementation of new services. Frontline staff were markedly less positive than managers in their views regarding the responsiveness of their organization and the pace of change. Conclusions: The data provide evidence that the setup of health care services is positively associated with outcomes in several areas, particularly tailored staff training, rewards for good service, staff satisfaction, and patient involvement. UR - https://nursing.jmir.org/2020/1/e20282/ UR - http://dx.doi.org/10.2196/20282 UR - http://www.ncbi.nlm.nih.gov/pubmed/34345792 ID - info:doi/10.2196/20282 ER - TY - JOUR AU - Gordon, Kayleigh AU - Dainty, N. Katie AU - Steele Gray, Carolyn AU - DeLacy, Jane AU - Shah, Amika AU - Resnick, Myles AU - Seto, Emily PY - 2020/9/29 TI - Experiences of Complex Patients With Telemonitoring in a Nurse-Led Model of Care: Multimethod Feasibility Study JO - JMIR Nursing SP - e22118 VL - 3 IS - 1 KW - telemonitoring KW - adherence KW - patient experience KW - complex patients KW - normalization process theory KW - implementation KW - mobile phone N2 - Background: Telemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCCs). Given the growing prevalence of complex patients, an evaluation of multi-condition TM is needed to expand TM interventions and tailor opportunities to manage complex chronic care needs. Objective: This study aims to evaluate the feasibility and patients? perceived usefulness of a multi-condition TM platform in a nurse-led model of care. Methods: A pragmatic, multimethod feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes. Patients were asked to take physiological readings at home via a smartphone-based TM app for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data were obtained through the TM system database. Patient questionnaires were administered, and patient interviews were conducted at the end of the study. An inductive analysis was performed, and codes were then mapped to the normalization process theory and Implementation Outcomes constructs by Proctor. Results: In total, 26 participants were recruited, 17 of whom used the TM app for 6 months. Qualitative interviews were conducted with 14 patients, and 8 patients were interviewed with their informal caregiver present. Patient adherence was high, with patients with HF taking readings on average 76.6% (141/184) of the days they were asked to use the system and patients with diabetes taking readings on average 72% (19/26) of the days. The HTN adherence rate was 55% (29/52) of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCCs. Conclusions: Multi-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCCs through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team. UR - https://nursing.jmir.org/2020/1/e22118/ UR - http://dx.doi.org/10.2196/22118 UR - http://www.ncbi.nlm.nih.gov/pubmed/34406972 ID - info:doi/10.2196/22118 ER - TY - JOUR AU - �berg, Ulrika AU - Orre, Johan Carl AU - H�rnsten, �sa AU - Jutterstr�m, Lena AU - Isaksson, Ulf PY - 2020/9/15 TI - Using the Self-Management Assessment Scale for Screening Support Needs in Type 2 Diabetes: Qualitative Study JO - JMIR Nursing SP - e16318 VL - 3 IS - 1 KW - eHealth KW - internet KW - type 2 diabetes KW - self-management KW - primary health care KW - qualitative research KW - nursing N2 - Background: Globally, most countries face a common challenge by moving toward a population-based structure with an increasing number of older people living with chronic conditions such as type 2 diabetes. This creates a considerable burden on health care services. The use of digital tools to tackle health care challenges established views on traditional nursing, based on face-to-face meetings. Self-management is considered a key component of chronic care and can be defined as management of the day-to-day impact of a condition, something that is often a lifelong task. The use of a screening instrument, such as the Self-Management Assessment Scale (SMASc), offers the potential to guide primary health care nurses into person-centered self-management support, which in turn can help people strengthen their empowerment and self-management capabilities. However, research on self-management screening instruments is sparse, and no research on nurses? experiences using a digitalized scale for measuring patients? needs for self-management support in primary health care settings has been found. Objective: This paper describes diabetes specialist nurses? (DSNs) experiences of a pilot implementation of the SMASc instrument as the basis for person-centered digital self-management support. Methods: This qualitative study is based on observations and interviews analyzed using qualitative content analysis. Results: From the perspectives of DSNs, the SMASc instrument offers insights that contribute to strengthened self-management support for people with type 2 diabetes by providing a new way of thinking and acting on the patient?s term. Furthermore, the SMASc was seen as a screening instrument with good potential that embraces more than medical issues; it contributed to strengthening person-centered self-management support, and the instrument was considered to lead both parts, that is, DSNs and patients, to develop together through collaboration. Conclusions: Person-centered care is advocated as a model for good clinical practice; however, this is not always complied with. Screening instruments, such as the SMASc, may empower both nurses and patients with type 2 diabetes with more personalized care. Using a screening instrument in a patient meeting may also contribute to a role change in the work and practice of DSNs. UR - https://nursing.jmir.org/2020/1/e16318/ UR - http://dx.doi.org/10.2196/16318 UR - http://www.ncbi.nlm.nih.gov/pubmed/34345780 ID - info:doi/10.2196/16318 ER - TY - JOUR AU - Stratton, B. Delaney AU - Shea, D. Kimberly AU - Knight, P. Elizabeth AU - Loescher, J. Lois PY - 2020/7/27 TI - Delivering Clinical Skin Examination Education to Nurse Practitioners Using an Internet-Based, Microlearning Approach: Development and Feasibility of a Video Intervention JO - JMIR Dermatol SP - e16714 VL - 3 IS - 1 KW - microlearning KW - clinical skin examination KW - primary care KW - nurse practitioners KW - melanoma KW - skin cancer N2 - Background: Skin cancer is the most common cancer; survival of the most serious skin cancers and malignant melanomas depends on early detection. Early detection relies on accessibility to clinical skin examination (CSE). Primary care nurse practitioners (PCNPs) are well-positioned to conduct CSEs; however, they require further education on CSE and have time constraints for continuing education. A digitally delivered intervention grounded in microlearning is a promising approach to deliver new information over a brief period. Objective: Our objective was to develop and explore the feasibility of implementing a 1-week digital video intervention with content on CSE skills, defined as melanoma risk assessment, head-to-toe skin examination, and pigmented lesion assessment, for PCNPs. Specific aims were as follows: (1) Aim 1: to develop three microlearning-based melanoma videos with content on CSE that are suitable for digital delivery to PCNPs in various formats and (2) Aim 2: to assess the feasibility of the video intervention, including enrollment and retention rates, adherence, and acceptability and usability of the video intervention. Methods: For Aim 1, the research team created storyboards for videos that addressed each CSE skill. An expert panel of three dermatologists reviewed the storyboards and videos for relevance, comprehension, and clarity using the content validity index (CVI). The panel evaluated the usability of the video intervention delivery by Research Electronic Data Capture (REDCap) and Vimeo using the System Usability Scale (SUS) and technical video production using Beaudin and Quick?s Quality Evaluation of Video (QEV). Aim 2 evaluated enrollment and retention rates of PCNPs, based on metrics from previous studies of CSE in the literature, and video intervention adherence. SUS and the Attitudes toward Web-based Continuing Learning Survey (AWCL) assessed usability and acceptability. Results: CVI scores indicated relevance and clarity for each video: mean scores ranged from 3.79 to 4, where 4 indicated the video was highly relevant and very clear. The integration of REDCap and Vimeo was usable: the SUS score was 96, where 0 was the worst and 100 was the best. The digital delivery of the videos was rated as exceptional on all five technical items: the mean score was 5, where scores ranged from 1 (poor) to 5 (exceptional). Of the 32 PCNPs who were sent emails, 12 enrolled (38%) and, out of these 12, 10 (83%) completed the intervention and the surveys. Video intervention adherence was ?50%. Participants rated the usability as better (mean 85.8, SD 10.6; better=70-90) and favorably ranked the acceptability of the AWCL?s constructs of perceived usefulness (mean 5.26, SD 0.08), perceived ease of use (mean 5.40, SD 0.41), behavior (mean 5.53, SD 0.12), and affection (mean 5.77, SD 0.04), where scores ranged from 1 (strongly disagree) to 7 (strongly agree). Conclusions: The video intervention was feasible to deliver to PCNPs using a digital, microlearning approach. The findings provide support for using the videos as an intervention in a future pilot randomized trial targeting behavioral CSE outcomes among PCNPs and other primary care providers. UR - http://derma.jmir.org/2020/1/e16714/ UR - http://dx.doi.org/10.2196/16714 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/16714 ER - TY - JOUR AU - Schweitzer, Marco AU - Huber, Lukas AU - Gorfer, Thilo AU - H�rbst, Alexander PY - 2020/4/23 TI - Experiences With Developing and Using Vital Sign Telemonitoring to Support Mobile Nursing in Rural Regions: Feasibility and Usability Study JO - JMIR Nursing SP - e17113 VL - 3 IS - 1 KW - mobile health KW - telemedicine KW - vital signs KW - health monitoring KW - mobile nursing N2 - Background: Modern information and communication technology has the potential to support mobile care in rural regions such as the Alpine region, which is characterized by long distances or even physically unreachable areas. Objective: This study investigated the potential of supporting mobile nursing organizations in rural regions with the use of mobile telemonitoring systems in a case study setting. Methods: As a subproject of the European Union?funded project INTESI, the VITAl parameter MOnitoring (VITAMO) project gathered stakeholders? requirements for telemonitoring support of mobile care in rural regions and then developed and implemented a prototype system that was used for a 3-month test period with a local nursing organization in Austria. Log analysis, surveys, and interviews were used to evaluate the system according to the Technology Acceptance Model. The focus was technology assessment and user satisfaction of both patients and nurses. Results: Participants were provided Bluetooth devices to measure blood pressure, body weight, and blood glucose and to track activity. They also received a tablet with a mobile internet connection to see the results. The nurses were able to access the results remotely. Regularly executed speed tests and log analysis demonstrated the availability of high-speed mobile internet in the rural test region. Log analysis, surveys, and interviews revealed the suitability of the technology environment and showed that the system was easy to use and potentially useful. The perceived usefulness for supporting mobile care was rated meaningfully low, and the frequency of nurses using the tool declined continuously over the field test period. Further group discussions investigated this issue. Conclusions: While the technology environment with mobile internet, Bluetooth devices, and smart vital sign monitoring devices was adequate and suitable to support mobile nursing in rural regions, the potential benefit for the nursing organization could not be confirmed. Further analysis revealed that operational care processes did not follow a well-defined care strategy. Technology has the potential to leverage the available environment for developing meaningful solutions. These experiences could contribute to further investigations that need to identify and analyze existing mobile care processes at an organizational level. UR - https://nursing.jmir.org/2020/1/e17113/ UR - http://dx.doi.org/10.2196/17113 UR - http://www.ncbi.nlm.nih.gov/pubmed/34345782 ID - info:doi/10.2196/17113 ER - TY - JOUR AU - Boucher, Carole Marie AU - Nguyen, Duc Michael Trong AU - Qian, Jenny PY - 2020/4/7 TI - Assessment of Training Outcomes of Nurse Readers for Diabetic Retinopathy Telescreening: Validation Study JO - JMIR Diabetes SP - e17309 VL - 5 IS - 2 KW - training KW - teleophthalmology KW - telemedicine KW - diabetic retinopathy KW - screening KW - referral KW - nurse N2 - Background: With the high prevalence of diabetic retinopathy and its significant visual consequences if untreated, timely identification and management of diabetic retinopathy is essential. Teleophthalmology programs have assisted in screening a large number of individuals at risk for vision loss from diabetic retinopathy. Training nonophthalmological readers to assess remote fundus images for diabetic retinopathy may further improve the efficiency of such programs. Objective: This study aimed to evaluate the performance, safety implications, and progress of 2 ophthalmology nurses trained to read and assess diabetic retinopathy fundus images within a hospital diabetic retinopathy telescreening program. Methods: In this retrospective interobserver study, 2 ophthalmology nurses followed a specific training program within a hospital diabetic retinopathy telescreening program and were trained to assess diabetic retinopathy images at 2 levels of intervention: detection of diabetic retinopathy (level 1) and identification of referable disease (level 2). The reliability of the assessment by level 1?trained readers in 266 patients and of the identification of patients at risk of vision loss from diabetic retinopathy by level 2?trained readers in 559 more patients were measured. The learning curve, sensitivity, and specificity of the readings were evaluated using a group consensus gold standard. Results: An almost perfect agreement was measured in identifying the presence of diabetic retinopathy in both level 1 readers (?=0.86 and 0.80) and in identifying referable diabetic retinopathy by level 2 readers (?=0.80 and 0.83). At least substantial agreement was measured in the level 2 readers for macular edema (?=0.79 and 0.88) for all eyes. Good screening threshold sensitivities and specificities were obtained for all level readers, with sensitivities of 90.6% and 96.9% and specificities of 95.1% and 85.1% for level 1 readers (readers A and B) and with sensitivities of 86.8% and 91.2% and specificities of 91.7% and 97.0% for level 2 readers (readers A and B). This performance was achieved immediately after training and remained stable throughout the study. Conclusions: Notwithstanding the small number of trained readers, this study validates the screening performance of level 1 and level 2 diabetic retinopathy readers within this training program, emphasizing practical experience, and allows the establishment of an ongoing assessment clinic. This highlights the importance of supervised, hands-on experience and may help set parameters to further calibrate the training of diabetic retinopathy readers for safe screening programs. UR - https://diabetes.jmir.org/2020/2/e17309 UR - http://dx.doi.org/10.2196/17309 UR - http://www.ncbi.nlm.nih.gov/pubmed/32255431 ID - info:doi/10.2196/17309 ER - TY - JOUR AU - Wong, Kin Man AU - Cheng, Ronald Sai Yip AU - Chu, Kit Tsun AU - Lam, Yee Fung AU - Lai, Kee Shiu AU - Wong, Chung Kai AU - Liang, Jun PY - 2020/3/31 TI - Impact of Motivational Interviewing on Self-Management in Patients With Type 2 Diabetes: Protocol for a Pilot Randomized Controlled Trial JO - JMIR Res Protoc SP - e15709 VL - 9 IS - 3 KW - motivational interviewing KW - diabetes KW - nurse KW - usual care KW - self-management KW - self-care N2 - Background: The nonpharmacological approach to diabetic control in patients with diabetes focuses on a healthy diet, physical activity, and self-management. Therefore, to help patients change their habits, it is essential to identify the most effective approach. Many efforts have been devoted to explain changes in or adherence to specific health behaviors. Such efforts have resulted in the development of theories that have been applied in prevention campaigns and include brief advice and counseling services. Within this context, motivational interviewing (MI) has proven to be effective in changing health behaviors for specific cases. However, stronger evidence is needed on the effectiveness of MI in treating chronic pathologies such as diabetes. Objective: This study will obtain preliminary data on the impact of a nurse-led MI intervention in improving glycemic control, as well as clinical, psychosocial, and self-care outcomes for individuals with type 2 diabetes mellitus when compared with usual care, with the aim of improving diabetic control in patients with diabetes. Methods: An open, two-arm, parallel, randomized controlled, pilot exploratory trial will be performed. Two government outpatient clinics in the New Territories West Cluster in Hong Kong will be involved. In total, 20 to 25 participants will be invited in each arm. Intervention participants will receive face-to-face MI interventions in addition to their usual care from the clinic. Control participants will only receive usual care. Outcomes are assessed at baseline, 6 months, and 12 months. The primary outcome measure is glycated hemoglobin levels. Secondary outcomes include blood pressure, BMI, hip and waist circumference, fasting blood, and psychosocial and self-care measures. Results: This study is currently underway with funding support from the Hong Kong College of Family Physician Research Seed Fund 2017. Conclusions: MI skills constitute the main strategies primary care nurses use on their patients. Having economical, simple, effective, and applicable techniques is essential for primary care professionals to help their patients change their lifestyle and improve their health. This study will provide scientific evidence on the effectiveness of MI. It will be performed with strict control over the data collection, ensuring the maintenance of therapeutic integrity. Trial Registration: Centre for Clinical Research and Biostatistics CUHK_CCRB00614; https://tinyurl.com/v9awzk6 International Registered Report Identifier (IRRID): DERR1-10.2196/15709 UR - http://www.researchprotocols.org/2020/3/e15709/ UR - http://dx.doi.org/10.2196/15709 UR - http://www.ncbi.nlm.nih.gov/pubmed/32229475 ID - info:doi/10.2196/15709 ER - TY - JOUR AU - Gordon, Kayleigh AU - Steele Gray, Carolyn AU - Dainty, N. Katie AU - DeLacy, Jane AU - Ware, Patrick AU - Seto, Emily PY - 2020/3/6 TI - Exploring an Innovative Care Model and Telemonitoring for the Management of Patients With Complex Chronic Needs: Qualitative Description Study JO - JMIR Nursing SP - e15691 VL - 3 IS - 1 KW - models of care KW - complex patients KW - multimorbidity KW - telemonitoring N2 - Background: The growing number of patients with complex chronic conditions presents an urgent challenge across the Canadian health care system. Current care delivery models are overburdened, struggling to monitor and stabilize the complex needs of this growing patient population. Objective: This qualitative study aimed to explore the needs and perspectives of patients and members of the care team to inform the development of an innovative integrated model of care and the needs of telemonitoring (TM) for patients with complex chronic conditions. Furthermore, we explored how these needs could be successfully embedded to support this novel model of complex chronic care. Methods: A qualitative description design was utilized to conduct and analyze 29 semistructured interviews with patients (n=16) and care team members (CTM) (n=13) involved in developing the model of care in an ambulatory care facility in Southern Ontario. Participants were identified through purposive sampling. Two researchers performed an iterative thematic analysis using NVivo 12 (QSR International; Melbourne, Australia) to gain insights from examining multiple perspectives of different participants on complex chronic care needs. Results: The analysis revealed 3 themes and 13 subthemes, including the following: (1) adequate health care delivery remains challenging for patients with complex care needs, (2) insights into how to structure an integrated care model, and (3) opportunities for TM in an integrated model of care. Participants not only identified continued challenges in accessing and navigating care in a fragmented and disconnected delivery system but also identified the need for more self-management support. Patients and CTM described the structure of an integrated model of care, including the need for a clear referral and triage processes and composing a tight-knit circle of collaborating interdisciplinary providers led by a nurse practitioner (NP). Finally, opportunities for TM in an integrated model of care were identified, including increasing access and communication, the ability to monitor specific signs and symptoms, and building a clinical workflow around TM-enabled care. Conclusions: Despite entrenched health care service delivery models, a new model of care is acutely needed to care for patients with complex chronic needs (CCN). NPs are in a unique position to lead TM-enabled integrated models of care. TM can facilitate frequent and necessary monitoring of patients with CCN with more than one condition in integrated models of care. UR - https://nursing.jmir.org/2020/1/e15691/ UR - http://dx.doi.org/10.2196/15691 UR - http://www.ncbi.nlm.nih.gov/pubmed/34345777 ID - info:doi/10.2196/15691 ER -