Technology-Related Safety Event Analysis in Community Clinical Informatics: A Case Study.

This case study presents a process that was iteratively developed for clinical informaticians to identify, analyse, and respond to safety events related to health information technologies (HIT) in community care settings (This research was supported by the CIHR Health Systems Impact Fellowship Program. We would also like to thank Vancouver Coastal Health for their valuable contributions.). The goal was to build capacity within a clinical informatics team to integrate patient safety into their work and to help them recognize and respond to HIT-related safety events. The technology-related safety event analysis process that was ultimately developed included three key components: 1) an internal workflow to analyse voluntarily reported HIT-related safety events using a sociotechnical model, 2) safety huddles to amplify learnings from reviewed events, and 3) a cumulative analysis of all events over time to identify and respond to patterns. A systematic approach to quickly identify and understand HIT safety concerns enables informatics teams to proactively reduce risks and prevent harm.

Supporting Clinical Informatics Competency Development Among the Clinical Informatics Team at Providence Health Care.

Clinical informatics (CI) competencies are crucial for health care organizations to effectively use information communication technologies (ICTs) and deliver quality care. An interdisciplinary CI team can assist organizations with leveraging ICTs, but may also require support. This case study describes a peer-led knowledge translation project designed, delivered and implemented over two years by members of the CI team at Providence Health Care (PHC). The project included CI competencies assessment of CI team members, followed by tailored education for identified knowledge gaps. The Kirkpatrick evaluation model was used to assess three levels of learning among CI team members, including a satisfaction survey, pre-and post-cognitive retention of the education intervention using a validated tool for informatics specialists, and project partner feedback of CI team performance 12 weeks after education completion. This case study provides evidence-informed guidance on 'how to' implement peer-led, practice-based CI training for CI teams.

Technology-Related Safety Events in Primary and Community Care Settings: A Scoping Review.

This scoping review assesses the current knowledge on technology-related safety events in primary and community care settings, focusing on patient safety and harm. Utilizing Arksey and O'Malley's methodological framework, a comprehensive literature search was conducted across various databases, yielding 17 relevant articles. The review highlighted predominant safety event issues, such as technology limitations, incorrect data, and software malfunctions, and identified essential risk mitigation strategies. Consultation with healthcare leaders reinforced these findings and revealed additional organizational challenges, emphasizing the need for continuous monitoring, reporting, and analyzing of HIT-related safety concerns. The findings suggest that while safety events in non-acute settings share similarities with those in acute care, they require specific attention and further research.

Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation.

BACKGROUND: In Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of Saskatchewan. OBJECTIVES: The aim of the project was to conduct a resident-oriented realist evaluation of an innovative supportive housing programme, Sanctum, for people living with HIV/AIDS who also face social care issues, such as homelessness. This project took place in Saskatchewan, a province that is seeking innovative approaches to improve quality of life and HIV/AIDS management for its citizens. Our evaluation addressed how and why participants were successful (or not) within the Sanctum programme. DESIGN AND SETTING: Sanctum is a housing programme located in an inner-city location within the province of Saskatchewan. A unique component of this evaluation was the inclusion of an individual with lived experience, a resident partner, as a member of the research team. PARTICIPANTS: 11 recent Sanctum graduates, seven men and four women, were recruited for client partner-led in-depth, semistructured interviews. INTERVENTIONS: Prior to the evaluation, we developed a realist programme theory with potential causal explanations, known as context-mechanism-outcomes (CMO) configurations. Interview data from the evaluation and ongoing discussions with Sanctum board members and our resident partner were used to test, refine and validate the final programme theory and CMO configurations. RESULTS: CMO configurations at the micro (individual), meso (interpersonal) and macro (community) levels complement the over-arching programme theory. Key findings were the importance of Sanctum's harm reduction philosophy, accompanied by a non-judgmental and patient-oriented approach. Participants were supported to reduce risky behaviour, improve self-care management and develop healthier relationships within a 'safe' home-like setting. Underlying mechanisms that contributed to participants' success in the programme included: intrinsic motivation, self-worth, belongingness, empowerment and self-efficacy. Evidence-informed recommendations are offered to support Sanctum-like programme development for individuals with holistic health needs related to HIV/AIDS diagnoses and lack of access to necessary social determinants of health. CONCLUSIONS: Stigma associated with HIV/AIDS and living circumstances, such as homelessness, were successfully addressed using harm reduction principles and judgement-free approaches within a family-like environment.

Effects of workplace incivility and workload on nurses' work attitude: The mediating effect of burnout.

AIM: The study's aim was to examine how workplace incivility and workload influence nurses' work attitudes (turnover intention, job satisfaction, and organizational commitment) using the stress-strain-outcome framework. BACKGROUND: There is a lack of comprehensive research on the combined effects of workplace incivility and workload on nurses' work attitudes. INTRODUCTION: Two workplace stressors, incivility and workload, were hypothesized to lead to burnout, which in turn influences nurses' work attitudes. METHODS: A cross-sectional, descriptive correlational study was conducted. Survey data were collected from 1,255 direct care nurses with a minimum of 6 months' nursing experiences in 34 general hospitals across Korea. Structural equation modeling was used to test the hypothesized model. This study is reported using the STROBE checklist. RESULTS: As hypothesized, both workplace incivility and workload increased burnout. Heightened burnout correlated with increased turnover intention, lowered job satisfaction, and reduced organizational commitment. While workplace incivility impacted these outcomes both directly and indirectly via its effect on burnout, workload influenced the outcomes solely through burnout. CONCLUSION: The study's findings are based on one, nonrandomized sample of nurses working at South Korean hospitals. Despite such study limitations, the study findings support the adverse impact of two workplace stressors on burnout and nurses' work attitudes. IMPLICATIONS FOR NURSING: Evidence-informed interventions for both workplace stressors include training programs, clear policy guidelines, open communication channels, and supportive work environments. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Zero tolerance and equity, diversity and inclusivity policies to promote workplace civility must be enforced. Workload needs to be patient-centered, ensuring a "fit" between patient needs and nurse staffing.

Utilizing Experience Bundles: A Novel Approach to Improving Quality of Care in Long-Term Care.

People-centred care is foundational to healthcare excellence. One urban Canadian long-term care residence recently participated in an initiative titled "Improving the Care Conference Experience" to engage residents and families in annual care conferences. The Institute for Healthcare Improvement introduced "care bundles" to group evidence-based practices within standard processes. For this initiative, one health region's Experience in Care team co-developed, implemented and evaluated an "experience bundle" for inclusive care conferences with key stakeholders including residents, family members, direct care providers and leadership. Our ongoing goal is to collaboratively create a culture shift from "doing to/for" to "doing with."

Clinical Informatics Team Members' Perspectives on Health Information Technology Safety After Experiential Learning and Safety Process Development: Qualitative Descriptive Study.

BACKGROUND: Although intended to support improvement, the rapid adoption and evolution of technologies in health care can also bring about unintended consequences related to safety. In this project, an embedded researcher with expertise in patient safety and clinical education worked with a clinical informatics team to examine safety and harm related to health information technologies (HITs) in primary and community care settings. The clinical informatics team participated in learning activities around relevant topics (eg, human factors, high reliability organizations, and sociotechnical systems) and cocreated a process to address safety events related to technology (ie, safety huddles and sociotechnical analysis of safety events). OBJECTIVE: This study aimed to explore clinical informaticians' experiences of incorporating safety practices into their work. METHODS: We used a qualitative descriptive design and conducted web-based focus groups with clinical informaticians. Thematic analysis was used to analyze the data. RESULTS: A total of 10 informants participated. Barriers to addressing safety and harm in their context included limited prior knowledge of HIT safety, previous assumptions and perspectives, competing priorities and organizational barriers, difficulty with the reporting system and processes, and a limited number of reports for learning. Enablers to promoting safety and mitigating harm included participating in learning sessions, gaining experience analyzing reported events, participating in safety huddles, and role modeling and leadership from the embedded researcher. Individual outcomes included increased ownership and interest in HIT safety, the development of a sociotechnical systems perspective, thinking differently about safety, and increased consideration for user perspectives. Team outcomes included enhanced communication within the team, using safety events to inform future work and strategic planning, and an overall promotion of a culture of safety. CONCLUSIONS: As HITs are integrated into care delivery, it is important for clinical informaticians to recognize the risks related to safety. Experiential learning activities, including reviewing safety event reports and participating in safety huddles, were identified as particularly impactful. An HIT safety learning initiative is a feasible approach for clinical informaticians to become more knowledgeable and engaged in HIT safety issues in their work.

A realist review of medication optimisation of community dwelling service users with serious mental illness.

BACKGROUND: Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI. OBJECTIVE: Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community? METHODS: A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations. RESULTS: Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation. CONCLUSIONS: Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers. PROSPERO REGISTRATION NUMBER: CRD42021280980.

Long COVID in long-term care: a rapid realist review.

OBJECTIVES: The goals of this rapid realist review were to ask: (a) what are the key mechanisms that drive successful interventions for long COVID in long-term care (LTC) and (b) what are the critical contexts that determine whether the mechanisms produce the intended outcomes? DESIGN: Rapid realist review. DATA SOURCES: Medline, CINAHL, Embase, PsycINFO and Web of Science for peer-reviewed literature and Google for grey literature were searched up to 23 February 2023. ELIGIBILITY CRITERIA: We included sources focused on interventions, persons in LTC, long COVID or post-acute phase at least 4 weeks following initial COVID-19 infection and ones that had a connection with source materials. DATA EXTRACTION AND SYNTHESIS: Three independent reviewers searched, screened and coded studies. Two independent moderators resolved conflicts. A data extraction tool organised relevant data into context-mechanism-outcome configurations using realist methodology. Twenty-one sources provided 51 intervention data excerpts used to develop our programme theory. Synthesised findings were presented to a reference group and expert panel for confirmatory purposes. RESULTS: Fifteen peer-reviewed articles and six grey literature sources were eligible for inclusion. Eleven context-mechanism-outcome configurations identify those contextual factors and underlying mechanisms associated with desired outcomes, such as clinical care processes and policies that ensure timely access to requisite resources for quality care delivery, and resident-centred assessments and care planning to address resident preferences and needs. The underlying mechanisms associated with enhanced outcomes for LTC long COVID survivors were: awareness, accountability, vigilance and empathetic listening. CONCLUSIONS: Although the LTC sector struggles with organisational capacity issues, they should be aware that comprehensively assessing and monitoring COVID-19 survivors and providing timely interventions to those with long COVID is imperative. This is due to the greater care needs of residents with long COVID, and coordinated efficient care is required to optimise their quality of life.

Characterization of Safety Events Involving Technology in Primary and Community Care.

BACKGROUND: The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings. OBJECTIVES: To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization. METHODS: Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event. RESULTS: Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions. CONCLUSION: Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.

Exploring the impact of evaluation on learning and health innovation sustainability: protocol for a realist synthesis.

BACKGROUND: Within the Learning Health System (LHS) model, learning routines, including evaluation, allow for continuous incremental change to take place. Within these learning routines, evaluation assists in problem identification, data collection, and data transformation into contextualized information, which is then re-applied to the LHS environment. Evaluation that catalyzes learning and improvement may also contribute to health innovation sustainability. However, there is little consensus as to why certain evaluations seem to support learning and sustainability, while others impede it. This realist synthesis seeks to understand the contextual factors and underlying mechanisms or drivers that best support health systems learning and sustainable innovation. METHODS: This synthesis will be guided by Pawson and colleagues' 2005 and Emmel and colleagues' 2018 guidelines for conducting realist syntheses. The review process will encompass five steps: (1) scoping the review, (2) building theories, (3) identifying the evidence, (4) evidence selection and appraisal, and (5) data extraction and synthesis. An Expert Committee comprised of leaders in evaluation, innovation, sustainability, and realist methodology will guide this synthesis. Review findings will be reported using the RAMESES guidelines. DISCUSSION: The use of a realist review will allow for exploration and theorizing about the contextual factors and underlying mechanisms that make evaluations 'work' (or 'not work') to support learning and sustainability. Depending on results, we will attempt to synthesize findings into a series of recommendations for evaluations with the intention to support health systems learning and sustainability. Finalized results will be presented at national and international conferences, as well as disseminated via a peer-reviewed publication. SYSTEMATIC REVIEW REGISTRATION: This realist synthesis protocol has been registered with PROSPERO ( https://www.crd.york.ac.uk/prospero/  ID 382690).

A Mixed Methods Study to Implement the Synergy Tool and Evaluate Its Impact on Long-Term Care Residents.

BACKGROUND: There are ongoing workforce challenges with the delivery of long-term care (LTC), such as staffing decisions based on arbitrary standards. The Synergy tool, a resident-centered approach to staffing, provides objective, real-time acuity and dependency scores (Synergy scores) for residents. The purpose of this study was to implement and evaluate the impact of the Synergy tool on LTC delivery. METHODS: A longitudinal mixed methods study took place within two publicly funded LTC homes in British Columbia, Canada. Quantitative data included weekly Synergy scores for residents (24 weeks), monthly aggregated resident falls data (18 months) and a six-month economic evaluation. Qualitative data were gathered from family caregivers and thematically analyzed. RESULTS: Quantitative findings from Synergy scores revealed considerable variability for resident acuity/dependency needs within and across units; and falls decreased during implementation. The six-month economic evaluation demonstrated some cost savings by comparing Synergy tool training and implementation costs with savings from resident fall rate reductions. Qualitative analyses yielded three positive impact themes (improved care delivery, better communication, and improved resident-family-staff relationships), and two negative structural themes (language barrier and staff shortages). CONCLUSIONS: The Synergy tool provides useful data for enhancing a 'fit' between resident needs and available staff.

Exploring the Impact of Storytelling for Hospitalized Patients Recovering from COVID-19.

There are mental and physical deficits associated with COVID-19 infection, particularly among individuals requiring hospitalization. Storytelling is a relational intervention that has been used to help patients make sense of their illness experiences and to share their experiences with others, including other patients, families and healthcare providers. Relational interventions strive to create positive, healing stories versus negative ones. In one urban acute care hospital, an initiative called the Patient Stories Project (PSP) uses storytelling as a relational intervention to promote patient healing, including the development of healthier relationships among themselves, with families and with healthcare providers. This qualitative study employed a series of interview questions that were collaboratively developed with patient partners and COVID-19 survivors. The questions asked consenting COVID-19 survivors about why they chose to tell their stories and to flesh out more about their recovery process. Thematic analyses of six participant interviews resulted in the identification of key themes along a COVID-19 recovery pathway. Patients' stories revealed how survivors progress from being overwhelmed by their symptoms to making sense of what is happening to them, providing feedback to their care providers, feeling gratitude for care received, becoming aware of a new state of normal, regaining control of their lives, and ultimately discovering meaning and an important lesson behind their illness experience. Our study's findings suggest that the PSP storytelling approach holds potential as a relational intervention to support COVID-19 survivors along a recovery journey. This study also adds knowledge about survivors beyond the first few months of recovery.

Priority Nursing Populations for Mental Health Support Before and During COVID-19: A Survey Study of Individual and Workplace Characteristics.

BACKGROUND: Nursing is a high-risk profession and nurses' exposure to workplace risk factors such as heavy workloads and inadequate staffing is well documented. The COVID-19 pandemic has exacerbated nurses' exposure to workplace risk factors, further deteriorating their mental health. Therefore, it is both timely and important to determine nursing groups in greatest need of mental health interventions and supports. PURPOSE: The purpose of this study is to provide a granular examination of the differences in nurse mental health across nurse demographic and workplace characteristics before and after COVID-19 was declared a pandemic. METHODS: This secondary analysis used survey data from two cross-sectional studies with samples (Time 1 study, 5,512 nurses; Time 2, 4,523) recruited from the nursing membership (∼48,000) of the British Columbia nurses' union. Data was analyzed at each timepoint using descriptive statistics and ordinal logistic regression. RESULTS: Several demographic and workplace characteristics were found to predict significant differences in the number of positive screenings on measures of poor mental health. Most importantly, in both survey times younger age was a strong predictor of worse mental health, as was full-time employment. Nurse workplace health authority was also a significant predictor of worse mental health. CONCLUSIONS: Structural and psychological strategies must be in place, proactively and preventively, to buffer nurses against workplace challenges that are likely to increase during the COVID-19 crisis.

Support interventions offered to family members of a child treated with hematopoietic stem cell transplant: A scoping review.

A scoping review was conducted to explore support interventions for family members of a child treated with hematopoietic stem cell transplant (HSCT). Three databases (CINAHL, Embase, and Medline) were searched to answer the review question: What are the support interventions offered to family members of a child treated with HSCT and are they based on a family-centred care approach? Out of 665 screened articles, nine were selected for full review. Findings revealed two main types of family-centred support interventions: psychological face-to-face and technology-based interventions. The majority of interventions assisted in improving family members' psychological well-being and included a portion of the core concepts from the Institute for Patient and Family-Centered Care Model in their approach. Based on the review findings, interventions that incorporate family-centred care concepts can enhance the psychological well-being and quality of life of family members whose child is undergoing HSCT treatment.

Unintended Consequences of Pandemic Management Strategies on Residents and Family in One Long-term Care Home in British Columbia: A Patient-Supported Qualitative Study.

Background and Objectives: In March 2020, pandemic management strategies were mandated across long-term care homes in British Columbia, Canada, to control the effects of COVID-19. This study describes and contextualizes the impact of visitation, infection prevention and control, and staffing strategies on the perceived health and well-being of residents and families. Research Design and Methods: This interpretive description study was part of a larger mixed-methods study at a publicly funded not-for-profit long-term care home in British Columbia, Canada. Eleven family members and 10 residents were interviewed between October and December 2020, and resident and family partners participated in a steering committee throughout all stages of the research. Findings: Early pandemic management strategies had an adverse impact on the perceived health and well-being of families and residents. Visitation restrictions eliminated care routinely provided by families and prevented in-person communication between residents, families, and care providers. Other infection prevention and control strategies isolated residents; group enrichment programs were stopped, and lockdowns created a perception of incarceration. Donning and doffing personal protective equipment took time away from staff-resident interactions and the single-site order reduced staff numbers, placing additional time restraints on residents' care. Discussion and Implications: Unintended adverse consequences of pandemic management strategies demonstrate the risks of creating policies based on a medicalized definition of health. Clear lines of communication are vital to increase a sense of control for families and residents. Elimination of care provided by families and paid companions exposed a gap in Canada's public long-term care system. This care gap raises concerns about equitable care access for residents without families or financial means to pay for additional care.

Implementing the Synergy Model: A Qualitative Descriptive Study.

Hospitals across our nation are seeking to implement models of care that meet the primary goals of Quadruple Aim: Improved population health, cost-effective care delivery, and patient and provider satisfaction. In an effort to address the Quadruple Aim and our patients' care needs, Hamilton Health Sciences (HHS) embarked on a model of care delivery redesign, beginning with nursing care delivery. From 2013 to 2018, 12 clinical programs at HHS implemented the Synergy Model with its accompanying synergy patient needs assessment tool for nurses to objectively assess patients' acuity and dependency needs. Data on patients' priority care needs were used to inform a nursing model of care redesign at HHS, including skill mix and staffing levels. This five-year project was an organization-wide quality improvement initiative. As part of the evaluation, HHS leaders partnered with health services nurse researchers to conduct a mixed methods study. This paper describes the evaluation outcomes from the qualitative component of the study, which included interviews with clinical nurse leaders and direct care nurses. Data were analyzed using descriptive thematic analysis. Some key findings were increased nurse awareness of patients' holistic care needs and leaders' capacity to plan staffing assignments based on patients' priority care needs. Themes helped inform recommendations for key stakeholders, including nurse leaders and direct care nurses.