Relationship between a risk score for QT interval prolongation and mortality across rural and urban inpatient facilities.

OBJECTIVES: To evaluate the relationship between a modified Tisdale QTc-risk score (QTc-RS) and inpatient mortality and length of stay in a broad inpatient population with an order for a medication with a known risk of torsades de pointes (TdP). BACKGROUND: Managing the risk of TdP is challenging due to the number of medications with known risk of TdP and the complexity of precipitating factors. A model to predict risk of mortality may be useful to guide treatment decisions. METHODS: This was a retrospective observational study using inpatient data from 28 healthcare facilities in the western United States. This risk score ranges from zero to 23 with weights applied to each risk factor based on a previous validation study. Logistic regression and a generalized linear model were performed to assess the relationship between QTc-RS and mortality and length of stay. RESULTS: Between April and December 2020, a QTc-RS was calculated for 92,383 hospitalized patients. Common risk factors were female (55.0%); age > 67 years (32.1%); and receiving a medication with known risk of TdP (24.5%). A total of 2770 (3%) patients died during their hospitalization. Relative to patients with QTc-RS < 7, the odds ratio for mortality was 4.80 (95%CI:4.42-5.21) for patients with QTc-RS = 7-10 and 11.51 (95%CI:10.23-12.94) for those with QTc-RS ≥ 11. Length of hospital stay increased by 0.7 day for every unit increase in the risk score (p < 0.0001). CONCLUSION: There is a strong relationship between increased mortality as well as longer duration of hospitalization with an increasing QTc-RS.

Prediction of GutCheck NEC and Its Relation to Severity of Illness and Measures of Deterioration in Necrotizing Enterocolitis.

BACKGROUND: Necrotizing enterocolitis (NEC) risk has been shown to arise from multiple sources and risk awareness may be supported using bedside tools. PURPOSE: The purpose of this research was to examine the extent to which GutCheck NEC was associated with scores for clinical deterioration, severity of illness, and clinical outcome, and further to examine how scores might improve NEC prediction. METHODS: A retrospective, correlational case-control study with infant data from 3 affiliated neonatal intensive care units was conducted. RESULTS: Of 132 infants (44 cases, 88 controls), most were 28 weeks of gestation at birth and less (74%). Median age at NEC onset was 18 days (range: 6-34 days), with two-thirds diagnosed before 21 days. At 68 hours of life, higher GutCheck NEC scores were associated with NEC requiring surgery or resulting in death (relative risk ratio [RRR] = 1.06, P = .036), associations that persisted at 24 hours prior to diagnosis (RRR = 1.05, P = .046), and at the time of diagnosis (RRR = 1.05, P = .022) but showed no associations for medical NEC. GutCheck NEC scores were significantly correlated with pediatric early warning scores (PEWS) ( r > 0.30; P < .005) and SNAPPE-II scores ( r > 0.44, P < .0001). Increasing numbers of clinical signs and symptoms were positively associated with GutCheck NEC and PEWS at the time of diagnosis ( r = 0.19, P = .026; and r = 0.25, P = .005, respectively). IMPLICATIONS FOR PRACTICE AND RESEARCH: GutCheck NEC provides structure to streamline assessment and communication about NEC risk. Yet, it is not intended to be diagnostic. Research is needed on how GutCheck NEC impacts timely recognition and treatment.

Prevalence and Characteristics of Hospital Nurse Leaders' Turnover Intention.

OBJECTIVE: This project aims to identify the prevalence of acute care nurse leader turnover intention and the contributing factors. BACKGROUND: Previous research has identified that nurse leaders often quit around 1 year after stepping into a leadership position. More in-depth investigations of the phenomenon are needed. METHODS: The 2018 National Sample Survey of Registered Nurses data were used in this quantitative, cross-sectional study. The sample of nurse leaders was drawn from survey participants. Characteristics of interest in this study were listed in the survey questionnaire and divided into 5 categories: education, primary nursing employment, race, marital status, and age. RESULTS: A total of 50 273 participants completed the survey. The final sample size of nurse leaders was 1310 based on the eligibility criteria. The characteristics of the nurse leaders with turnover intention were reported in the 5 previously identified categories. Age, federally assisted student loans, and hours worked in a typical week predicted turnover intention. Low dissatisfaction and ability to practice to the full extent of knowledge, education, and training were strongly associated with nurse leader turnover intention. CONCLUSIONS: The study findings contribute to a more in-depth discovery of the causes of nurse leader turnover and future interventional research.

A virtual dissemination framework to inform and evaluate a neonatal project ECHO (NeoECHO).

AIM: To present the development, implementation and evaluation of a theoretically grounded novel virtual dissemination evaluation (VDE) framework. BACKGROUND: Care of intensive care unit patients requires access to the most up-to-date knowledge and best practices. To address this challenge, we present the development, implementation and evaluation of a theoretically grounded novel VDE framework. This framework is applied to a dissemination strategy, NeoECHO, in neonatal intensive care units. Evidence-based virtual education is implemented to prevent, detect and treat necrotizing enterocolitis in neonates. DESIGN: Research Methodology: Discussion Paper-Methodology. METHODS: The virtual dissemination evaluation framework is a sequential combination of Integration of Integrated-Promoting Action on Research Implementation in Health Services and Moore's Expanded Outcomes frameworks. The framework's conceptual determinants, virtual facilitators and implementation evaluations were operationalized in the NeoECHO dissemination strategy and evaluated for feasibility. The virtual dissemination evaluation framework was conceptually mapped, and operational activities were examined including theoretical constructs drawing on insights of nursing theorists, especially Fawcett's criteria (2005) for frameworks with practical application (significance, internal consistency, parsimony, testability and design fit). The NeoECHO strategy was evaluated for virtual dissemination evaluation adherence, operationalization and feasibility of implementation evaluation. RESULTS: The virtual dissemination evaluation framework meets the criteria for a practical application and demonstrates feasibility for adherence and operationalization consistency. The implementation evaluation was usable in the virtual dissemination of best practices for neonatal care for necrotizing enterocolitis and healthcare providers were actively engaged in using NeoECHO as an implementation strategy. CONCLUSION: This examination of the foundational aspects of the framework underscores the rigour required for generalization of practical application. Effective virtual dissemination of evidence-based practices to hospital units requires structured delivery and evaluation, enabling engaged healthcare providers to actualize education rapidly. The virtual dissemination evaluation frameworks' potential for narrowing the evidence-based practice gap in neonatal care showcases its wider significance and applicability. IMPLICATIONS: Care of neonates in NICUs requires a multidisciplinary approach and necessitates access to the most up-to-date knowledge and best practices. More than traditional dissemination methods are required to bridge the implementation gap. IMPACT: The effective use of the VDE framework can enhance the design, implementation and evaluation of knowledge dissemination, ultimately elevating neonatal care quality. CLINICAL RELEVANCE: This paper introduces the VDE framework, a sequential combination of the iPARIHS and Moore's EO frameworks-as a methodological tool for designing, implementing and evaluating a neonatal strategy (NeoECHO) for virtual dissemination of education in NICUs. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Neonatal Intensive Care Workflow Analysis Informing NEC-Zero Clinical Decision Support Design.

Decision support in neonatal ICUs is needed, especially for prevention and risk awareness of the devastating complication of necrotizing enterocolitis, a major cause of emergency surgery among fragile infants. The purpose of this study was to describe the current clinical workflow and sociotechnical processes among clinicians for necrotizing enterocolitis risk awareness, timely recognition of symptoms, and treatment to inform decision support design. A qualitative descriptive study was conducted. Focus groups were held in two neonatal ICUs (five groups in Unit A and six in Unit B). Transcripts were analyzed using content analysis and compared with field notes. Clinicians (N = 27) included nurses (37%), physicians (30%), neonatal nurse practitioners (19%), and other staff (16%). Workflow processes differed for nurses (who see necrotizing enterocolitis signs and notify providers to order diagnostic tests and treatments) and providers (who receive notification of necrotizing enterocolitis concern and then decide how to act). Clinicians desired (1) a necrotizing enterocolitis-relevant dashboard to support nutrition tracking and necrotizing enterocolitis recognition; (2) features to support decision-making (eg, necrotizing enterocolitis risk and adherence scoring); (3) breast milk tracking and feeding clinical decision support; (4) tools for necrotizing enterocolitis surveillance and quality reporting; and (5) general EHR optimizations to improve user experience.

Developing a Preclinical Nurse-Nurse Communication Framework for Clinical Trial Patient-Related Safety Information.

Clinical trial trials have become increasingly complex in their design and implementation. Investigational safety profiles are not easily accessed by clinical nurses and providers when trial participants present for clinical care, such as in emergency or urgent care. Wearable devices are now commonly used as bridging technologies to obtain participant data and house investigational product safety information. Clinical nurse identification and communication of safety information are critical to dissuade adverse events, patient injury, and trial withdrawal, which may occur when clinical care is misaligned to a research protocol. Based on a feasibility study and follow-up wearable device prototype study, this preclinical nurse-nurse communication framework guides clinical nurse verbal and nonverbal communication of safety-related trial information to direct patient care activities in the clinical setting. Communication and information theories are incorporated with Carrington's Nurse-to-Nurse Communication Framework to encompass key components of a clinical nurse's management of a trial participant safety event when a clinical trial wearable device is encountered during initial assessment. Use of the preclinical nurse-nurse communication framework may support clinical nurse awareness of trial-related wearable devices. The framework may further emphasize the importance of engaging with research nurses, patients, and caregivers to acquire trial safety details impacting clinical care decision-making.

Unintended consequences of the electronic health record and cognitive load in emergency department nurses.

AIM: The study aimed to explore the relationship between the unintended consequences of the electronic health record and cognitive load in emergency department nurses. METHODS: The study utilized a correlational quantitative design with a survey method approach. This study had a 30.4 % response rate for a total of 304 ED nurse participants who were members of a national ED nursing organization. Data analysis included descriptive and correlational measurements of two instruments. RESULTS: In this study, there was a statistically significant, weak negative relationship between CL and UC-EHR in ED nurses, rs (264) = -0.154, p 0.002. Although a significant weak relationship was identified in this study, the study variables, subscales, and demographic data groupings presented moderate-to-strong positive, statistically significant correlations. Descriptive frequency data unveiled EHR stimulated patient safety threats occurring once a week to monthly. CONCLUSIONS: The novelty of this research study provided profound implications for the future of nursing practice, policy, and nursing science. EHR optimization to minimize patient safety risks is recommended with the inclusion of end-users from this study's identified subgroups. The researchers propose a reduction of EHR burden in nursing practice.

Placement disruption of children with disabilities in foster care.

PURPOSE: To investigate and describe available data on children with disabilities in the United States foster care system and examine placement disruptions. DESIGN: This quantitative descriptive study was a secondary data analysis of the Adoption and Foster Care Analysis and Reporting System (AFCARS) and included 680,611 children. METHODS: Descriptive and regression analyses were conducted. FINDINGS: Of 680,611 children in the U.S. foster care system in 2017, 22% had a medical or disability diagnosis, requiring additional or specialized care. Children with disabilities in foster care (CDFC) had a mean of 4.0 disruptions-significantly higher than the mean 2.37 disruptions among those without a disability (p < .001, d = 0.51). CDFC spent an average of 915 days in foster care compared to 514 days for children without a disability (p < .001, d = 0.59). Predictive risk factors for disruptions were increased child age, race (American Indian or Black), and increased foster parent age. Protective factors against disruptions included married foster parents and a child being placed outside of the child's initial state of residence. CONCLUSIONS: CDFC have significantly more disruptions and longer stays in foster care. While risk and protective factors affect all foster children similarly, they have significantly greater effect on foster children with disabilities. PRACTICE IMPLICATIONS: Increased disruptions compound the vulnerability of CDFC as relationships and support systems are broken. Understanding the extent to which childhood disabilities play a role allows school nurses, healthcare providers, and child advocates to better design interventions to improve lifelong health outcomes.

Engaging Parents of Fragile Infants in the Design and Appraisal of Health Literature: An Español Toolkit for Necrotizing Enterocolitis.

WHAT WAS OBSERVED OR INVESTIGATED: The increased morbidity of diverse infants is unacceptable, and methods to reduce necrotizing enterocolitis (NEC) in their communities are needed. This article discusses the importance of the Español toolkit; provides a backstory of how the Español toolkit came about and how it was verified and validated; and concludes with impressions from involving parents in the research process. SUBJECTS AND METHODS: After research evidence was translated from English into Spanish, a cross-sectional exploratory, descriptive, mixed-methods study was conducted, guided by the knowledge translation into practice (Translating Research Into Practice [TRIP]) framework. Twenty bilingual English-Spanish parents of fragile infants evaluated the NEC-Zero Español toolkit from a single neonatal intensive care unit. RESULTS AND CONCLUSIONS: The NEC-Zero Español toolkit was found to be easy-to-use and useful and provided information that can be used to augment information sharing. Having access to health information offers a meaningful way to start a conversation and may even impact positive behaviors such as breastfeeding promotion. To lessen Spanish speakers' linguistic barriers, providing materials in Spanish can help meet their information needs and initiate conversations with healthcare providers. This is particularly important because Hispanic infants are at high risk for NEC.

Applying Computational Ethnography to Examine Nurses' Workflow Within Electronic Health Records.

OBJECTIVE: The aim of this study was to describe computational ethnography as a contemporary and supplemental methodology in EHR workflow analysis and the relevance of this method to nursing research. METHODS: We explore the use of audit logs as a computational ethnographic data source and the utility of data mining techniques, including sequential pattern mining (SPM) and Markov chain analysis (MCA), to analyze nurses' workflow within the EHRs. SPM extracts frequent patterns in a given transactional database (e.g., audit logs from the record). MCA is a stochastic process that models a sequence of states and allows for calculating the probability of moving from one state to the next. These methods can help uncover nurses' global navigational patterns (i.e., how nurses navigate within the record) and enable robust workflow analyses. RESULTS: We demonstrate hypothetical examples from SPM and MCA, such as (a) the most frequent sequential pattern of nurses' workflow when navigating the EHR using SPM and (b) transition probability from one record screen to the next using MCA. These examples demonstrate new methods to address the inflexibility of current approaches used to examine nursing EHR workflow. DISCUSSION: Within a clinical context, the use of computational ethnographic data and data mining techniques can inform the optimization of the EHR. Results from these analyses can be used to supplement the data needed in redesigning the EHR, such as organizing and combining features within a screen or predicting future navigation to improve the record that nurses use.

Exploring Internal Facilitators' Experience With NeoECHO to Foster NEC Prevention and Timely Recognition Through the iPARIHS Lens.

BACKGROUND: Necrotizing enterocolitis (NEC) remains a major complication in the neonatal population. Standard practices regarding the care of premature infants and attitudes toward NEC prevention strategies vary across neonatal intensive care units (NICUs). Evidence-based best practice dissemination was presented through the NEC-Zero bundle. To close gaps between evidence and practice, a telehealth-delivered intervention (ie, NeoECHO) was provided to NICUs. PURPOSE: The purpose of this study was to enable adoption of best practice for NEC prevention using NeoECHO through describing the local volunteer unit leaders', or internal facilitators' (IFs'), experiences in participating in NeoECHO and identifying the extent to which the facilitation activities within the NeoECHO experience were consistent with constructs from the integrated Promoting Action on Research Implementation in Health Services (iPARHIS) framework. METHODS: The design of this study was qualitative descriptive. Six IFs were recruited in the Southwest. After 6 NeoECHO sessions, individual interviews were conducted and transcribed verbatim. Content analysis was applied. Codes were informed by the iPARIHS framework. RESULTS: Major themes were (1) Innovation: Quality Improvement Projects, Bundles of Care, and Huddle; (2) Recipient: Reluctant Stakeholders and Technical Modalities; (3) Context: Buy-In, Timing, Resources, Leadership, and Blame; (4) Facilitation: Betterment, Buddy System, Passionate Care, and Empowerment; and (5) Adoption: Continuous Quality Improvement, Evidence-Based Practice, and Honest Discussions. IMPLICATIONS FOR PRACTICE AND RESEARCH: NeoECHO fostered a learning community to share current practices, policies, and strategies for NEC prevention, but the IFs were essential to foster local participation. The long-term impacts of NeoECHO are the focus of current research.Video Abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Feasibility and Acceptability of a Neonatal Project ECHO (NeoECHO) as a Dissemination and Implementation Strategy to Prevent Necrotizing Enterocolitis.

BACKGROUND: Caregivers in the neonatal intensive care unit (NICU) often determine care practices in silos, although access to learning communities can improve quality. Project ECHO, a telehealth-delivered mentoring intervention, provides specialists' expertise but not in the NICU until now. Necrotizing enterocolitis (NEC) prevention and timely recognition is one area where specialist support and engaging with a learning community could improve outcomes. NEC-Zero is one care bundle that aims to improve care quality by providing tools to implement NEC prevention in family-engaged ways. AIMS: To examine the feasibility and acceptability of NeoECHO to disseminate NEC-Zero education and describe the intentions of internal facilitators (IFs) and clinicians to initiate quality improvement changes. METHODS: This was a convergent mixed-methods study. Our team delivered the first neonatal adaptation of Project ECHO called "NeoECHO" to leverage facilitation as an implementation strategy to disseminate NEC-Zero evidence and support practice change. RESULTS: Six IFs and seven NICUs participated. All units and IFs that began the series finished it. Of the 261 session attendees, 206 (79%) study evaluations were completed. Of those who completed evaluations, 89 (100%) completed at least one session and 29 (33%) completed three or more. Satisfaction was high. Participants appreciated the engaged and accessible format to learn from experts using real case examples and didactic sessions. Individuals and IFs reported intentions to adopt evidence based on NeoECHO. LINKING EVIDENCE TO ACTION: NeoECHO was an acceptable and feasible way to engage under-resourced NICUs and share NEC-Zero evidence and tools. More research is needed to examine the impact of NeoECHO on care processes and patient outcomes.

Grading the evidence to identify strategies to modify risk for necrotizing enterocolitis.

Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.

State of the Science of Dimensions of Nurses' User Experience When Using an Electronic Health Record.

This integrative review synthesized relevant studies in the last decade associated to nurses' experience with the electronic health record using Robert and Lesage's dimensions of User Experience: functional, physical, perceptual, cognitive, psychological, and social. A comprehensive search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance across four electronic databases. We included articles if they were specific to nurses' electronic health record experience and workflow, published between January 2008 and June 2018, and available in English. The search resulted in 793 records with 26 articles included in the final analysis. Articles ranged from quantitative, qualitative, mixed-methods, and quality improvement studies. Across studies, the suboptimal design of the electronic health record affected the functional experience of nurses, often resulting in interruptions. The navigational design contributed to nurses' perceptual experience leading to many workarounds and workflow mismatches. Most of the studies reported overall satisfaction with the electronic health record that represented the psychological dimension of nurses' experience. Communication barriers due to the use of the electronic health record prevented nurses from having meaningful interaction with other clinicians and patients. Although nurses reported substandard user experience, many stated that reverting to a linear paper-based system was not an option.

Development of the NEC-Zero Toolkit: Supporting Reliable Implementation of Necrotizing Enterocolitis Prevention and Recognition.

The goal of the NEC-Zero project is to reduce the burden of necrotizing enterocolitis (NEC) by increasing access to evidence-based tools to help clinicians and parents integrate evidence into daily care. It involves (a) human milk feeding with prioritized mother's own milk; (b) use of a unit-adopted standardized feeding protocol; (c) a unit-adopted strategy for timely recognition that integrates risk awareness and a structured communication tool when symptoms develop; and (d) stewardship of empiric antibiotics and avoidance of antacids. A toolkit for caregivers and parents was developed to make implementation consistent. For clinicians the toolkit includes: the GutCheckNEC risk score, a structured communication tool, the "Avoiding NEC" checklist, and the NEC-Zero website. For parents, NEC-Zero tools include the website, three educational brochures in English and Spanish, and a collaborative care video produced with the NEC Society. This article describes the toolkit and how it has been accessed and used.

Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units.

BACKGROUND: Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%. PURPOSE: This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC. METHODS: A descriptive cross-sectional correlational study was completed among US quality improvement-focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs. RESULTS: NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = -0.26, P = .049), as was colostrum for oral care (Rho = -0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003). IMPLICATIONS FOR PRACTICE: Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount. IMPLICATIONS FOR RESEARCH: Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.

Models of collaboration and dissemination for nursing informatics innovations in the 21st century.

BACKGROUND: Nursing informatics innovations are constantly adapting to a rapidly changing health care environment. PURPOSE: This study aims to present the lessons learned from 4 nursing informatics projects and rationale for development decisions to inform future informatics innovations. METHODS: Using a comparative cross-case analysis, four case studies of informatics projects led by nurse scientists were described and analyzed through the lens of the Informatics Research Organizing Model which was modified to include policy and interoperability contexts. FINDINGS: The comparison analysis examined dynamic relationships between processes and constructs in nursing informatics interventions and also highlighted the scientific, intellectual property, technical, and policy challenges encountered among the four case studies. DISCUSSION: The analysis provided implications for future intervention development and implementation in consideration of multiple contexts for nursing informatics innovations.

Precision health research and implementation reviewed through the conNECT framework.

BACKGROUND: Precision health is a population-based approach that incorporates big-data strategies to understand the complex interactions between biological, environmental, lifestyle, and psychosocial factors that influence health. PURPOSE: A promising tool to facilitate precision health research and its dissemination is the ConNECT Framework. METHODS: Here, we discuss the relationship of the five broad and synergistic principles within the ConNECT Framework as they may apply to nursing science research: (1) Integrating Context, (2) Fostering a Norm of Inclusion, (3) Ensuring Equitable Diffusion of Innovations, (4) Harnessing Communication Technology, and (5) Prioritizing Specialized Training. DISCUSSION/CONCLUSION: The principles within this framework can be used by nurse scientists and educators to guide and disseminate precision health research.

External Facilitation as an Evidence-Based Practice Implementation Strategy During an Antibiotic Stewardship Collaborative in Neonatal Intensive Care Units.

BACKGROUND: Despite research support, evidence-based practices (EBPs) are inconsistently implemented throughout the United States. Facilitation is one implementation strategy to speed adoption in clinical settings. Facilitation has not been previously described in the literature as an implementation strategy within neonatal care. PURPOSE: The purpose of this study was to categorize and describe essential features of facilitation in the context of implementing an EBP using perspectives elicited from neonatal clinicians and external facilitators (EFs). METHODS: In this qualitative descriptive study, semistructured interviews were conducted with a purposive sample of neonatal clinicians and EFs. Participants shared their experiences related to the strategy of facilitation while implementing an EBP during the California Perinatal Quality Care Antibiotic Stewardship Collaborative. Interviews were transcribed, coded, and analyzed using directed content analysis. RESULTS: Five categories emerged to address facilitation as an implementation strategy: (a) facilitated change management, (b) unit and organization receptivity, (c) evaluation strategies, (d) supportive culture, and (e) facilitator stewardship. LINKING EVIDENCE TO ACTION: Implementing EBP is complex and multifactorial. Results from this study provide insights into influencing barriers and drivers as experienced by internal and external facilitators, and context factors that impacted the success of implementation.

Neonatal Nurses Experience Unintended Consequences and Risks to Patient Safety With Electronic Health Records.

In this article, we examine the unintended consequences of nurses' use of electronic health records. We define these as unforeseen events, change in workflow, or an unanticipated result of implementation and use of electronic health records. Unintended consequences experienced by nurses while using electronic health records have been well researched. However, few studies have focused on neonatal nurses, and it is unclear to what extent unintended consequences threaten patient safety. A new instrument called the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire has been validated, and secondary analysis using the tool explored the phenomena among neonatal nurses (N = 40). The purposes of this study were to describe unintended consequences of use of electronic health records for neonatal nurses and to explore relationships between the phenomena and characteristics of the nurse and the electronic health record. The most frequent unintended consequences of electronic health record use were due to interruptions, followed by a heavier workload due to the electronic health record, changes to the workflow, and altered communication patterns. Neonatal nurses used workarounds most often with motivation to better assist patients. Teamwork was moderately related to higher unintended consequences including patient safety risks (r = 0.427, P = .007), system design (r = 0.419, P = .009), and technology barriers (r = 0.431, P = .007). Communication about patients was reduced when patient safety risks were high (r = -0.437, P = .003). By determining the frequency with which neonatal nurses experience unintended consequences of electronic health record use, future research can be targeted to improve electronic health record design through customization, integration, and refinement to support patient safety and better outcomes.