Building and testing a patient-centric electronic bedside communication center.

In this article, the authors describe the development and pilot testing of an electronic bedside communication center (eBCC) prototype to improve access to health information for hospitalized adults and their family caregivers. Focus groups were used to identify improvements for the initial eBCC prototype developed by the research team. Face-to-face bedside interviews and questions were presented while patients used the eBCC for usability testing to drive further development. Qualitative methods within an iterative, participatory approach supported the development of an eBCC prototype that was considered both easy to use and helpful for accessing tailored patient information during an inpatient hospitalization to receive acute care.

An electronic fall prevention toolkit: effect on documentation quality.

BACKGROUND: Nursing documentation is the record of care that is planned and given to patients, yet it is often missing or incomplete. A study of translating results from nurses' assessments of fall risk into tailored interventions using health information technology was used to examine nursing documentation of risk assessment, plans to manage those risks, and interventions to prevent falls. OBJECTIVE: The aim of this study was to evaluate the effectiveness of an electronic fall prevention toolkit for promoting documentation of fall risk status and planned and completed fall prevention interventions. METHODS: Nursing documentation related to fall risk and prevention was reviewed in 30% of randomly selected medical records for patients on the eight study units (four intervention units; 5,267 patients) and four usual care units (5,116 patients) during three separate study visits. RESULTS: Patients on the intervention units were more likely to have fall risk documented (89% vs. 64%, p < .0001). There were significantly more comprehensive plans of care for the patients on the interventions documented, although no differences were found related to documentation of completed interventions compared with usual care unit patient records. DISCUSSION: The documentation of fall risk status and planned interventions tailored to patient-specific areas of risk was significantly better on the intervention units that used the fall prevention toolkit as compared with usual care units. Improved documentation quality did not extend to the documentation of completed interventions.

Adaptation and Testing of a Military Version of the Measure of Moral Distress for Healthcare Professionals.

BACKGROUND: Moral distress is well-documented among civilian critical care nurses and adversely affects patient outcomes, care delivery, and retention of health care providers. Despite its recognized significance, few studies have addressed moral distress in military critical care nurses. OBJECTIVES: To refine and validate an instrument to assess moral distress in military critical care nurses. METHODS: This study examined moral distress in military critical care nurses (N = 245) using a new instrument, the Measure of Moral Distress for Healthcare Professionals-Military (MMD-HP-M). The psychometric properties of the refined scale were assessed by use of descriptive statistics, tests of reliability and validity, exploratory factor analysis, correlations, and qualitative analysis of open-ended responses. RESULTS: Initial testing showed promising evidence of instrument performance. The Cronbach α (0.94) suggested good internal consistency of the instrument for the overall sample. Scores for the MMD-HP items and the MMD-HP-M items showed a strong, significant correlation (α= 0.78, P < .001). Unique attributes of military nursing that contribute to moral distress included resource access, futile care, and austere conditions. Exploratory factor analysis established a new military-centric factor for question items associated with inadequate training for patient care, providing care in resource-limited settings, and personal exhaustion. CONCLUSIONS: These results will help guide specific, targeted interventions to reduce the negative effects of moral distress on our military health care providers, especially in terms of readiness for the next global pandemic and retention of these invaluable personnel.

Development and Validation of a Fall Prevention Efficiency Scale.

OBJECTIVES: Fall TIPS (Tailoring Interventions for Patient Safety) is an evidence-based fall prevention program that led to a 25% reduction in falls in hospitalized adults. Because it would be helpful to assess nurses' perceptions of burdens imposed on them by using Fall TIPS or other fall prevention program, we conducted a study to learn benefits and burdens. METHODS: A 3-phase mixed-method study was conducted at 3 hospitals in Massachusetts and 3 in New York: (1) initial qualitative, elicited and categorized nurses' views of time spent implementing Fall TIPS; (2) second qualitative, used nurses' quotes to develop items, research team inputs for refinement and organization, and clinical nurses' evaluation and suggestions to develop the prototype scale; and (3) quantitative, evaluated psychometric properties. RESULTS: Four "time" themes emerged: (1) efficiency, (2) inefficiency, (3) balances out, and (4) valued. A 20-item prototype Fall Prevention Efficiency Scale was developed, administered to 383 clinical nurses, and reduced to 13 items. Individual items demonstrated robust stability with Pearson correlations of 0.349 to 0.550 and paired t tests of 0.155 to 1.636. Four factors explained 74.3% variance and provided empirical support for the scale's conceptual basis. The scale achieved excellent internal consistency values (0.82-0.92) when examined with the test, validation, and paired (both test and retest) samples. CONCLUSIONS: This new scale assess nurses' perceptions of how a fall prevention program affects their efficiency, which impacts the likelihood of use. Learning nurses' beliefs about time wasted when implementing new programs allows hospitals to correct problems that squander time.

Scales for assessing self-efficacy of nurses and assistants for preventing falls.

AIM: This paper is a report of the development and testing of the Self-Efficacy for Preventing Falls Nurse and Assistant scales. BACKGROUND: Patient falls and fall-related injuries are traumatic ordeals for patients, family members and providers, and carry a toll for hospitals. Self-efficacy is an important factor in determining actions persons take and levels of performance they achieve. Performance of individual caregivers is linked to the overall performance of hospitals. Scales to assess nurses and certified nursing assistants' self-efficacy to prevent patients from falling would allow for targeting resources to increase SE, resulting in improved individual performance and ultimately decreased numbers of patient falls. METHOD: Four phases of instrument development were carried out to (1) generate individual items from eight focus groups (four each nurse and assistant conducted in October 2007), (2) develop prototype scales, (3) determine content validity during a second series of four nurse and assistant focus groups (January 2008) and (4) conduct item analysis, paired t-tests, Student's t-tests and internal consistency reliability to refine and confirm the scales. Data were collected during February-December, 2008. RESULTS: The 11-item Self-Efficacy for Preventing Falls Nurse had an alpha of 0·89 with all items in the range criterion of 0·3-0·7 for item total correlation. The 8-item Self-Efficacy for Preventing Falls Assistant had an alpha of 0·74 and all items had item total correlations in the 0·3-0·7 range. CONCLUSIONS: The Self-Efficacy for Preventing Falls Nurse and Self-Efficacy for Preventing Falls Assistant scales demonstrated psychometric adequacy and are recommended to measure bedside staff's self-efficacy beliefs in preventing patient falls.

An Implementation Science Approach to Promote Optimal Implementation, Adoption, Use, and Spread of Continuous Clinical Monitoring System Technology.

OBJECTIVES: This study aimed to apply implementation science tenets to guide the deployment and use of in-hospital Clinical Monitoring System Technology (CMST) and to develop a toolkit to promote optimal implementation, adoption, use, and spread of CMST. METHODS: Six steps were carried out to (1) establish leadership support; (2) identify, educate, and sustain champions; (3) enlist clinical staff users to learn barriers and facilitators; (4) examine initial qualitative data from 11 clinician group interviews; (5) validate barriers/facilitators to CMST use and toolkit content; and (6) propose a toolkit to promote utilization. Clinical Monitoring System Technology output before and after implementation were compared. RESULTS: The top 3 barriers to effective CMST use were as follows: (1) inadequate education/training/support, (2) clinical workflow challenges, and (3) lack of communication. Facilitators to CMST implementation and adoption included the following: (1) providing comprehensive and consistent CMST education, (2) presenting evidence early and often, (3) tailoring device and usage expectations to individual environments, and (4) providing regular feedback about progress. Empirical data drove the development of a CMST implementation toolkit covering 6 areas: (1) why, (2) readiness, (3) readiness and implementation, (4) patient/family introduction, (5) champions, (6) care team saves, and (7) troubleshooting. Clinical Monitoring System Technology positively impacted failure to rescue events. Monthly median cardiac alert responses decreased from 30 to 3.64 minutes (87.9%), and respiratory alert responses decreased from 26 to 4.85 minutes (81.4%). CONCLUSIONS: Using implementation science tenets to concurrently guide deployment and study performance of 2 CMST devices and impact on workload was effective for both learning CMST efficacy at 2 hospital systems and developing a toolkit to promote optimal implementation, adoption, use, and spread.

Validating Fall Prevention Icons to Support Patient-Centered Education.

INTRODUCTION: Falls with injury are the most prevalent hospital adverse event. The objective of this project was to refine fall risk and prevention icons for a patient-centric bedside toolkit to promote patient and nurse engagement in accurately assessing fall risks and developing a tailored fall prevention plan. METHODS: Eighty-eight patients and 60 nurses from 2 academic medical centers participated in 4 iterations of testing to refine 6 fall risk and 10 fall prevention icons. During individual interviews, participants rated their satisfaction with the degree to which that icon represented the concept on a 4-point Likert scale, enabling computation of a Content Validity Index (CVI), and provided comments and suggestions for improvement. After reviewing CVI scores and feedback, the research team consulted with the illustrator to revise the icons. RESULTS: Content Validity Index scores improved after icon modifications. Icons that depicted multiple concepts required further iterations to be acceptable. DISCUSSION: Using icons to depict an accurate and easy-to-interpret fall risk assessment and intervention plan for all care team members including patients and family to follow should lead to improved adherence with that plan and decreased falls. CONCLUSIONS: All 16 icons were refined and used to form the basis for a bedside fall prevention toolkit.

Use of a perceived efficacy tool to evaluate the FallTIPS program.

BACKGROUND/OBJECTIVES: To assess nurses' opinions of the efficacy of using the FallTIPS (Tailoring Interventions for Patient Safety) fall prevention program. DESIGN: Survey research. SETTING: Seven adult acute-care hospitals in 2 hospital centers located in Boston and NYC. PARTICIPANTS: A total of 298 medical-surgical nurses on 14 randomly selected units. INTERVENTION: Three-step FallTIPS fall prevention program that had been in use as a clinical program for a minimum of 2 years in each hospital. MEASUREMENTS: Fall Prevention Efficiency Scale (FPES), range 13-52; four-factorilly derived subscales: valued, efficiency, balances out and inefficiency; and 13 psychometrically validated individual items. RESULTS: Nurses perceived the FallTIPS fall prevention program to be efficacious. The FPES mean score of 38.55 (SD = 5.05) and median of 39 were well above the lowest possible score of 13 and scale midpoint of 32.5. Most nurses (N = 270, 90.6%) scored above 33. There were no differences in FPES scores between nurses who had only used FallTIPS and nurses who had previously used a different fall prevention program. CONCLUSION: The nurses who used FallTIPS perceived that efficiencies in patient care compensated for the time spent on FallTIPS. Nurses valued the program and findings confirmed the importance of patient and family engagement with staff in the fall prevention process. Regardless of the fall prevention program used, organizations should examine staff perceptions of their fall prevention program because programs that are not perceived as being useful, efficient, and valuable will lead to nonadherence over time and then will not reduce falls and injuries. The recently developed FPES used in this study is a brief tool available for organizations to assess nurses' perceptions of the efficacy of their fall prevention program. Additional FPES research is needed with larger and more diverse samples.

Recovered Medical Error Inventory.

PURPOSE: To describe the development and psychometric testing of the Recovered Medical Error Inventory (RMEI). DESIGN AND METHODS: Content analysis of structured interviews with expert critical care registered nurses (CCRNs) was used to empirically derive a 25-item RMEI. The RMEI was pilot tested with 345 CCRNs. The data set was randomly divided to use the first half for reliability testing and the second half for validation. A principal components analysis with Varimax rotation was conducted. Cronbach's alpha values were examined. A t test and Pearson correlation were used to compare scores of the two samples. FINDINGS: The RMEI consists of 25 items and two subscales. Evidence for initial reliability includes a total scale alpha of .9 and subscale alpha coefficients of .88 (mistake) and .75 (poor judgment). CONCLUSIONS: The RMEI subscales have satisfactory internal consistency reliability and evidence for construct validity. Additional testing is warranted. CLINICAL RELEVANCE: A tool to measure CCRNs' experiences with recovering medical errors allows quantification of nurse surveillance in promoting safe care and preventing unreimbursed hospital costs for treating nosocomial events.

Medical errors recovered by critical care nurses.

OBJECTIVE: : The frequency and types of medical errors are well documented, but less is known about potential errors that were intercepted by nurses. We studied the type, frequency, and potential harm of recovered medical errors reported by critical care registered nurses (CCRNs) during the previous year. BACKGROUND: : Nurses are known to protect patients from harm. Several studies on medical errors found that there would have been more medical errors reaching the patient had not potential errors been caught earlier by nurses. METHODS: : The Recovered Medical Error Inventory, a 25-item empirically derived and internally consistent (alpha =.90) list of medical errors, was posted on the Internet. Participants were recruited via e-mail and healthcare-related listservs using a nonprobability snowball sampling technique. Investigators e-mailed contacts working in hospitals or who managed healthcare-related listservs and asked the contacts to pass the link on to others with contacts in acute care settings. RESULTS: : During 1 year, 345 CCRNs reported that they recovered 18,578 medical errors, of which they rated 4,183 as potentially lethal. CONCLUSION: : Surveillance, clinical judgment, and interventions by CCRNs to identify, interrupt, and correct medical errors protected seriously ill patients from harm.

Fall prevention in acute care hospitals: a randomized trial.

CONTEXT: Falls cause injury and death for persons of all ages, but risk of falls increases markedly with age. Hospitalization further increases risk, yet no evidence exists to support short-stay hospital-based fall prevention strategies to reduce patient falls. OBJECTIVE: To investigate whether a fall prevention tool kit (FPTK) using health information technology (HIT) decreases patient falls in hospitals. DESIGN, SETTING, AND PATIENTS: Cluster randomized study conducted January 1, 2009, through June 30, 2009, comparing patient fall rates in 4 urban US hospitals in units that received usual care (4 units and 5104 patients) or the intervention (4 units and 5160 patients). INTERVENTION: The FPTK integrated existing communication and workflow patterns into the HIT application. Based on a valid fall risk assessment scale completed by a nurse, the FPTK software tailored fall prevention interventions to address patients' specific determinants of fall risk. The FPTK produced bed posters composed of brief text with an accompanying icon, patient education handouts, and plans of care, all communicating patient-specific alerts to key stakeholders. MAIN OUTCOME MEASURES: The primary outcome was patient falls per 1000 patient-days adjusted for site and patient care unit. A secondary outcome was fall-related injuries. RESULTS: During the 6-month intervention period, the number of patients with falls differed between control (n = 87) and intervention (n = 67) units (P=.02). Site-adjusted fall rates were significantly higher in control units (4.18 [95% confidence interval {CI}, 3.45-5.06] per 1000 patient-days) than in intervention units (3.15 [95% CI, 2.54-3.90] per 1000 patient-days; P = .04). The FPTK was found to be particularly effective with patients aged 65 years or older (adjusted rate difference, 2.08 [95% CI, 0.61-3.56] per 1000 patient-days; P = .003). No significant effect was noted in fall-related injuries. CONCLUSION: The use of a fall prevention tool kit in hospital units compared with usual care significantly reduced rate of falls. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00675935.

Patients' perspectives of falling while in an acute care hospital and suggestions for prevention.

Patient falls and falls with injury are the largest category of reportable incidents and a significant problem in hospitals. Patients are an important part of fall prevention; therefore, we asked patients who have fallen about reason for fall and how falls could be prevented. There were two categories for falls: the need to toilet coupled with loss of balance and unexpected weakness. Patients asked to be included in fall risk communication and asked to be part of the team to prevent them from falling. Nurses need to share a consistent and clear message that they are there for patient safety.

Classification of Injurious Fall Severity in Hospitalized Adults.

BACKGROUND: Many hospital systems in the United States report injurious inpatient falls using the National Database of Nursing Quality Indicators categories: None, Minor, Moderate, Major, and Death. The Major category is imprecise, including injuries ranging from a wrist fracture to potentially fatal subdural hematoma. The purpose of this project was to refine the Major injury classification to derive a valid and reliable categorization of the types and severities of Major inpatient fall-related injuries. METHODS: Based on published literature and ranking of injurious fall incident reports (n = 85) from a large Academic Medical Center, we divided the National Database of Nursing Quality Indicators Major category into three subcategories: Major A-injuries that caused temporary functional impairment (eg, wrist fracture), major facial injury without internal injury (eg, nasal bone fracture), or disruption of a surgical wound; Major B-injuries that caused long-term functional impairment or had the potential risk of increased mortality (eg, multiple rib fractures); and Major C-injuries that had a well-established risk of mortality (eg, hip fracture). Based on the literature and expert opinion, our research team reached consensus on an administration manual to promote accurate classification of Major injuries into one of the three subcategories. RESULTS: The team tested and validated each of the categories which resulted in excellent interrater reliability (kappa = .96). Of the Major injuries, the distribution of Major A, B, and C was 40.3%, 16.1%, and 43.6%, respectively. CONCLUSIONS: These subcategories enhance the National Database of Nursing Quality Indicators categorization. Using the administration manual, trained personnel can classify injurious fall severity with excellent reliability.

Why do patients in acute care hospitals fall? Can falls be prevented?

OBJECTIVE: Obtain the views of nurses and assistants as to why patients in acute care hospitals fall. BACKGROUND: Despite a large quantitative evidence base for guiding fall risk assessment and not needing highly technical, scarce, or expensive equipment to prevent falls, falls are serious problems in hospitals. METHODS: Basic content analysis methods were used to interpret descriptive data from 4 focus groups with nurses (n = 23) and 4 with assistants (n = 19). A 2-person consensus approach was used for analysis. RESULTS: Positive and negative components of 6 concepts-patient report, information access, signage, environment, teamwork, and involving patient/family-formed 2 core categories: knowledge/ communication and capability/actions that are facilitators or barriers, respectively, to preventing falls. CONCLUSION: Two conditions are required to reduce patient falls. A patient care plan including current and accurate fall risk status with associated tailored and feasible interventions needs to be easily and immediately accessible to all stakeholders (entire healthcare team, patients, and family). Second, stakeholders must use that information plus their own knowledge and skills and patient and hospital resources to carry out the plan.

Fall TIP: validation of icons to communicate fall risk status and tailored interventions to prevent patient falls.

This paper reports on the development and validation of a set of icons designed to communicate fall risk status and tailored interventions to prevent patient falls in hospitals. The icons will populate a fall prevention toolkit to provide actionable alerts to nurses, nursing assistants, and other interdisciplinary health care team members and educational materials for patients and families in acute hospital settings.

Validation of the Impact of Health Information Technology (I-HIT) Scale: an international collaborative.

In 2005, the Healthcare Information Management Systems Society (HIMSS) Nursing Informatics Community developed a survey to measure the impact of health information technology (HIT), the I-HIT Scale, on the role of nurses and interdisciplinary communication in hospital settings. In 2007, nursing informatics colleagues from Australia, England, Finland, Ireland, New Zealand, Scotland and the United States formed a research collaborative to validate the I-HIT across countries. All teams have completed construct and face validation in their countries. Five out of six teams have initiated reliability testing by practicing nurses. This paper reports the international collaborative's validation of the I-HIT Scale completed to date.

Development and Validation of a Fall Prevention Knowledge Test.

Falls are a serious, persistent problem in hospitals. Ensuring that all hospital staff have adequate knowledge of how to prevent falls is the first step in prevention. We identified validated fall prevention knowledge tests (FPKTs) and planned to conduct a systematic literature review. When the review identified a lack of FPKTs, we developed and evaluated a FPKT, confirmed its conceptual framework, identified the content domain, drafted test items, devised the format, selected items for empirical examination, and conducted a psychometric evaluation. We randomly divided a 209-subject data set into test and validation samples to make item reduction decisions and examine reliability and validity. The typical respondent was a white, 42-year old female nurse with a bachelor's degree and 7 years' experience. Subjects were confident in their ability to prevent falls, rating themselves an 8 on a self-efficacy scale of 1 (not at all) to 10 (very). The 11-item FPKT scale (range 0-11) attained a tetrachoric coefficient of 0.73, confirming initial reliability. FPKT mean scores obtained before and after fall prevention education improved from 5.1 ± 1.8 to 6.6 ± 1.7. Statistically significant differences (paired t-test = 12.4, p < .001) confirmed validity. A robust way to assess nurses' knowledge of fall prevention is needed to inform effective educational programs. Addressing gaps in validated FPKTs provides an opportunity to inform and evaluate effective fall prevention programs. J Am Geriatr Soc 67:133-138, 2019.

Development and psychometric evaluation of the Impact of Health Information Technology (I-HIT) scale.

OBJECTIVE: The use of health information technology (HIT) for the support of communication processes and data and information access in acute care settings is a relatively new phenomenon. A means of evaluating the impact of HIT in hospital settings is needed. The purpose of this research was to design and psychometrically evaluate the Impact of Health Information Technology scale (I-HIT). I-HIT was designed to measure the perception of nurses regarding the ways in which HIT influences interdisciplinary communication and workflow patterns and nurses' satisfaction with HIT applications and tools. DESIGN: Content for a 43-item tool was derived from the literature, and supported theoretically by the Coiera model and by nurse informaticists. Internal consistency reliability analysis using Cronbach's alpha was conducted on the 43-item scale to initiate the item reduction process. Items with an item total correlation of less than 0.35 were removed, leaving a total of 29 items. MEASUREMENTS: Item analysis, exploratory principal component analysis and internal consistency reliability using Cronbach's alpha were used to confirm the 29-item scale. RESULTS: Principal components analysis with Varimax rotation produced a four-factor solution that explained 58.5% of total variance (general advantages, information tools to support information needs, information tools to support communication needs, and workflow implications). Internal consistency of the total scale was 0.95 and ranged from 0.80-0.89 for four subscales. CONCLUSION: I-HIT demonstrated psychometric adequacy and is recommended to measure the impact of HIT on nursing practice in acute care settings.

Recovery from medical errors: the critical care nursing safety net.

BACKGROUND: Safety initiatives have primarily focused on physicians despite the fact that nurses provide the majority of direct inpatient care. Patient surveillance and preventing errors from harming patients represent essential nursing responsibilities but have received relatively little study. METHODS: The study was conducted between July 2003 and July 2004 in a 10-bed academic coronary care unit. Direct observation of nursing care and solicited and institutional incident reports were used to find potential incidents. Two physician reviewers rated incidents as to the presence, preventability, and potential severity of harm of errors and associated factors. RESULTS: Overall data were collected for 147 days, including 150 hours of direct observation. One hundred forty-two recovered medical errors were found, including 61% (86/142) during direct observations. Most errors (69%; 98/142) were intercepted before reaching the patients. Errors that reached patients included 13% that were mitigated before resulting in harm and 18% that were ameliorated before more severe harm could occur. DISCUSSION: Protecting patients from the potentially dangerous consequences of medical errors is one of the many ways critical care nurses improve patient safety. Interventions designed to increase the ability of nurses to recover and promptly report errors have the potential to improve patient outcomes.