Examining Care Planning Efficiency and Clinical Decision Support Adoption in a System Tailoring to Nurses' Graph Literacy: National, Web-Based Randomized Controlled Trial.

BACKGROUND: The proliferation of health care data in electronic health records (EHRs) is fueling the need for clinical decision support (CDS) that ensures accuracy and reduces cognitive processing and documentation burden. The CDS format can play a key role in achieving the desired outcomes. Building on our laboratory-based pilot study with 60 registered nurses (RNs) from 1 Midwest US metropolitan area indicating the importance of graph literacy (GL), we conducted a fully powered, innovative, national, and web-based randomized controlled trial with 203 RNs. OBJECTIVE: This study aimed to compare care planning time (CPT) and the adoption of evidence-based CDS recommendations by RNs randomly assigned to 1 of 4 CDS format groups: text only (TO), text+table (TT), text+graph (TG), and tailored (based on the RN's GL score). We hypothesized that the tailored CDS group will have faster CPT (primary) and higher adoption rates (secondary) than the 3 nontailored CDS groups. METHODS: Eligible RNs employed in an adult hospital unit within the past 2 years were recruited randomly from 10 State Board of Nursing lists representing the 5 regions of the United States (Northeast, Southeast, Midwest, Southwest, and West) to participate in a randomized controlled trial. RNs were randomly assigned to 1 of 4 CDS format groups-TO, TT, TG, and tailored (based on the RN's GL score)-and interacted with the intervention on their PCs. Regression analysis was performed to estimate the effect of tailoring and the association between CPT and RN characteristics. RESULTS: The differences between the tailored (n=46) and nontailored (TO, n=55; TT, n=54; and TG, n=48) CDS groups were not significant for either the CPT or the CDS adoption rate. RNs with low GL had longer CPT interacting with the TG CDS format than the TO CDS format (P=.01). The CPT in the TG CDS format was associated with age (P=.02), GL (P=.02), and comfort with EHRs (P=.047). Comfort with EHRs was also associated with CPT in the TT CDS format (P<.001). CONCLUSIONS: Although tailoring based on GL did not improve CPT or adoption, the study reinforced previous pilot findings that low GL is associated with longer CPT when graphs were included in care planning CDS. Higher GL, younger age, and comfort with EHRs were associated with shorter CPT. These findings are robust based on our new innovative testing strategy in which a diverse national sample of RN participants (randomly derived from 10 State Board of Nursing lists) interacted on the web with the intervention on their PCs. Future studies applying our innovative methodology are recommended to cost-effectively enhance the understanding of how the RN's GL, combined with additional factors, can inform the development of efficient CDS for care planning and other EHR components before use in practice.

Application of a practice-based approach in variable selection for a prediction model development study of hospital-induced delirium.

BACKGROUND: Prognostic models of hospital-induced delirium, that include potential predisposing and precipitating factors, may be used to identify vulnerable patients and inform the implementation of tailored preventive interventions. It is recommended that, in prediction model development studies, candidate predictors are selected on the basis of existing knowledge, including knowledge from clinical practice. The purpose of this article is to describe the process of identifying and operationalizing candidate predictors of hospital-induced delirium for application in a prediction model development study using a practice-based approach. METHODS: This study is part of a larger, retrospective cohort study that is developing prognostic models of hospital-induced delirium for medical-surgical older adult patients using structured data from administrative and electronic health records. First, we conducted a review of the literature to identify clinical concepts that had been used as candidate predictors in prognostic model development-and-validation studies of hospital-induced delirium. Then, we consulted a multidisciplinary task force of nine members who independently judged whether each clinical concept was associated with hospital-induced delirium. Finally, we mapped the clinical concepts to the administrative and electronic health records and operationalized our candidate predictors. RESULTS: In the review of 34 studies, we identified 504 unique clinical concepts. Two-thirds of the clinical concepts (337/504) were used as candidate predictors only once. The most common clinical concepts included age (31/34), sex (29/34), and alcohol use (22/34). 96% of the clinical concepts (484/504) were judged to be associated with the development of hospital-induced delirium by at least two members of the task force. All of the task force members agreed that 47 or 9% of the 504 clinical concepts were associated with hospital-induced delirium. CONCLUSIONS: Heterogeneity among candidate predictors of hospital-induced delirium in the literature suggests a still evolving list of factors that contribute to the development of this complex phenomenon. We demonstrated a practice-based approach to variable selection for our model development study of hospital-induced delirium. Expert judgement of variables enabled us to categorize the variables based on the amount of agreement among the experts and plan for the development of different models, including an expert-model and data-driven model.

Twenty-first Century Bedside Manner: Exploring Patient-Centered Communication in Secure Messaging with Cancer Patients.

Patient-centered communication (PCC) is integral to providing high-quality health care and is recommended to be incorporated during face-to-face consultations. Electronic communication, such as the use of secure messaging (SM) within patient portals, is a popular form of patient-provider communication, but preliminary studies have shown that PCC is rarely utilized by providers in SM. As a consequence, the patient-provider relationship can be negatively affected, especially for cancer patients who have greater electronic health information needs than the general population. Therefore, our objective was to determine the importance of SM to cancer patients and to identify which attributes of PCC are preferred to be incorporated into secure messages. Five focus groups were conducted, comprised of patients with a current or previous cancer diagnosis (three all-female; two all-male). Participants recalled their own experiences and reviewed simulated messages. Three main topics emerged from the thematic analysis: (1) the normalization of SM, (2) SM quality can affect perceptions of care, and (3) patients need guidance. Overall, participants valued the ability to communicate with their care team using SM and indicated that electronic communication may have the potential to have just as big of an impact on a patient's care than in-person communication.

Fall Prevention Decision Making of Acute Care Registered Nurses.

OBJECTIVE: The aim of this study was to examine acute care registered nurses' (RNs') fall prevention decision-making. BACKGROUND: The RN decision-making process related to fall prevention needs to be investigated to ensure that hospital policies align with nursing workflow and support nursing judgment. METHODS: Qualitative semistructured interviews based on the Critical Decision Method were conducted with RNs about their planning and decision making during their last 12-hour shift worked. RESULTS: Data saturation was achieved with 12 RNs. Nine themes emerged related to the RN decision-making process and included hospital-level (eg, fear of discipline), unit-level (eg, value of bed alarm technology), and nurse-level (eg, professional judgment) factors that could influence fall prevention. CONCLUSIONS: Nursing administrators should consider a multilevel approach to fall prevention policies that includes promoting a practice environment that embraces self-reporting adverse events without fear of shame or being reprimanded, evaluating unit-level practice and technology acceptance and usability, and supporting autonomous nursing practice.

The Role of Nurse Managers in the Adoption of Health Information Technology: Findings From a Qualitative Study.

OBJECTIVE: This study aims to investigate the role of nurse managers in supporting point-of-care nurses' health information technology (IT) use and identify strategies employed by nurse managers to improve adoption, while also gathering point-of-care nurses' perceptions of these strategies. BACKGROUND: Nurse managers are essential in facilitating point-of-care nurses' use of health IT; however, the underlying phenomenon for this facilitation remains unreported. METHODS: A qualitative descriptive study was conducted with 10 nurse managers and 14 point-of-care nurses recruited from a mental health hospital environment in Ontario, Canada. Inductive and deductive content analyses were used to analyze the semistructured interviews. RESULTS: Nurse managers adopt the role of advocate, educator, and connector, using the following strategies: communicating system updates, demonstrating use of health IT, linking staff to resources, facilitating education, and providing IT oversight. CONCLUSIONS: Nurse managers use a variety of strategies to support nurses' use of health IT. Future research should focus on the effectiveness of these strategies.

Nurse Documentation of Sexual Orientation and Gender Identity in Home Healthcare: A Text Mining Study.

Health disparities have been documented in the lesbian, gay, bisexual, and transgender population, but more research is needed to better understand how to address them. To that end, this observational study examined what is documented about sexual orientation and gender identity in narrative home care nurses' notes in an electronic health record. Lexical text mining approaches were used to examine a total of 862 715 clinical notes from 20 447 unique patients who received services from a large home care agency in Manhattan, New York, and extracted notes were qualitatively reviewed to build a lexicon of terms for use in future research. Forty-two notes, representing 35 unique patients, were identified as containing documentation of the patient's sexual orientation or gender identity. Documentation of sexual orientation or gender identity was relatively infrequent, compared to the estimated frequency of lesbian, gay, bisexual, and transgender people in the US population. Issues related to fragmentary language emerged, and variety in phrasing and word frequency was identified between different types of notes and between providers. This study provides insight into what nurses in home healthcare document about sexual orientation and gender identity and their clinical priorities related to such documentation, and provides a lexicon for use in further research in the home care setting.

Benefits of Implementing and Improving Collection of Sexual Orientation and Gender Identity Data in Electronic Health Records.

Individuals in lesbian, gay, bisexual, and transgender communities experience several disparities in physical and mental health (eg, cardiovascular disease and depression), as well as difficulty accessing care that is compassionate and relevant to their unique needs. Access to care is compromised in part due to inadequate information systems that fail to capture identity data. Beginning in January 2018, meaningful use criteria dictate that electronic health records have the capability to collect data related to sexual orientation and gender identity of patients. Nurse informaticists play a vital role in the process of developing new electronic health records that are sensitive to the needs and identities of the lesbian, gay, bisexual, and transgender communities. Improved collection of sexual orientation and gender identity data will advance the identification of health disparities experienced by lesbian, gay, bisexual, and transgender populations. More inclusive electronic health records will allow providers to monitor risk behavior, assess progress toward the reduction of disparities, and provide healthcare that is patient and family centered. Concrete suggestions for the modification of electronic health record systems are presented, as well as how nurse informaticists may be able to bridge gaps in provider knowledge and discomfort through interprofessional collaboration when implementing changes in electronic health records.

Patient perspectives on answering questions about sexual orientation and gender identity: an integrative review.

AIMS AND OBJECTIVES: To examine patients' perceptions of being asked about their sexual orientation and gender identity in the healthcare setting. BACKGROUND: Health disparities exist in the lesbian, gay, bisexual and transgender population, but further research is needed to better understand these disparities. To address this issue, experts recommend the routine collection of sexual orientation and gender identity data in health care. Nurses on the front line of patient care play a key role in the collection of these data. However, to enable nurses to conduct such assessments it is important to understand the perspective of the patients on being asked about their sexual orientation and gender identity in a healthcare setting. DESIGN: An integrative review was conducted using the methodology proposed by Whittemore and Knafl (Journal of Advanced Nursing, 2005, 52, 546). METHODS: Six electronic databases were searched, and two reviewers independently reviewed papers for inclusion. Papers were included if they were empirical studies, peer-reviewed papers or reports, assessing patient perspectives on discussing sexual orientation and gender identity in the healthcare setting. RESULTS: Twenty-one relevant studies that met the inclusion criteria were identified. A majority of the studies indicated patients' willingness to respond to, and a perceived importance of, questions about sexual orientation and gender identity. However, fears of homophobia and negative consequences hindered willingness to disclose this information. CONCLUSIONS: This review indicates that in most cases patients are willing to answer routine questions about their sexual orientation in the healthcare setting and perceive them as important questions to ask. RELEVANCE TO CLINICAL PRACTICE: The findings of this review have implications for nurses looking to incorporate questions about sexual orientation into their routine patient assessment. The findings indicate that care providers need to be mindful of heteronormative assumptions and take steps to ensure they are knowledgeable about lesbian, gay, bisexual and transgender health.

Implementation of Electronic Health Records in US Nursing Homes.

While electronic health records have emerged as promising tools to help improve quality of care, nursing homes have lagged behind in implementation. This study assessed electronic health records implementation, associated facility characteristics, and potential impact on quality indicators in nursing homes. Using national Centers for Medicare & Medicaid Services and survey data for nursing homes, a cross-sectional analysis was conducted to identify variations between nursing homes that had and had not implemented electronic health records. A difference-in-differences analysis was used to estimate the longitudinal effect of electronic health records on commonly used quality indicators. Data from 927 nursing homes were examined, 49.1% of which had implemented electronic health records. Nursing homes with electronic health records were more likely to be nonprofit/government owned (P = .04) and had a lower percentage of Medicaid residents (P = .02) and higher certified nursing assistant and registered nurse staffing levels (P = .002 and .02, respectively). Difference-in-differences analysis showed greater quality improvements after implementation for five long-stay and two short-stay quality measures (P = .001 and .01, respectively) compared with those who did not implement electronic health records. Implementation rates in nursing homes are low compared with other settings, and better-resourced facilities are more likely to have implemented electronic health records. Consistent with other settings, electronic health records implementation improves quality in nursing homes, but further research is needed to better understand the mechanism for improvement and how it can best be supported.

"Striving for Excellence": Minimum Data Set Coordinators' Perceptions of Their Role in the Nursing Home.

The purpose of the current study was to explore how Minimum Data Set (MDS) coordinators perceive their role and the assessment process. Eleven MDS coordinators from 10 geographically dispersed nursing homes (NHs) were interviewed between May and September 2013. Four broad themes emerged from content analysis: (a) information gathering, (b) interdisciplinary coordination, (c) role challenges, and (d) resources. The first two themes referred to key components and competencies in the MDS coordinators' role, the third theme dealt with certain challenges inherent in the role, and the fourth theme highlighted resources that helped address these challenges. The current study provides insight into how MDS coordinators perceive their role, as well as some of the challenges they face to successfully enact that role. The current findings can help inform NH management staff, such as directors of nursing and NH administrators, and policy makers, on how best to support MDS coordinators' work to enable efficient and accurate resident assessment processes.

Understanding infection prevention and control in nursing homes: A qualitative study.

Infections have been identified as a priority issue in nursing homes (NHs). We conducted a qualitative study purposively sampling 10 NHs across the country where 6-8 employees were recruited (N = 73). Semi-structured, open-ended guides were used to conduct in-depth interviews. Data were audiotaped, transcribed and a content analysis was performed. Five themes emerged: 'Residents' Needs', 'Roles and Training' 'Using Infection Data,' 'External Resources' and 'Focus on Hand Hygiene.' Infection prevention was a priority in the NHs visited. While all sites had hand hygiene programs, other recommended areas were not a focus and many sites were not aware of available resources. Developing ways to ensure effective, efficient and standardized infection prevention and control in NHs continues to be a national priority.

Perceived barriers to infection prevention and control for nursing home certified nursing assistants: a qualitative study.

Healthcare-associated infections, while preventable, result in increased morbidity and mortality in nursing home (NH) residents. Frontline personnel, such as certified nursing assistants (CNAs), are crucial to successful implementation of infection prevention and control (IPC) practices. The purpose of this study was to explore barriers to implementing and maintaining IPC practices for NH CNAs as well as to describe strategies used to overcome these barriers. We conducted a multi-site qualitative study of NH personnel important to infection control. Audio-recorded interviews were transcribed verbatim and transcripts were analyzed using conventional content analysis. Five key themes emerged as perceived barriers to effective IPC for CNAs: 1) language/culture; 2) knowledge/training; 3) per-diem/part-time staff; 4) workload; and 5) accountability. Strategies used to overcome these barriers included: translating in-services, hands on training, on-the-spot training for per-diem/part-time staff, increased staffing ratios, and inclusion/empowerment of CNAs. Understanding IPC barriers and strategies to overcome these barriers may better enable NHs to achieve infection reduction goals.

Unveiling Fall Risk Factors: Nurse-Driven Corpus Development for Natural Language Processing.

Hospital-acquired falls are a continuing clinical concern. The emergence of advanced analytical methods, including NLP, has created opportunities to leverage nurse-generated data, such as clinical notes, to better address the problem of falls. In this nurse-driven study, we employed an iterative process for expert manual annotation of RNs clinical notes to enable the training and testing of an NLP pipeline to extract factors related to falls. The resulting annotated data corpus had moderately high interrater reliability (F-score=0.74) and captured a breadth of clinical concepts for extraction with potential utility beyond patient falls. Further research is needed to determine which annotation tasks most benefit from nursing expert annotators, to optimize efficiency when tapping into the invaluable resource represented by the nursing workforce.

Clinical Prediction Models for Hospital-Induced Delirium Using Structured and Unstructured Electronic Health Record Data: Protocol for a Development and Validation Study.

BACKGROUND: Hospital-induced delirium is one of the most common and costly iatrogenic conditions, and its incidence is predicted to increase as the population of the United States ages. An academic and clinical interdisciplinary systems approach is needed to reduce the frequency and impact of hospital-induced delirium. OBJECTIVE: The long-term goal of our research is to enhance the safety of hospitalized older adults by reducing iatrogenic conditions through an effective learning health system. In this study, we will develop models for predicting hospital-induced delirium. In order to accomplish this objective, we will create a computable phenotype for our outcome (hospital-induced delirium), design an expert-based traditional logistic regression model, leverage machine learning techniques to generate a model using structured data, and use machine learning and natural language processing to produce an integrated model with components from both structured data and text data. METHODS: This study will explore text-based data, such as nursing notes, to improve the predictive capability of prognostic models for hospital-induced delirium. By using supervised and unsupervised text mining in addition to structured data, we will examine multiple types of information in electronic health record data to predict medical-surgical patient risk of developing delirium. Development and validation will be compliant to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement. RESULTS: Work on this project will take place through March 2024. For this study, we will use data from approximately 332,230 encounters that occurred between January 2012 to May 2021. Findings from this project will be disseminated at scientific conferences and in peer-reviewed journals. CONCLUSIONS: Success in this study will yield a durable, high-performing research-data infrastructure that will process, extract, and analyze clinical text data in near real time. This model has the potential to be integrated into the electronic health record and provide point-of-care decision support to prevent harm and improve quality of care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48521.

Risk of bias in prognostic models of hospital-induced delirium for medical-surgical units: A systematic review.

PURPOSE: The purpose of this systematic review was to assess risk of bias in existing prognostic models of hospital-induced delirium for medical-surgical units. METHODS: APA PsycInfo, CINAHL, MEDLINE, and Web of Science Core Collection were searched on July 8, 2022, to identify original studies which developed and validated prognostic models of hospital-induced delirium for adult patients who were hospitalized in medical-surgical units. The Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies was used for data extraction. The Prediction Model Risk of Bias Assessment Tool was used to assess risk of bias. Risk of bias was assessed across four domains: participants, predictors, outcome, and analysis. RESULTS: Thirteen studies were included in the qualitative synthesis, including ten model development and validation studies and three model validation only studies. The methods in all of the studies were rated to be at high overall risk of bias. The methods of statistical analysis were the greatest source of bias. External validity of models in the included studies was tested at low levels of transportability. CONCLUSIONS: Our findings highlight the ongoing scientific challenge of developing a valid prognostic model of hospital-induced delirium for medical-surgical units to tailor preventive interventions to patients who are at high risk of this iatrogenic condition. With limited knowledge about generalizable prognosis of hospital-induced delirium in medical-surgical units, existing prognostic models should be used with caution when creating clinical practice policies. Future research protocols must include robust study designs which take into account the perspectives of clinicians to identify and validate risk factors of hospital-induced delirium for accurate and generalizable prognosis in medical-surgical units.

Use of a Data Repository to Identify Delirium as a Presenting Symptom of COVID-19 Infection in Hospitalized Adults: Cross-Sectional Cohort Pilot Study.

BACKGROUND: Delirium, an acute confusional state highlighted by inattention, has been reported to occur in 10% to 50% of patients with COVID-19. People hospitalized with COVID-19 have been noted to present with or develop delirium and neurocognitive disorders. Caring for patients with delirium is associated with more burden for nurses, clinicians, and caregivers. Using information in electronic health record data to recognize delirium and possibly COVID-19 could lead to earlier treatment of the underlying viral infection and improve outcomes in clinical and health care systems cost per patient. Clinical data repositories can further support rapid discovery through cohort identification tools, such as the Informatics for Integrating Biology and the Bedside tool. OBJECTIVE: The specific aim of this research was to investigate delirium in hospitalized older adults as a possible presenting symptom in COVID-19 using a data repository to identify neurocognitive disorders with a novel group of International Classification of Diseases, Tenth Revision (ICD-10) codes. METHODS: We analyzed data from 2 catchment areas with different demographics. The first catchment area (7 counties in the North-Central Florida) is predominantly rural while the second (1 county in North Florida) is predominantly urban. The Integrating Biology and the Bedside data repository was queried for patients with COVID-19 admitted to inpatient units via the emergency department (ED) within the health center from April 1, 2020, and April 1, 2022. Patients with COVID-19 were identified by having a positive COVID-19 laboratory test or a diagnosis code of U07.1. We identified neurocognitive disorders as delirium or encephalopathy, using ICD-10 codes. RESULTS: Less than one-third (1437/4828, 29.8%) of patients with COVID-19 were diagnosed with a co-occurring neurocognitive disorder. A neurocognitive disorder was present on admission for 15.8% (762/4828) of all patients with COVID-19 admitted through the ED. Among patients with both COVID-19 and a neurocognitive disorder, 56.9% (817/1437) were aged ≥65 years, a significantly higher proportion than those with no neurocognitive disorder (P<.001). The proportion of patients aged <65 years was significantly higher among patients diagnosed with encephalopathy only than patients diagnosed with delirium only and both delirium and encephalopathy (P<.001). Most (1272/4828, 26.3%) patients with COVID-19 admitted through the ED during our study period were admitted during the Delta variant peak. CONCLUSIONS: The data collected demonstrated that an increased number of older patients with neurocognitive disorder present on admission were infected with COVID-19. Knowing that delirium increases the staffing, nursing care needs, hospital resources used, and the length of stay as previously noted, identifying delirium early may benefit hospital administration when planning for newly anticipated COVID-19 surges. A robust and accessible data repository, such as the one used in this study, can provide invaluable support to clinicians and clinical administrators in such resource reallocation and clinical decision-making.

The relationship between electronic health records user interface features and data quality of patient clinical information: an integrative review.

OBJECTIVES: Electronic health records (EHRs) user interfaces (UI) designed for data entry can potentially impact the quality of patient information captured in the EHRs. This review identified and synthesized the literature evidence about the relationship of UI features in EHRs on data quality (DQ). MATERIALS AND METHODS: We performed an integrative review of research studies by conducting a structured search in 5 databases completed on October 10, 2022. We applied Whittemore & Knafl's methodology to identify literature, extract, and synthesize information, iteratively. We adapted Kmet et al appraisal tool for the quality assessment of the evidence. The research protocol was registered with PROSPERO (CRD42020203998). RESULTS: Eleven studies met the inclusion criteria. The relationship between 1 or more UI features and 1 or more DQ indicators was examined. UI features were classified into 4 categories: 3 types of data capture aids, and other methods of DQ assessment at the UI. The Weiskopf et al measures were used to assess DQ: completeness (n = 10), correctness (n = 10), and currency (n = 3). UI features such as mandatory fields, templates, and contextual autocomplete improved completeness or correctness or both. Measures of currency were scarce. DISCUSSION: The paucity of studies on UI features and DQ underscored the limited knowledge in this important area. The UI features examined had both positive and negative effects on DQ. Standardization of data entry and further development of automated algorithmic aids, including adaptive UIs, have great promise for improving DQ. Further research is essential to ensure data captured in our electronic systems are high quality and valid for use in clinical decision-making and other secondary analyses.

Fall risk management using clinical decision support in a rural nursing-led primary care practice.

BACKGROUND: The leading cause of injuries among older adults in the United States is unintentional falls. The American Geriatrics Society/British Geriatrics Society promote fall risk management in primary care; however, this is challenging in low-resource settings. LOCAL PROBLEM: Archer Family Health Care (AFHC), an Advanced Practice Registered Nurse (APRN)-managed and federally designated rural health clinic, identified a care gap with falls adherence to guidelines for patients at higher risk for falls. METHODS: The aim of this quality improvement effort was to integrate an evidence-based fall risk management tool in a rural nurse-managed primary care practice. A standardized fall risk management process with a new brief paper-based clinical decision support (CDS) tool was developed and tested in two phases. INTERVENTION: Phase 1 focused on developing a fall risk management CDS tool, identifying the primary care visit workflow, communicating the workflow patterns to the AFHC staff, and collaborating with the staff to identify when and who should implement the tool. Phase 2 focused on implementation of the fall risk management CDS tool into standard practice among older adults aged 65 years and older. RESULTS: We found that integrating the tool did not disrupt the workflow of primary care visits at AFHC. The most common recommended intervention for patients at risk of falling was daily vitamin D supplementation. CONCLUSION: This project revealed that it is feasible to introduce a brief fall risk management decision support tool in an APRN-managed rural primary care practice.

Clinical Decision Support for Fall Prevention: Defining End-User Needs.

BACKGROUND AND SIGNIFICANCE: Falls in community-dwelling older adults are common, and there is a lack of clinical decision support (CDS) to provide health care providers with effective, individualized fall prevention recommendations. OBJECTIVES: The goal of this research is to identify end-user (primary care staff and patients) needs through a human-centered design process for a tool that will generate CDS to protect older adults from falls and injuries. METHODS: Primary care staff (primary care providers, care coordinator nurses, licensed practical nurses, and medical assistants) and community-dwelling patients aged 60 years or older associated with Brigham & Women's Hospital-affiliated primary care clinics and the University of Florida Health Archer Family Health Care primary care clinic were eligible to participate in this study. Through semi-structured and exploratory interviews with participants, our team identified end-user needs through content analysis. RESULTS: User needs for primary care staff (n = 24) and patients (n = 18) were categorized under the following themes: workload burden; systematic communication; in-person assessment of patient condition; personal support networks; motivational tools; patient understanding of fall risk; individualized resources; and evidence-based safe exercises and expert guidance. While some of these themes are specific to either primary care staff or patients, several address needs expressed by both groups of end-users. CONCLUSION: Our findings suggest that there are many care gaps in fall prevention management in primary care and that personalized, actionable, and evidence-based CDS has the potential to address some of these gaps.

Spiritual Interventions Delivered by Nurses to Address Patients' Needs in Hospitals or Long-Term Care Facilities: A Systematic Review.

Introduction: Despite increasing evidence of the benefits of spiritual care and nurses' efforts to incorporate spiritual interventions into palliative care and clinical practice, the role of spirituality is not well understood and implemented. There are divergent meanings and practices within and across countries. Understanding the delivery of spiritual interventions may lead to improved patient outcomes. Aim: We conducted a systematic review to characterize spiritual interventions delivered by nurses and targeted outcomes for patients in hospitals or assisted long-term care facilities. Methodology: The systematic review was developed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and a quality assessment was performed. Our protocol was registered on PROSPERO (Registration No. CRD42020197325). The CINAHL, Embase, PsycINFO, and PubMed databases were searched from inception to June 2020. Results: We screened a total of 1005 abstracts and identified 16 experimental and quasi-experimental studies of spiritual interventions delivered by nurses to individuals receiving palliative care or targeted at chronic conditions, such as advanced cancer diseases. Ten studies examined existential interventions (e.g., spiritual history, spiritual pain assessment, touch, and psychospiritual interventions), two examined religious interventions (e.g., prayer), and four investigated mixed interventions (e.g., active listening, presence, and connectedness with the sacred, nature, and art). Patient outcomes associated with the delivery of spiritual interventions included spiritual well-being, anxiety, and depression. Conclusion: Spiritual interventions varied with the organizational culture of institutions, patients' beliefs, and target outcomes. Studies showed that spiritual interventions are associated with improved psychological and spiritual patient outcomes. The studies' different methodological approaches and the lack of detail made it challenging to compare, replicate, and validate the applicability and circumstances under which the interventions are effective. Further studies utilizing rigorous methods with operationalized definitions of spiritual nursing care are recommended.