Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis.

BACKGROUND: Implementation strategies targeting individual healthcare professionals and teams, such as audit and feedback, educational meetings, opinion leaders, and reminders, have demonstrated potential in promoting evidence-based nursing practice. This systematic review examined the effects of the 19 Cochrane Effective Practice and Organization Care (EPOC) healthcare professional-level implementation strategies on nursing practice and patient outcomes. METHODS: A systematic review was conducted following the Cochrane Handbook, with six databases searched up to February 2023 for randomized studies and non-randomized controlled studies evaluating the effects of EPOC implementation strategies on nursing practice. Study selection and data extraction were performed in Covidence. Random-effects meta-analyses were conducted in RevMan, while studies not eligible for meta-analysis were synthesized narratively based on the direction of effects. The quality of evidence was assessed using GRADE. RESULTS: Out of 21,571 unique records, 204 studies (152 randomized, 52 controlled, non-randomized) enrolling 36,544 nurses and 340,320 patients were included. Common strategies (> 10% of studies) were educational meetings, educational materials, guidelines, reminders, audit and feedback, tailored interventions, educational outreach, and opinion leaders. Implementation strategies as a whole improved clinical practice outcomes compared to no active intervention, despite high heterogeneity. Group and individual education, patient-mediated interventions, reminders, tailored interventions and opinion leaders had statistically significant effects on clinical practice outcomes. Individual education improved nurses' attitude, knowledge, perceived control, and skills, while group education also influenced perceived social norms. Although meta-analyses indicate a small, non-statistically significant effect of multifaceted versus single strategies on clinical practice, the narrative synthesis of non-meta-analyzed studies shows favorable outcomes in all studies comparing multifaceted versus single strategies. Group and individual education, as well as tailored interventions, had statistically significant effects on patient outcomes. CONCLUSIONS: Multiple types of implementation strategies may enhance evidence-based nursing practice, though effects vary due to strategy complexity, contextual factors, and variability in outcome measurement. Some evidence suggests that multifaceted strategies are more effective than single component strategies. Effects on patient outcomes are modest. Healthcare organizations and implementation practitioners may consider employing multifaceted, tailored strategies to address local barriers, expand the use of underutilized strategies, and assess the long-term impact of strategies on nursing practice and patient outcomes. TRIAL REGISTRATION: PROSPERO CRD42019130446.

Acceptability and Feasibility of a Patient-Oriented Music Intervention to Reduce Pain in the Intensive Care Unit: Protocol for a Crossover Pilot Randomized Controlled Trial.

BACKGROUND: Many patients experience pain in the intensive care unit (ICU) despite receiving pain medication. Research has shown that music can help reduce pain. Music interventions studied so far have not used music streaming to generate playlists based on patient preferences while incorporating recommended tempo and duration. Previous research has focused on postoperative ICU patients able to self-report, which is underrepresentative of the ICU population that might benefit from a music intervention for pain management. We developed a new patient-oriented music intervention (POMI) that incorporates features based on theoretical, empirical, and experiential data intended to be used in the ICU. Such a music intervention should consider the expertise of ICU patients, family members, and nursing staff, as well as the practicality of the intervention when used in practice. OBJECTIVE: The primary objectives of this study are to (1) evaluate the acceptability and feasibility of the POMI to reduce pain in ICU patients and (2) evaluate the feasibility of conducting a crossover pilot randomized controlled trial (RCT) for intervention testing in the ICU. A secondary objective is to examine the preliminary efficacy of the POMI to reduce pain in ICU patients. METHODS: A single-blind 2×2 crossover pilot RCT will be conducted. Patients will undergo 1 sequence of 2 interventions: the POMI which delivers music based on patients' preferences via headphones or music pillow for 20-30 minutes and the control intervention (headphones or pillow without music). The sequence of the interventions will be inverted with a 4-hour washout period. Timing of the interventions will be before a planned bed turning procedure. Each patient will undergo 1 session of music. Twenty-four patients will be recruited. Patients able to self-report (n=12), family members of patients unable to self-report (n=12), and nursing staff (n=12) involved in the bed turning procedure will be invited to complete a short questionnaire on the POMI acceptability. Data will be collected on the feasibility of the intervention delivery (ie, time spent creating a playlist, any issue related to headphones/pillow or music delivery, environmental noises, and intervention interruptions) and research methods (ie, number of patients screened, recruited, randomized, and included in the analysis). Pain scores will be obtained before and after intervention delivery. RESULTS: Recruitment and data collection began in March 2022. As of July 5, 2022, in total, 22 patients, 12 family members, and 11 nurses were recruited. CONCLUSIONS: Methodological limitations and strengths are discussed. Study limitations include the lack of blinding for patients able to self-report. Strengths include collecting data from various sources, getting a comprehensive evaluation of the intervention, and using a crossover pilot RCT design, where participants act as their own control, thus reducing confounding factors. TRIAL REGISTRATION: ClinicalTrials.gov NCT05320224; https://clinicaltrials.gov/ct2/show/NCT05320224. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40760.

Clinical outcomes following out-of-hospital cardiac arrest: The minute-by-minute impact of bystander cardiopulmonary resuscitation.

AIMS: The time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients' outcomes. METHODS: This cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0-2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes. RESULTS: Out of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR] = 1.70 [95%CI 1.61-1.80]) and survival with a good neurologic outcome (AOR = 1.87 [95%CI 1.70-2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR = 0.92 [95%CI 0.91-0.93], p < 0.001) and lower survival with a good neurologic outcome (AOR = 0.88 [95%CI 0.86-0.89], p < 0.001). There was no interaction between bystander CPR and EMS response time's association with survival (p = 0.12) and neurologic outcomes (p = 0.65). CONCLUSIONS: Although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.

Development and Design of E_MOTIV: A Theory-Based Adaptive E-Learning Program to Support Nurses' Provision of Brief Behavior Change Counseling.

Brief counseling, when provided by adequately trained nurses, can motivate and support patient health behavior change. However, numerous barriers can impede nurses' capability and motivation to provide brief counseling. Theory-based interventions, as well as information and communication technologies, can support evidence-based practice by addressing these barriers. The purpose of this study was to document the development process of the E_MOTIV asynchronous, theory-based, adaptive e-learning program aimed at supporting nurses' provision of brief counseling for smoking cessation, healthy eating, and medication adherence. Development followed French's stepwise theory- and evidence-based approach: (1) identifying who needs to do what, differently, that is, provision of brief counseling in acute care settings by nurses; (2) identifying determinants of the provision of brief counseling; (3) identifying which intervention components and mode(s) of delivery could address determinants; and (4) developing and evaluating the program. The resulting E_MOTIV program, guided by the Theory of Planned Behavior, Cognitive Load Theory, and the concept of engagement, is unique in its adaptive functionality-personalizing program content and sequence to each learners' beliefs, motivation, and learning preferences. E_MOTIV is one of the first adaptive e-learning programs developed to support nurses' practice, and this study offers key insights for future work in the field.

Association of Initial Pulseless Electrical Activity Heart Rate and Clinical Outcomes following Adult Non-Traumatic Out-of-Hospital Cardiac Arrest.

OBJECTIVE: Studies evaluating the prognostic value of the pulseless electrical activity (PEA) heart rate in out-of-hospital cardiac arrest (OHCA) patients have reported conflicting results. The objective of this study was to evaluate the association between the initial PEA heart rate and favorable clinical outcomes for OHCA patients. METHODS: The present post-hoc cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry Version 3, which included OHCA patients in seven US and three Canadian sites from April 2011 to June 2015. The primary outcome was survival to hospital discharge and the secondary outcome was survival with a good functional outcome. For the primary analysis, the patients were separated into eight groups according to their first rhythms and PEA heart rates: (1) initial PEA heart rate of 1-20 beats per minute (bpm); (2) 21-40 bpm; (3) 41-60 bpm; (4) 61-80 bpm; (5) 81-100 bpm; (6) 101-120 bpm; (7) over 120 bpm; (8) initial shockable rhythm (reference category). Multivariable logistic regression models were used to assess the associations of interest. RESULTS: We identified 17,675 patients (PEA: 7,089 [40.1%]; initial shockable rhythm: 10,797 [59.9%]). Patients with initial PEA electrical frequencies ≤100 bpm were less likely to survive to hospital discharge than patients with initial shockable rhythms (1-20 bpm: adjusted odds ratio [AOR] = 0.15 [95%CI 0.11-0.21]; 21-40 bpm: AOR = 0.21 [0.18-0.25]; 41-60 bpm: AOR = 0.30 [0.25-0.36]; 61-80 bpm: AOR = 0.37 [0.28-0.49]; 81-100 bpm: AOR = 0.55 [0.41-0.65]). However, there were no statistical outcome differences between PEA patients with initial electrical frequencies of >100 bpm and patients with initial shockable rhythms (101-120 bpm: AOR = 0.65 [95%CI 0.42-1.01]; >120 bpm: AOR = 0.72 [95%CI 0.37-1.39]). Similar results were observed for survival with good functional outcomes (101-120 bpm: AOR = 0.60 [95%CI 0.31-1.15]; >120 bpm: AOR = 1.08 [95%CI 0.50-2.28]). CONCLUSIONS: We observed a good association between higher initial PEA electrical frequency and favorable clinical outcomes for OHCA patients. As there is no significant difference in outcomes between patients with initial PEA heart rates of more than 100 bpm and those with initial shockable rhythms, we can hypothesize that these patients could be considered in the same prognostic category.

Accuracy of the Initial Rhythm to Predict a Short No-Flow Time in Out-of-Hospital Cardiac Arrest.

OBJECTIVES: The no-flow time (NFT) can help establish prognosis in out-of-hospital cardiac arrest (OHCA) patients. It is often used as a selection criterion for extracorporeal resuscitation. In patients with an unwitnessed OHCA for whom the NFT is unknown, the initial rhythm has been proposed to identify those more likely to have had a short NFT. Our objective was to determine the predictive accuracy of an initial shockable rhythm for an NFT of 5 minutes or less (NFT ≤ 5). DESIGN: Retrospective analysis of prospectively collected data. SETTING: Prehospital OHCA in eight U.S. and three Canadian sites. PATIENTS: A total of 28,139 adult patients with a witnessed nontraumatic OHCA were included, of whom 11,228 (39.9%) experienced an emergency medical service-witnessed OHCA (NFT = 0), 695 (2.7%) had a bystander-witnessed OHCA, and an NFT less than or equal to 5, and 16,216 (57.6%) with a bystander-witnessed OHCA and an NFT greater than 5. INTERVENTIONS: Sensitivity, specificity, and likelihood ratios of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 minutes. MEASUREMENTS AND MAIN RESULTS: The sensitivity of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 was poor (25% [95% CI, 25-26]), but specificity was moderate (70% [95% CI, 69-71]). The positive and likelihood ratios were inverted (negative accuracy) (positive likelihood ratio, 0.76 [95% CI, 0.74-0.79]; negative likelihood ratio, 1.12 [95% CI, 1.10-1.12]). Including only patients with a bystander-witnessed OHCA improved the sensitivity to 48% (95% CI, 45-52), the positive likelihood ratio to 1.45 (95% CI, 1.33-1.58), and the negative likelihood ratio to 0.77 (95% CI, 0.72-0.83), while slightly lowering the specificity to 67% (95% CI, 66-67). CONCLUSIONS: Our analysis demonstrated that the presence of a shockable rhythm at the time of initial assessment was poorly sensitive and only moderately specific for OHCA patients with a short NFT. The initial rhythm, therefore, should not be used as a surrogate for NFT in clinical decision-making.

The development of the MENTOR_D nursing intervention: Supporting family involvement in delirium management.

BACKGROUND: Although families are increasingly seen as allies to improve delirium management and reduce its consequences, their involvement in the postcardiac surgery setting is challenging considering patients' critical state and short hospital stay. To our knowledge, no theory-based nursing intervention exists that optimally supports the involvement of families in delirium management in the context of postcardiac surgery. OBJECTIVES: We aimed to develop MENTOR_D, a nursing intervention to support the involvement of families in delirium management. METHODS: MENTOR_D was developed based on Sidani and Braden's (2011) intervention development framework. Narrative literature reviews paired with the clinical experience of an expert committee were used to inform these three steps: (1) develop an understanding of the problem under study; (2) define the objectives of the intervention and identify a theoretical framework for highlighting strategies to be used in the intervention; and (3) operationalize the intervention and identify its anticipated outcomes. RESULTS: As a result of the three steps, the MENTOR_D nursing intervention relies on a caring-mentoring relationship between a nurse and the family. The aim of MENTOR_D is to increase the presence of the family at their relative's bedside and their involvement in delirium management. MENTOR_D's content is delivered over three phases that are organised around the visits of the family at the patient's bedside. During these phases, families used their knowledge of the patient to tailor the delirium management actions. These actions include orientation and reminiscence and were aimed at diminishing anxiety and increasing sense of self-efficacy in families and diminishing delirium severity and improving recovery in patients. CONCLUSIONS: A deep understanding of the underlying mechanisms of an intervention is key in its success to reach the targeted goals of effectiveness in practice. This understanding can be achieved through the careful development of a theory of the intervention before the operationalisation of its components and its testing. The proposed paper presents the theory of the MENTOR_D intervention, that is, its conceptualization and proposed mechanisms of action. IMPLICATIONS FOR PRACTICE: As delirium continues to be a major complication, this intervention is a promising solution to increase families' involvement in delirium management and highlights the support that nurses can offer to facilitate this involvement. With its use in future studies and practice, it can be further refined.

Psychometric properties of the French and English short form of the Protective Behavioural Strategies for Marijuana Scale in Canadian university students.

BACKGROUND: The Protective Behavioural Strategies for Marijuana (PBSM-17) scale serves to identify and measure strategies employed by young adults before, during or after cannabis use. After the adaptation and translation of the PBSM-17 into French, a methodological study was conducted to evaluate the psychometric properties of this French version (FV) and of the original English version (EV) in a sample of bilingual Canadian university students. METHODS: A total of 211 cannabis users (mean age=22.1 years) completed a sociodemographic questionnaire, a question on frequency of cannabis use (four categories: 1-3 times a month, once a week, more than once a week, everyday) and both versions (FV and EV) of the PBSM-17. RESULTS: Both versions had similar internal reliability (α=0.91; α=0.88). The one-factor solution explained 36.46% of the variance for the FV and 42.26% for the EV. As hypothesised, greater use of protective behavioural strategies was related to lower frequency of cannabis use. One-way ANOVA test results revealed a statistically significant difference in use of strategies by frequency of cannabis use for both the FV (F(3, 207)=27.38, p<0.001) and EV (F(3, 207)=29.32, p<0.001). Post hoc comparisons showed that everyday users employed fewer strategies on average than lower-frequency users. CONCLUSION: The FV and EV of the PBSM-17 demonstrated satisfactory psychometric properties. The proposed FV of the PBSM-17 is a reliable instrument that could be used for research and clinical purposes. Protective behavioural strategies can serve as indicator of lower-risk cannabis use and could be targeted in prevention interventions.

Subsyndromal Delirium in Cardiac Surgery Patients: Risk Factors and Outcomes of the Different Trajectories.

BACKGROUND: Subsyndromal delirium (SSD), a subthreshold form of delirium, is related to longer length of stay and increased mortality rates among older adults. Risk factors and outcomes of SSD in cardiac surgery patients are not fully understood. OBJECTIVE: The aim of this study was to assess and describe the characteristics and outcomes related to trajectories of SSD and delirium in cardiac surgery patients. METHODS: In this secondary analysis of a retrospective case-control (1:1) cohort study, SSD was defined as a score between 1 and 3 on the Intensive Care Delirium Screening Checklist paired with an absence of diagnosis of delirium on the day of assessment. Potential risk factors (eg, age) and outcomes (eg, mortality) were identified from existing literature. Patients were grouped into 4 trajectories: (1) without SSD or delirium, (2) SSD only, (3) both, and (4) delirium only. These trajectories were contrasted using analysis of variance or χ2 test. RESULTS: Among the cohort of 346 patients, 110 patients did not present with SSD or delirium, 62 presented with only SSD, 69 presented with both, and 105 presented with only delirium. In comparison with patients without SSD or delirium, patients with SSD presented preoperative risk factors known for delirium (ie, older age, higher European System for Cardiac Operative Risk Evaluation II) but underwent less complicated surgical procedures, received fewer transfusions postoperatively, and had a lower positive fluid balance postoperatively than patients who presented with delirium. Patients with both SSD and delirium had worse outcomes in comparison with those with delirium only. CONCLUSION: This study stresses the importance for healthcare professionals to identify SSD and prevent its progression to delirium.

[French translation, cultural adaptation and assessment of preliminary psychometric properties of the Protective Behavioral Strategies for Marijuana Scale]. / Traduction française, adaptation culturelle et évaluation des propriétés psychométriques préliminaires de l'échelle des stratégies de protection comportementale liées à la consommation de cannabis.

OBJECTIVE: Young adults (18- to 24-year-olds) constitute the age group with the highest proportion of cannabis users. In the context of legalization, it is important to promote lower-risk cannabis use. The Protective Behavioral Strategies for Marijuana Scale (PBSM-17) identifies strategies used by consumers. However, this scale is not available in French and is not adapted to the Canadian context. This article presents the process that led to the translation, cultural adaptation and evaluation of the preliminary psychometric properties of PBSM-17. METHOD: The methodological study was carried out in six steps. The first four steps led to the translation towards French and adaptation of the scale. A validation among 12 young people contributed to establish the criterion equivalency (step 5). The evaluation of psychometric properties (step 6) was carried out among 211 bilingual university students (61 % women; mean age 22 years old). RESULTS: The French version presents satisfactory preliminary psychometric properties: internal consistency is acceptable (α = 0.88); criterion equivalency was established between the French and the original English version (t (210) = 1.04, p = 0.30; 95% CI [-0.20, 0.63]). The scores obtained on both versions by the same participant were found to be strongly correlated (r = 0.95, p <0.001). CONCLUSION: The results support the use of the French version of PBSM-17. The proposed protective strategies can be used as a measurement tool and represent behaviors that can be targeted in a lower-risk cannabis use context.

OBJECTIF: Les jeunes de 18 à 24 ans constituent la plus grande proportion de consommateurs de cannabis. Dans un contexte de légalisation de cette substance, il importe de promouvoir une consommation à moindre risque. L'échelle Protective Behavioral Strategies for Marijuana Scale (PBSM-17) permet d'identifier les stratégies de protection comportementale utilisées chez les consommateurs. Toutefois, cette échelle n'est pas disponible en français et n'est pas adaptée au contexte canadien. Cet article présente la démarche ayant mené à la traduction, l'adaptation culturelle et l'évaluation des propriétés psychométriques préliminaires du PBSM-17. MÉTHODE: L'étude méthodologique s'est déroulée en six étapes. Les quatre premières étapes ont mené à la traduction et l'adaptation de l'échelle. La validation auprès de 12 jeunes a permis d'établir l'équivalence conceptuelle. L'évaluation des propriétés psychométriques a été réalisée auprès de 211 étudiants universitaires bilingues (61 % femme; âge moyen 22 ans). RÉSULTATS: La version traduite et adaptée présente des propriétés psychométriques préliminaires satisfaisantes : la cohérence interne est acceptable (α = 0,88); l'équivalence de critères (validité de construit) est établie entre la version française et la version anglaise (t (210) = 1,04, p = 0,30 ; IC 95 % [-0,20, 0,63]). Les scores obtenus aux deux versions par le même participant s'avèrent fortement corrélées (r = 0,95, p < 0,001). CONCLUSION: Les résultats soutiennent l'utilisation de la version française du PBSM-17. Les stratégies de protection proposées peuvent être utilisées comme outil de mesure et représentent des comportements à adopter dans un contexte d'usage du cannabis à moindre risque.

Front-line emergency department nurses' and physicians' assessments of processes of elder-friendly care for quality improvement.

INTRODUCTION: Geriatric emergency department (ED) care has gained increasing importance and interest due to increasing visits in seniors. AIM: Among ED front-line nurses and physicians, to assess and compare ratings of elder-friendly care process indicators, variability in ratings, and concurrent validity of ratings. METHODS: Four Quebec EDs' full-time registered nurses and physicians rated their geriatric care using 9 subscales. Nurse and physician subscale scores were compared. Inter-rater variability within disciplines and variability between nurses and physicians were measured. Associations between the subscale scores and perceived overall quality of care were tested. RESULTS: 38 nurses and 36 physicians completed the survey (83% of 89 eligible). Scores differed by discipline for 3 of 9 subscales computed; nurses had higher mean scores on Protocols, Family-Centered Discharge, and Staff Education. Very high variation for Staff Education was found within disciplines. Variations for Family-Centered Discharge differed significantly between nurses and physicians. Almost all subscale scores were significantly positively associated with perceived overall quality of care. CONCLUSIONS: ED nurses and physicians rate geriatric care components similarly except for protocols, discharge processes, and continuing education. The subscales have concurrent validity. Results suggest a need for improvement in continuing educational strategies with a particular attention to discharge processes.

A theory-based adaptive E-learning program aimed at increasing intentions to provide brief behavior change counseling: Randomized controlled trial.

BACKGROUND: Unhealthy behaviors are significant contributors to non-communicable diseases. Nurses can support patient health behavior change by providing brief behavior change counseling. However, training programs in brief counseling are generally not personalized, or adapted, to the barriers and theoretical determinants of its provision in clinical practice. OBJECTIVE: This study aimed to evaluate the effectiveness of the E_MOTIVA theory-based adaptive e-learning program on nurses' and nursing students' intentions to provide brief counseling for smoking, unhealthy eating habits and medication nonadherence. DESIGN AND METHODS: A randomized controlled trial was conducted with nurses and nursing students in Canada. Experimental group participants were allocated to the E_MOTIVA theory-based adaptive e-learning program. Control group participants were allocated to the E_MOTIVB knowledge-based standardized e-learning program. E_MOTIVA was designed to influence the constructs of the Theory of Planned Behavior (e.g., attitude, subjective norms) in relation to brief counseling. Outcomes were improvement in intention to provide brief counseling, improvement in other Theory of Planned Behavior variables, as well as cognitive load and engagement related to e-learning. RESULTS: A total of 102 participants were randomized to the experimental (n = 51) and control (n = 51) groups. End of study questionnaires were completed by 27 experimental group and 38 control group participants. Analyses indicated no significant differences between groups in the change of scores for intention to provide brief counseling. However, while not significant, the change of score was greater in the experimental group (10.22 ± 3.34 versus 9.04 ± 2.80; p = 0.787). Scores in both groups improved significantly for attitude, subjective norms, perceived behavioral control, behavioral beliefs, and control beliefs. However, there were no statistically significant differences between groups for these variables as well as for cognitive load and engagement. CONCLUSIONS: Both e-learning programs had a similar positive effect on nurses' and nursing students' intentions to provide brief counseling and on Theory of Planned Behavior variables. TRIAL REGISTRATION: ISRCTN Registry ISRCTN32603572; http://www.isrctn.com/ISRCTN32603572. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/18894; https://doi.org/10.2196/18894.

Electrical rhythm degeneration in adults with out-of-hospital cardiac arrest according to the no-flow and bystander low-flow time.

AIMS: For out-of-hospital cardiac arrest (OHCA) patients, the influence of the delay before the initiation of resuscitation, termed the no-flow time (NFT), and duration of bystander-only resuscitation low-flow time (BLFT) on the type of electrical rhythm observed has not been well described. The objective of this study is to determine the relationship between NFT, BLFT and the likelihood of a shockable rhythm over time. METHODS: Using a North American prospective registry (2005-2015; mostly urban settings), we selected adult (18 years and over) patients who experienced a witnessed OHCA from a suspected cardiac etiology. Patients with an emergency medical services witnessed OHCA were only included in sensitivity analyses. The association between the NFT, BLFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression adjusting for the registry version, age, sex, and public location. RESULTS: A total of 229,632 patients were logged in the registry, 50,957 of whom were included. Of these, 17,704 (34.7%) had an initial shockable rhythm. After the first minute, a significant decrease over time in the occurrence of shockable rhythm is observed but is slower when bystander cardiopulmonary resuscitation (CPR) is provided (each supplemental minute of BLFT: adjusted odds ratio = 0.95, 95 %CI = 0.94-0.95; each supplemental minute of NFT: adjusted odds ratio = 0.91, 95 %CI = 0.90-0.91]). CONCLUSIONS: In this large observational study, we were able to demonstrate that longer NFT were associated with lower odds of shockable presenting rhythms. Bystander CPR significantly mitigates the degradation of shockable rhythms over time, strengthening the need to improve bystander CPR rates around the world.

Involvement of End Users in the Development of Serious Games for Health Care Professions Education: Systematic Descriptive Review.

BACKGROUND: On the basis of ethical and methodological arguments, numerous calls have been made to increase the involvement of end users in the development of serious games (SGs). Involving end users in the development process is considered a way to give them power and control over educational software that is designed for them. It can also help identify areas for improvement in the design of SGs and improve their efficacy in targeted learning outcomes. However, no recognized guidelines or frameworks exist to guide end users' involvement in SG development. OBJECTIVE: The aim of this study is to describe how end users are involved in the development of SGs for health care professions education. METHODS: We examined the literature presenting the development of 45 SGs that had reached the stage of efficacy evaluation in randomized trials. One author performed data extraction using an ad hoc form based on a design and development framework for SGs. Data were then coded and synthesized on the basis of similarities. The coding scheme was refined iteratively with the involvement of a second author. Results are presented using frequencies and percentages. RESULTS: End users' involvement was mentioned in the development of 21 of 45 SGs. The number of end users involved ranged from 12 to 36. End users were often involved in answering specific concerns that arose during the SG design (n=6) or in testing a prototype (n=12). In many cases, researchers solicited input from end users regarding the goals to reach (n=10) or the functional esthetics of the SGs (n=7). Most researchers used self-reported questionnaires (n=7). CONCLUSIONS: Researchers mentioned end users' involvement in the development of less than half of the identified SGs, and this involvement was also poorly described. These findings represent significant limitations to evaluating the impact of the involvement of end users on the efficacy of SGs and in making recommendations regarding their involvement.

Oxygen Therapy and Risk of Infection for Health Care Workers Caring for Patients With Viral Severe Acute Respiratory Infection: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: To synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. Health care workers face significant risk of infection when treating patients with a viral severe acute respiratory infection. To ensure health care worker safety and limit nosocomial transmission of such infection, it is crucial to synthesize the evidence regarding the infection risk associated with different modalities of oxygen therapy used in treating patients with severe acute respiratory infection. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to April 1, 2020, for studies describing the risk of infection associated with the modalities of oxygen therapy used for patients with severe acute respiratory infection. The study selection, data extraction, and quality assessment were performed by independent reviewers. The primary outcome measure was the infection of health care workers with a severe acute respiratory infection. Random-effect models were used to synthesize the extracted data. RESULTS: Of 22,123 citations, 50 studies were eligible for qualitative synthesis and 16 for meta-analysis. Globally, the quality of the included studies provided a very low certainty of evidence. Being exposed or performing an intubation (odds ratio 6.48; 95% confidence interval 2.90 to 14.44), bag-valve-mask ventilation (odds ratio 2.70; 95% confidence interval 1.31 to 5.36), and noninvasive ventilation (odds ratio 3.96; 95% confidence interval 2.12 to 7.40) were associated with an increased risk of infection. All modalities of oxygen therapy generate air dispersion. CONCLUSION: Most modalities of oxygen therapy are associated with an increased risk of infection and none have been demonstrated as safe. The lowest flow of oxygen should be used to maintain an adequate oxygen saturation for patients with severe acute respiratory infection, and manipulation of oxygen delivery equipment should be minimized.

Can a Shockable Initial Rhythm Identify Out-of-Hospital Cardiac Arrest Patients with a Short No-flow Time?

AIMS: Initial shockable rhythms may be a marker of shorter duration between collapse and initiation of cardiopulmonary resuscitation, known as no-flow time (NFT), for patients suffering an out-of-hospital cardiac arrest (OHCA). Eligibility for extracorporeal resuscitation is conditional on a short NFT. Patients with an unwitnessed OHCA could be candidate for extracorporeal resuscitation despite uncertain NFT if an initial shockable rhythm is a reliable stand-in. Herein, we sought to describe the sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minutes or less. METHODS: Using a registry of OHCA in Montreal, Canada, adult patients who experienced a witnessed non-traumatic OHCA, but who did not receive bystander cardiopulmonary resuscitation, were included. The sensitivity and specificity of an initial shockable rhythm for predicting a NFT of five minute or less were calculated. The association between the NFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression. RESULTS: A total of 2450 patients were included, of whom 863 (35%) had an initial shockable rhythm and 1085 (44%) a NFT of five minutes or less. The sensitivity of an initial shockable rhythm to predict a NFT of five minutes or less was 36% (95% confidence interval [95%CI] 33-39), specificity was 66% (95%CI 63-68), the positive likelihood ratio was 1.05 (95%CI 0.94-1.17) and the negative likelihood ratio of 0.97 (95%CI 0.92-1.03). The probabilities of observing a shockable rhythm stayed stable up to 15 minutes, while the probabilities of observing a PEA lowered rapidly initially. Longer NFT were associated with lower odds of observing an initial shockable rhythm (adjusted odds ratio = 0.97 [95%CI 0.94-0.99], p = 0.012). CONCLUSIONS: An initial shockable rhythm is a poor predictor of a short NFT, despite there being an association between the NFT and the presence of a shockable rhythm.

Efficacy of Serious Games in Healthcare Professions Education: A Systematic Review and Meta-analysis.

SUMMARY STATEMENT: Serious games (SGs) are interactive and entertaining software designed primarily with an educational purpose. This systematic review synthesizes evidence from experimental studies regarding the efficacy of SGs for supporting engagement and improving learning outcomes in healthcare professions education. Randomized controlled trials (RCTs) published between January 2005 and April 2019 were included. Reference selection and data extraction were performed in duplicate, independently. Thirty-seven RCTs were found and 29 were included in random-effect meta-analyses. Compared with other educational interventions, SGs did not lead to more time spent with the intervention {mean difference 23.21 minutes [95% confidence interval (CI) = -1.25 to 47.66]}, higher knowledge acquisition [standardized mean difference (SMD) = 0.16 (95% CI = -0.20 to 0.52)], cognitive [SMD 0.08 (95% CI = -0.73 to 0.89)], and procedural skills development [SMD 0.05 (95% CI = -0.78 to 0.87)], attitude change [SMD = -0.09 (95% CI = -0.38 to 0.20)], nor behavior change [SMD = 0.2 (95% CI = -0.11 to 0.51)]. Only a small SMD of 0.27 (95% CI = 0.01 to 0.53) was found in favor of SGs for improving confidence in skills.

Effectiveness of a Theory- and Web-Based Adaptive Implementation Intervention on Nurses' and Nursing Students' Intentions to Provide Brief Counseling: Protocol for a Randomized Controlled Trial.

BACKGROUND: Brief counseling can motivate patients to initiate health behavior change. However, increasing the provision of brief counseling by nurses is difficult due to contextual and practitioner-level factors impeding nurses' motivation and intentions to provide brief counseling (eg, unfavorable attitude toward brief counseling, lack of perceived control linked to barriers). Theory-based implementation interventions could address these practitioner-level factors and support evidence-based practice in the context of brief counseling. Web-based, adaptive e-learning (electronic learning) programs are a novel type of implementation intervention that could address the limitations of current brief counseling training programs, such as accessibility and personalization. OBJECTIVE: This paper presents a study protocol for evaluating the effectiveness of the E_MOTIVA implementation intervention-a theory- and web-based adaptive e-learning program-to increase nurses' and nursing students' intentions to provide brief counseling for smoking, an unbalanced diet, and medication nonadherence. METHODS: A two-group, single-blind, randomized controlled trial will be conducted with nurses and nursing students enrolled in a Bachelor of Science in Nursing program in Quebec, Canada. Participants in the experimental group will be allocated to the E_MOTIVA intervention-a theory- and web-based adaptive e-learning program-while participants in the active control group will be allocated to the E_MOTIVB intervention, a knowledge- and web-based standardized e-learning program. The E_MOTIVA intervention was designed to influence the constructs of the Theory of Planned Behavior (eg, attitude, subjective norms, and perceived behavioral control) in the context of brief counseling. The Cognitive Load Index and User Engagement Scale will be used to assess participants' cognitive load and engagement related to e-learning. Participants will complete the Brief Counseling Nursing Practices Questionnaire-Abridged Version at baseline and follow-up. All study measures will be completed online. RESULTS: The study is ongoing. The results of the study will provide answers to the primary hypothesis (H1) that experimental group participants will demonstrate a greater change in the score of intentions to provide brief counseling between baseline (-T1) and follow-up (T4). Secondary hypotheses include greater improvements in scores of attitude (H2), subjective norms (H3), perceived control (H4), behavioral beliefs (H5), normative beliefs (H6), and control beliefs (H7) regarding brief counseling in the experimental group between baseline and follow-up. We also anticipate lower intrinsic and extrinsic cognitive loads (H8, H9), higher germane cognitive load (H10), and higher engagement (H11, H12) in the experimental group. CONCLUSIONS: This study will be among the first in evaluating a novel type of implementation intervention, a theory- and web-based adaptive e-learning program, in nurses and nursing students. This type of intervention has the potential to support evidence-based practice through accessible, personalized training in wide-ranging domains in nursing. TRIAL REGISTRATION: ISRCTN Registry ISRCTN32603572; http://www.isrctn.com/ISRCTN32603572. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/18894.

Experiences of an Emergency Department Visit Among Older Adults and Their Families: Qualitative Findings From a Mixed-Methods Study.

BACKGROUND: Emergency department (ED) visits are critical events for older adults, but little is known regarding their experiences, particularly about their physical needs, the involvement of accompanying family members, and the transition back to the community. OBJECTIVE: To explore experiences of an ED visit among patients aged 75 and older. METHODS: In a mixed-methods study, a cohort of patients aged 75 and older (or a family member) discharged from the ED back to the community was recruited from 4 urban EDs. A week following discharge, structured telephone interviews supplemented with open-ended questions were conducted. A subsample (76 patients, 32 family members) was purposefully selected. Verbatim transcripts of responses to the open-ended questions were thematically analyzed. RESULTS: Experiences related to physical needs included comfort, equipment supporting mobility and autonomy, help when needed, and access to drink and food. Family members required opportunities to provide patient support and greater involvement in their care. At discharge, patients/families required adequate discharge education, resolution of their health problem, information on medications, and greater certainty about planned follow-up medical and home care services. CONCLUSIONS: Our findings suggest several areas that could be targeted to improve patient and family perceptions of the care at an ED visit.