A Narrative Study on the Impact of Information and Communication Technology on the Relationship between Patients and Medical Learners.

BACKGROUND: Current medical learners are immersed in an era of tremendous technological advancements. Consequently, the use of information and communication technologies (ICTs) might impact entrustable professional activities (EPAs), such as interpersonal and communication skills between learners and patients. OBJECTIVE: The aim of this study was to explore medical learners' perspectives on ICTs and its impact on the relationship between them and their patients. METHODS: Semi-structured interviews were conducted with medical learners to elicit their perspectives regarding ICTs in a clinical setting. Interviews were recorded, transcribed and analyzed to identify key themes. RESULTS: Participants reported that ICTs implementation improved quality of care by allowing for rapid access to patient information and facilitating clinical decision making. However, technology use created a potential challenge to forging empathy toward patients and developing a rapport with them. CONCLUSION: It is paramount to devise safeguards or milestone requirements in student evaluations for graduation.

Nursing Leadership in the Fully Digital Practice Realm.

In the fully digital practice realm, a new relationship has emerged between nurses, patients and technology. Nursing leadership in this unique practice setting requires new and enhanced skills, knowledge and abilities. Maintaining the principles of patient and family centredness, attentiveness to nurses' concerns regarding workflows and involvement of nurses in the design of technologies is critical for creating a safe, professional practice environment in the fully digital hospital. Technology cannot replace the humanness of caring. Mindfulness of the digital impact on the therapeutic relationship is necessary. Competency in technology is the new proficiency that nursing leaders will need to acquire.

Closed-Loop Medication System: Leveraging Technology to Elevate Safety.

BACKGROUND: Healthcare organizations have long been dependent on the vigilance of nurses to identify and intercept medication errors before they can adversely affect patients. New technologies have been implemented in an effort to reduce medication errors; however, few studies have evaluated the long-term effects of technology-based interventions in reducing medication errors. AIM: The aim of this study was to evaluate the effects of barcode medication administration (BCMA) and the closed-loop medication system (CLMS) interventions on medication errors and adverse drug event (ADE) rates. METHODS: An autoregressive integrated moving average model for interrupted time series design was used to evaluate the impact of the BCMA and CLMS interventions on the monthly reported medication error and ADE rates at Humber River Hospital between September 2013 and August 2018. Descriptive statistics were generated to evaluate the types of error and their gravity. RESULTS: A total of 1,712 medication errors and ADEs were reported in the five-year study period. The results of the interrupted time series indicated that the introduction of the BCMA intervention was associated with a statistically significant gradual decrease in reported medication error and ADE rates at 0.002 percentage points per month (p = 0.003). The introduction of the CLMS intervention was associated with an immediate absolute decrease in reported medication error and ADE rates of 0.010% (p = 0.020). CONCLUSIONS: The findings from this study support the adoption of both BCMA and CLMS interventions to prevent medication errors. Staged implementation of CLMS allows time for learning and incorporating barcode scanning. Interprofessional and cross-functional collaboration is necessary to successfully integrate the requirements of each respective discipline and service in the CLMS.

Smartphone Technology: Enabling Prioritization of Patient Needs and Enhancing the Nurse-Patient Relationship.

BACKGROUND: Mobile health (mHealth) is a rapidly growing field with the potential to transform healthcare delivery. Smartphone technologies have been developed and integrated into the patient call bell system for healthcare staff to receive calls; however, there is a lack of high-quality evidence to support the implementation and evaluate the effectiveness of these devices in a healthcare setting. AIM: The aim of this study is to explore nurses' perceptions of smartphone technology devices in enhancing the nurse-patient relationship and improving nursing workflows. METHODS: A semi-structured focus group and interviews were used to illicit nurses' experiences with smartphone technology. Interviews were audio recorded, transcribed and subjected to a content analysis to identify emerging themes from the data. RESULTS: Interviews with nurses provided insight into the benefits and challenges of smartphone use in the clinical setting. Multiple benefits were identified by nurse participants, including time management and convenience, prioritization, patient safety and enhancement of the nurse-patient relationship. CONCLUSION: There are multiple benefits of smartphone technology for both nurses and patients. Hospitals proposing to introduce smartphone technology need to educate patients and families about the clinical use of smartphones to avoid unfavourable perceptions. Smartphone technology must be interoperable with the electronic medical record to optimize interprofessional communication and exchange of patient information.

Violence Prevention: Technology-Enabled Therapeutic Intervention.

BACKGROUND: Nurses are disproportionately prone to experience incidents of violent victimization. Despite the vast literature on violence in healthcare settings, few studies have identified effective violence prevention interventions. AIM: The aim of the study was to explore the experiences of nurses regarding the implementation of technology-based violence prevention interventions. METHODS: Qualitative data were collected through semi-structured focus groups and interviews with 11 nurses at Humber River Hospital. Interviews were audiotaped, transcribed and subjected to a content analysis to identify core themes from the data. RESULTS: Three themes were identified: reassurance of safety, an increase in proactive measures and limitations of technology. Nurses held positive perceptions of the impact of technology-based interventions on violent incidents. The interventions were regarded as effective for the detection of potentially violent patients as well as for providing assistance from security staff when a violent incident occurs or appears imminent. However, nurses also acknowledged that patient-related violence was "unavoidable" and that technology cannot fully prevent violence from occurring. CONCLUSION: The findings from this study support the replication of these interventions in other healthcare facilities. Engaging staff, patients and families in this unique digital and technology-enriched environment has been critical for the successful implementation of the violence prevention electronic flagging system. Patient and family education and communication were essential for addressing concerns related to "labelling."

Patient Empowerment and Nursing Clinical Workflows Enhanced by Integrated Bedside Terminals.

BACKGROUND: Integrated bedside terminals (IBTs) were implemented at Humber River Hospital with the goal of supporting patient independence and autonomy and improving nursing workflows. The IBTs provide access to a range of convenience and entertainment services as well as access to personal health information. Due to the novelty of the technology, there is a paucity of empirical data on patients' use of, satisfaction with and perceptions of bedside terminals. AIM: The purpose of this study was to evaluate the impact of IBTs on patient empowerment and nursing workflows. METHODS: A mixed methods design was employed using a cross-sectional patient survey and semi-structured interviews with nurses. The patient survey assessed patient empowerment and satisfaction with the range of services offered through the IBT. Patient scores were summarized using descriptive statistics. Additionally, face-to-face interviews with nurses were used to illicit feedback regarding the IBTs' impacts on nursing workflows. RESULTS: In total, 113 patients and 11 nurses participated in the study. Analysis of patient satisfaction surveys indicated that the IBTs enhanced the patient experience and increased self-care management. Nurses reported that the IBTs helped patients feel comfortable and entertained and helped enhance the nurse-patient relationship. However, nurses also expressed concern that elderly patients were less inclined to use the IBT. CONCLUSION: The results from the present study suggest that the IBT system has the potential to empower patients and decrease demands on nurses. Patients' notes incorporated into the IBT may provide the necessary level of involvement to garner a greater sense of patient empowerment. The IBT does not replace the need for nurses to deliver information to patients in a manner that supports their trust.

Experiences of Nurses Working in a Fully Digital Hospital: A Phenomenological Study.

BACKGROUND: With the increasing development and integration of information and communication technology (ICT) into hospitals, there remains a lack of understanding of the impact of these technologies on the hospital's largest core users: nurses. Humber River Hospital (HRH), one of the first hospitals to completely integrate technology across all hospital systems and workflows, has sought to understand how ICTs have transformed the clinical working environment. OBJECTIVE: The aim of the study was to achieve a deeper understanding of the lived experiences of nurses practising in North America's first digital hospital. METHODS: The methodological approach was informed by van Manen's hermeneutic phenomenological methodology. Data were gathered through in-depth semi-structured interviews with eight nurses at HRH. Thematic analysis was conducted using the van Manen and Colaizzi methods of data analysis. RESULTS: Six thematic categories that formed the nurses' lived experiences of working in a digital environment were identified: safety, time, teamwork, technology failures, patient responses and adapting. CONCLUSION: Nurses at HRH identified six themes regarding their lived experiences working in a fully digital hospital that provide an insight into nurses' values and cause us to reflect on how we might use this information to further support nursing practice in the fully digital environment. Nurses at HRH seem to have normalized the nursing process within the fully digital environment. Technology appears to be viewed by nurses at HRH within the premise of nursing as an art, allowing patient responses to be acknowledged and incorporated into nursing workflows, and as a science, permitting safe care delivery. Overall, nurses perceived technology as being essential for patient safety and facilitating nursing practice. These findings offer insight into nurses' perception of ICTs, and as technological advancements continue to emerge, these findings will inform education, practice and policy.

Generational Differences in Hospital Technology Adoption: A Cross-Sectional Study.

BACKGROUND: The advancement of technological change within healthcare means that it is essential for nurses to have the necessary technological skills to deliver safe and efficient nursing care. Few studies have examined whether generational differences affect the adoption of technology within the healthcare system. AIM: The primary purpose of this study was to explore predictors that influence the adoption of technology. METHODS: In this cross-sectional study, nurses were asked to rate their level of competency on 20 key skills related to clinical technological devices (CTDs) in a self-administered questionnaire. Participants' demographic data and level of proficiency related to personal computer skills were also collected. Multiple linear regression analysis was used to examine whether demographic characteristics and personal computer skills predicted higher scores related to CTDs. RESULTS: Sixty-three nurses completed the questionnaires. Overall mean score for skills related to CTD was high at 3.74 (SD = 0.75) out of 5. Length of employment at the hospital and previous exposure to the technology used at the hospital (ß = 0.06, p = 0.021; ß = 0.054, p = 0.011, respectively) were the only variables significantly associated with higher CTD skills scores. Generational cohort, gender, years of nursing experience and self-rated proficiency related to personal computer skills were not related to higher CTD skills scores. CONCLUSION: The results of this study emphasize that consistent exposure to technology enhances its adoption. Generational cohort did not play a role in the perception of nurses' technology competency at Humber River Hospital.

Optimizing Nursing Practice through Integration of Best Practice Guidelines into Electronic Medical Records.

A commitment to best practice guidelines (BPGs) is crucial for ensuring the safety of patients. Recognizing the power of information technology, Humber River Hospital has integrated BPGs into the electronic medical record (EMR) infrastructure. The large-scale implementation institutes a uniform standard of care and ensures adherence to BPGs through a forcing function designed to require nurses to complete and document the necessary assessments. The initiative strengthens the audit process and provides the opportunity to identify long-term trends. The implications of the quality improvement initiative are discussed. Due to the widespread use of EMRs, the replication of this initiative is economically feasible in other healthcare settings.

Predictors of new graduate nurses' health over the first 4 years of practice.

AIM: To examine predictors of Canadian new graduate nurses' health outcomes over 1 year. DESIGN: A time-lagged mail survey was conducted. METHOD: New graduate nurses across Canada (N = 406) responded to a mail survey at two time points: November 2012-March 2013 (Time 1) and May-July 2014 (Time 2). Multiple linear regression (mental and overall health) and logistic regression (post-traumatic stress disorder risk) analyses were conducted to assess the impact of Time 1 predictors on Time 2 health outcomes. RESULTS: Both situational and personal factors were significantly related to mental and overall health and post-traumatic stress disorder risk. Regression analysis identified that cynicism was a significant predictor of all three health outcomes, while occupational coping self-efficacy explained unique variance in mental health and work-life interference explained unique variance in post-traumatic stress disorder risk.

A comparison of hospital-acquired pressure injuries in intensive care and non-intensive care units: a multifaceted quality improvement initiative.

Hospital-acquired pressure injuries (HAPI) are a significant cause of morbidity and mortality, and represent a major health concern worldwide. Patients suffering from HAPI report a poor quality of life on several dimensions of health. Moreover, HAPI is reported to lengthen in-hospital stay in the acute setting, posing significant healthcare resource utilisations and costs. Given the clinical and economic burden of HAPI, recent best practice guidelines provide recommendations to reduce the prevalence of pressure injuries. Humber River Hospital (HRH), a large community hospital in Toronto, Canada, has a daily census of approximately 500 patients. The aim of this project was to reduce the prevalence of HAPI within the intensive care unit (ICU) and non-ICU setting at HRH within a 1-year period. Using the International Pressure Injury/Ulcer Prevalence (IPUP) Survey we established a baseline prevalence of HAPI of 27.6% (n=315) for non-ICU and 30% for ICU (n=33) patients at our institution in 2015. Using the Plan-Do-Study-Act (PDSA) method for quality improvement, we implemented a multifaceted approach aimed at improving equipment, digital documentation and education on risk assessment, prevention and treatment strategies. Over multiple PDSA cycles, our prevalence of HAPI reduced to 16% for non-ICU patients with no changes to the HAPI prevalence in ICU patients in 2016. Sustainability continues with HAPI prevalence currently at 10% in 2017 for non-ICU patients, which outperforms the Canadian prevalence (13.7%) by census size for 2017. However, the prevalence of HAPI in the ICU increased to 45% in 2017 despite multiple quality improvement initiatives, suggesting critically ill patients represent a unique challenge for reducing HAPI for these patients at our institution.

Starting Out: qualitative perspectives of new graduate nurses and nurse leaders on transition to practice.

AIM: To describe new graduate nurses' transition experiences in Canadian healthcare settings by exploring the perspectives of new graduate nurses and nurse leaders in unit level roles. BACKGROUND: Supporting successful transition to practice is key to retaining new graduate nurses in the workforce and meeting future demand for healthcare services. METHOD: A descriptive qualitative study using inductive content analysis of focus group and interview data from 42 new graduate nurses and 28 nurse leaders from seven Canadian provinces. RESULTS: New graduate nurses and nurse leaders identified similar factors that facilitate the transition to practice including formal orientation programmes, unit cultures that encourage constructive feedback and supportive mentors. Impediments including unanticipated changes to orientation length, inadequate staffing, uncivil unit cultures and heavy workloads. CONCLUSIONS: The results show that new graduate nurses need access to transition support and resources and that nurse leaders often face organisational constraints in being able to support new graduate nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Organisations should ensure that nurse leaders have the resources they need to support the positive transition of new graduate nurses including adequate staffing and realistic workloads for both experienced and new nurses. Nurse leaders should work to create unit cultures that foster learning by encouraging new graduate nurses to ask questions and seek feedback without fear of criticism or incivility.

Starting Out: A time-lagged study of new graduate nurses' transition to practice.

BACKGROUND: As the nursing profession ages, new graduate nurses are an invaluable health human resource. OBJECTIVES: The purpose of this study was to investigate factors influencing new graduate nurses' successful transition to their full professional role in Canadian hospital settings and to determine predictors of job and career satisfaction and turnover intentions over a one-year time period in their early employment. DESIGN: A national two-wave survey of new graduate nurses across Canada. PARTICIPANTS: A random sample of 3906 Registered Nurses with less than 3 years of experience currently working in direct patient care was obtained from the provincial registry databases across Canada. At Time 1, 1020 of 3743 eligible nurses returned completed questionnaires (usable response rate=27.3%). One year later, Time 1 respondents were mailed a follow-up survey; 406 returned a completed questionnaire (response rate=39.8%). METHODS: Surveys containing standardized questionnaires were mailed to participants' home address. Descriptive statistics, correlations, and hierarchical linear regression analyses were conducted using SPSS software. RESULTS: Overall, new graduate nurses were positive about their experiences and committed to nursing. However, over half of new nurses in the first year of practice reported high levels of emotional exhaustion and many witnessed or experienced incivility (24-42%) at work. Findings from hierarchical linear regression analyses revealed that situational and personal factors explained significant amounts of variance in new graduate nurses' job and career satisfaction and turnover intentions. Cynicism was a significant predictor of all four outcomes one year later, while Psycap predicted job and career satisfaction and career turnover intentions. CONCLUSIONS: Results provide a look into the worklife experiences of Canadian new graduate nurses over a one-year time period and identify factors that influence their job-related outcomes. These findings show that working conditions for new graduate nurses are generally positive and stable over time, although workplace mistreatment is an issue to be addressed.

Measuring physicians' productivity: a three-year study to evaluate a new remuneration system.

PURPOSE: To evaluate a new assessment tool measuring physicians' academic productivity and its use in a performance-based remuneration system. METHOD: The authors developed an assessment tool based on existing tools to measure productivity. Yearly, from 2008 to 2011, physicians at the University of Western Ontario received a score of up to three points for each of four components (impact, application, scholarly activity, mentorship) in each of four domains (clinical practice, education, research, administration). Scores were weighted by the percentage of time physicians spent on tasks in each domain. Year 1 scores were a baseline. In Years 2 and 3, scores were tied to remuneration. The authors compared scores and associations, accounting for age and academic rank, across the three years. RESULTS: The 37 participating physicians included 11 assistant, 23 associate, and 4 full professors. The mean weighted total baseline score across all four domains was 7.44. Years 2 and 3 scores were highly correlated with Year 1 scores (r = 0.85, Years 1 and 2; r = 0.89, Years 1 and 3). Year 2 mean weighted scores did not differ significantly from Year 1 scores. Assistant professors' scores improved significantly between Years 1 and 2 (+1.08, P < .001). Lower Year 1 scores were correlated with a greater improvement in scores between Years 1 and 2, and age was negatively correlated with score changes between Years 2 and 3. CONCLUSIONS: Although the tool may be a robust measurement of physicians' productivity, performance-based remuneration had no effect on physicians' overall performance.

Part 2: Nurses' career aspirations to management roles: qualitative findings from a national study of Canadian nurses.

AIM: Our aim was to investigate direct-care nurses' interests in formal management roles and factors that facilitate their decision-making. BACKGROUND: Based on a projected shortage of nurses by 2022, the profession could be short of 4200 nurse managers in Canada within the next decade. However, no data are currently available that identify nurses' interests in assuming manager roles. METHODS: Using focus group methodology, we conducted 18 focus groups with 125 staff nurses and managers in four regions across Canada. RESULTS: Major themes and subthemes influencing nurses' decisions to pursue management roles included personal demographic (education, age, clinical experience and life circumstances), personal disposition (leadership skills, intrinsic rewards and professional commitment) and situation (leadership development opportunities, manager role perceptions and presence of mentors). Although nurses see management roles as positive opportunities, they did not perceive the rewards to be great enough to outweigh their concerns. CONCLUSIONS: Findings suggested that organizations need to provide support, leadership development and succession opportunities and to redesign manager roles for optimum success. IMPLICATIONS FOR NURSING MANAGEMENT: Leaders need to ensure that they convey positive images of manager roles and actively identify and support staff nurses with leadership potential.

Part 1: The influence of personal and situational predictors on nurses' aspirations to management roles: preliminary findings of a national survey of Canadian nurses.

AIM: To examine the influence of personal and situational factors on direct-care nurses' interests in pursuing nursing management roles. BACKGROUND: Nursing managers are ageing and nurses do not appear to be interested in nursing management roles, raising concerns about a nursing leadership shortage in the next decade. Little research has focused on factors influencing nurses' career aspirations to nursing management roles. METHODS: A national survey of nurses from nine Canadian provinces was conducted (n = 1241). Multiple regression was used to test a model of personal and situational predictors of nurses' career aspirations to management roles. RESULTS: Twenty-four per cent of nurses expressed interest in pursuing nursing management roles. Personal and situational factors explained 60.2% of nurses' aspirations to management roles. Age, educational preparation, feasibility of further education, leadership self-efficacy, career motivation, and opportunity to motivate others were the strongest predictors of aspirations for management roles. CONCLUSIONS: Personal factors were more strongly associated with career aspirations than situational factors. There is a steady decline in interest in management roles with increasing age. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leadership training to develop leadership self-efficacy (particularly for younger nurses) and organizational support for pursuing advanced education may encourage nurses to pursue nursing management roles.

Continuous quality improvement: a shared governance model that maximizes agent-specific knowledge.

Motivate, Innovate, Celebrate: an innovative shared governance model through the establishment of continuous quality improvement (CQI) councils was implemented across the London Health Sciences Centre (LHSC). The model leverages agent-specific knowledge at the point of care and provides a structure aimed at building human resources capacity and sustaining enhancements to quality and safe care delivery. Interprofessional and cross-functional teams work through the CQI councils to identify, formulate, execute and evaluate CQI initiatives. In addition to a structure that facilitates collaboration, accountability and ownership, a corporate CQI Steering Committee provides the forum for scaling up and spreading this model. Point-of-care staff, clinical management and educators were trained in LEAN methodology and patient experience-based design to ensure sufficient knowledge and resources to support the implementation.

Policy to practice: collaboration in the evolution of a nursing health human resources policy.

In 2007, the Ontario Ministry of Health and Long-Term Care made an investment to support full-time employment for new graduate nurses. This paper describes the collaboration of policy makers and researchers in the creation and implementation of the Nursing Graduate Guarantee (NGG). We provide historical context for the development of the initiative and discuss some of the issues related to its implementation. Relevant stakeholders assisted researchers and policy makers in the creation, implementation and evaluation of the NGG. Researchers continue to work with policy makers in ongoing evaluations of the multi-year strategy, which are informed by stakeholder input.