Smart Technology for Aging and Reducing Disability (STAReD): Study protocol for a randomized pragmatic clinical trial.

BACKGROUND: There is a critical need to improve quality of life for community-dwelling older adults with disabilities. Prior research has demonstrated that a smart, in-home sensor system can facilitate aging in place for older adults living in independent living apartments with care coordination support by identifying early illness and injury detection. Self-management approaches have shown positive outcomes for many client populations. Pairing the smart, in-home sensor system with a self-management intervention for community-dwelling older adults with disabilities may lead to positive outcomes. METHODS: This study is a prospective, two-arm, randomized, pragmatic clinical trial to compare the effect of a technology-supported self-management intervention on disability and health-related quality of life to that of a health education control, for rural, community-dwelling older adults. Individuals randomized to the self-management study arm will receive a multidisciplinary (nursing, occupational therapist, and social work) self-management approach coupled with the smart-home sensor system. Individuals randomized to the health education study arm will receive standard health education coupled with the smart-home sensor system. The primary outcomes of disability and health-related quality of life will be assessed at baseline and post-intervention. Generalizable guidance to scale the technology-supported self-management intervention will be developed from qualitatively developed exemplar cases. CONCLUSION: This study has the potential to impact the health and well-being of rural, community-dwelling older adults with disabilities. We have overcome barriers including recruitment in a rural population and supply chain issues for the sensor system. Our team remains on track to meet our study aims.

Perceptions and Attitudes toward a Proposed Digital Health Physical Activity Program among Older Family Caregivers of Persons with Heart Failure: A Qualitative Study.

Tailored physical activity (PA) programs using digital health technologies in the home can promote family caregivers' (FCGs) physical function and psychological wellbeing. However, there is a gap in research for digital health PA interventions targeting older FCGs of persons with HF (HF-FCGs). The burden of caregiving for persons with HF may displace the FCG's self-care, including PA. Therefore, we examined older HF-FCGs' perceptions and attitudes toward three technology components (video-conferencing, fitness tracker, text messaging) that would be most useful in delivering a digital health PA program. Interviews were conducted with 13 HF-FCGs (≥65 years old) between January and April 2021. Directed content analysis was used and the analysis was guided by the adapted unified theory of acceptance and use of technology (UTAUT) model. In addition to HF-FCGs' perceptions and attitudes toward each technology component in each construct of the adapted UTAUT model (ease of use, usefulness, facilitating conditions), three additional factors were associated with intention to use technology. These were: (1) HF patients' positive experience, (2) digital skills, and (3) quality of internet connectivity. The findings provide digital health requirements for design and modification of a technology-supported PA program that engages older FCGs who care for persons with HF.

A Technology-Enhanced Intervention for Violence and Substance Use Prevention Among Young Black Men: Protocol for Adaptation and Pilot Testing.

BACKGROUND: Black boys and men from disinvested communities are disproportionately survivors and perpetrators of youth violence. Those presenting to emergency departments with firearm-related injuries also report recent substance use. However, young Black men face several critical individual and systemic barriers to accessing trauma-focused prevention programs. These barriers contribute to service avoidance, the exacerbation of violence recidivism, substance use relapse, and a revolving-door approach to prevention. In addition, young Black men are known to be digital natives. Therefore, technology-enhanced interventions offer a pragmatic and promising opportunity to mitigate these barriers, provide vital life skills for self-led behavior change, and boost service engagement with vital community resources. OBJECTIVE: The study aims to systematically adapt and pilot-test Boosting Violence-Related Outcomes Using Technology for Empowerment, Risk Reduction, and Life Skills Preparation in Youth Based on Acceptance and Commitment Therapy (BrotherlyACT), a culturally congruent, trauma-focused digital psychoeducational and service-engagement tool tailored to young Black men aged 15-24 years. BrotherlyACT will incorporate microlearning modules, interactive safety planning tools for risk assessment, goal-setting, mindfulness practice, and a service-engagement conversational agent or chatbot to connect young Black men to relevant services. METHODS: The development of BrotherlyACT will occur in 3 phases. In phase 1, we will qualitatively investigate barriers and facilitators influencing young Black men's willingness to use violence and substance use prevention services with 15-30 young Black men (aged 15-24 years) who report perpetrating violence and substance use in the past year and 10 service providers (aged >18 years; any gender; including health care providers, street outreach workers, social workers, violence interrupters, community advocates, and school staff). Both groups will be recruited from community and pediatric emergency settings. In phase 2, a steering group of topic experts (n=3-5) and a youth and community advisory board comprising young Black men (n=8-12) and service providers (n=5-10) will be involved in participatory design, alpha testing, and beta testing sessions to develop, refine, and adapt BrotherlyACT based on an existing skills-based program (Achieving Change Through Values-Based Behavior). We will use user-centered design principles and the Assessment, Decision, Administration, Production, Topical, Experts, Integration, Training, and Testing framework to guide this adaptation process (phase 2). In phase 3, a total of 60 young Black men will pilot-test the adapted BrotherlyACT over 10 weeks in a single-group, pretest-posttest design to determine its feasibility and implementation outcomes. RESULTS: Phase 1 data collection began in September 2021. Phases 2 and 3 are scheduled to start in June 2023 and end in September 2024. CONCLUSIONS: The development and testing of BrotherlyACT is a crucial first step in expanding an evidence-based psychoeducational and service-mediating intervention for young Black men involved in violence. This colocation of services shifts the current prevention strategy from telling them why to change to teaching them how. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/43842.

Community-dwelling older adults' acceptance of smartwatches for health and location tracking.

BACKGROUND: Despite rapid growth in the popularity of smartwatches, evidence lacks regarding older adults' acceptance of smartwatches. Since most wearable sensors are not designed specifically for older adults, there is a need to examine wearability and usability challenges of wearable sensing devices faced by older adults to facilitate the use of objective measurements of health and mobility. OBJECTIVES: We aimed to examine older adults' perceptions of GPS-enabled smartwatches and to identify potential barriers and facilitators of smartwatch and sensor data use. METHODS: As part of a larger feasibility study, we conducted a mixed-methods study that included a descriptive content analysis of interviews and a brief usability survey with 30 participants aged 60 years and older after they had used a smartwatch for 3 days. RESULTS: Most participants perceived wearable activity trackers including smartwatches and sensor-based data as useful for tracking health, finding activity patterns and promoting healthy behaviours. Privacy was of little concern, leading to willingness to share activity and location data with others. Participants identified barriers to usability as clumsy design, lack of aesthetic appeal, and difficulty reading the display and using the GPS tracking function. In contrast, identified facilitators of adoption included a big display, high-tech look, self-awareness and possible behaviour change. CONCLUSIONS: Smartwatches have the potential of personalised detection of health deterioration and disability prevention, based on analysis of older adults' activities in free-living environments. The usefulness of this technology for older adults can be significantly increased by addressing usability issues and providing instructions on challenging features. IMPLICATIONS FOR PRACTICE: To support sustained self-monitoring behaviours through wearable sensor devices in older adults, it is critical to examine how they perceive those devices and identify factors affecting technology acceptance that can maximise adoption.

Dashboard Design to Identify and Balance Competing Risk of Multiple Hospital-Acquired Conditions.

BACKGROUND: Hospital-acquired conditions (HACs) are common, costly, and national patient safety priority. Catheter-associated urinary tract infections (CAUTIs), hospital-acquired pressure injury (HAPI), and falls are common HACs. Clinicians assess each HAC risk independent of other conditions. Prevention strategies often focus on the reduction of a single HAC rather than considering how actions to prevent one condition could have unintended consequences for another HAC. OBJECTIVES: The objective of this study is to design an empirical framework to identify, assess, and quantify the risks of multiple HACs (MHACs) related to competing single-HAC interventions. METHODS: This study was an Institutional Review Board approved, and the proof of concept study evaluated MHAC Competing Risk Dashboard to enhance clinicians' management combining the risks of CAUTI, HAPI, and falls. The empirical model informing this study focused on the removal of an indwelling urinary catheter to reduce CAUTI, which may impact HAPI and falls. A multisite database was developed to understand and quantify competing risks of HACs; a predictive model dashboard was designed and clinical utility of a high-fidelity dashboard was qualitatively tested. Five hospital systems provided data for the predictive model prototype; three served as sites for testing and feedback on the dashboard design and usefulness. The participatory study design involved think-aloud methods as the clinician explored the dashboard. Individual interviews provided an understanding of clinician's perspective regarding ease of use and utility. RESULTS: Twenty-five clinicians were interviewed. Clinicians favored a dashboard gauge design composed of green, yellow, and red segments to depict MHAC risk associated with the removal of an indwelling urinary catheter to reduce CAUTI and possible adverse effects on HAPI and falls. CONCLUSION: Participants endorsed the utility of a visual dashboard guiding clinical decisions for MHAC risks preferring common stoplight color understanding. Clinicians did not want mandatory alerts for tool integration into the electronic health record. More research is needed to understand MHAC and tools to guide clinician decisions.

Remote Usability Testing to Facilitate the Continuation of Research.

Usability testing has historically been an in-person activity where test participants and evaluation researchers are co-located. Recruiting participants into usability studies can be a challenging endeavor especially when potential participants are concerned about time commitments and social distancing. The global COVID-19 pandemic has driven the development of remote usability testing methods. In this paper, we describe remote usability testing as it evolved during a pre-pandemic research study. We adapted our in-person usability evaluation methodology for a commercially available mHealth app to a remote usability testing methodology to accommodate potential participants during a more convenient participant-identified time. In doing so we met the needs, preferences, and availability of our participants and maintained research progress. Adapting to patient-centered needs through remote usability testing has the potential to facilitate continued research and engage potential participants due to its convenience, flexibility, and decrease constraints presented by geographic limits.

Digital Methodology for Mobile Clinical Decision Support Development in Long-Term Care.

The global COVID-19 pandemic has driven innovations in methods to sustain initiatives for the design, development, evaluation, and implementation of clinical support technology in long-term care settings while removing risk of infection for residents, family members, health care workers, researchers and technical professionals. We adapted traditional design and evaluation methodology for a mobile clinical decision support app - designated Mobile Application Information System for Integrated Evidence ("MAISIE") - to a completely digital design methodology that removes in-person contacts between the research team, developer, and nursing home staff and residents. We have successfully maintained project continuity for MAISIE app development with only minor challenges while working remotely. This digital design methodology can be implemented in projects where software can be installed without in-person technical support and remote work is feasible. Team skills, experience, and relationships are key considerations for adapting to digital environments and maintaining project momentum.

Designing a Cloud-Based System for Affordable Cyberinfrastructure to Support Software-Based Research.

Interest in cloud-based cyberinfrastructure among higher-education institutions is growing rapidly, driven by needs to realize cost savings and access enhanced computing resources. Through a nonprofit entity, we have created a platform that provides hosting and software support services enabling researchers to responsibly build on cloud technologies. However, there are technical, logistic, and administrative challenges if this platform is to support all types of research. Software-enhanced research is distinctly different from industry applications, typically characterized by needs for lower reduced availability, greater flexibility, and fewer resources for upkeep costs. We describe a swarm environment specifically designed for research in academic settings and our experience developing an operating model for sustainable cyberinfrastructure. We also present three case studies illustrating the types of applications supported by the cyberinfrastructure and explore techniques that address specific application needs. Our findings demonstrate safer, faster, cheaper cloud services by recognizing the intrinsic properties of academic research environments.

Challenges in Heart Failure Disease Management in Skilled Nursing Facilities: A Qualitative Study.

Clinical guidelines recommend clinicians in skilled nursing facilities (SNFs) monitor body weight and signs and symptoms related to heart failure (HF) and encourage a sodium restricted diet to improve HF outcomes; however, SNFs face considerable challenges in HF disease management (HF-DM). In the current study, we characterized the challenges of HF-DM with data from semi-structured, in-depth interviews with patients, caregivers, staff, and physicians from nine SNFs. Patients receiving skilled nursing care were interviewed together as a dyad with their caregiver. A data-driven, qualitative descriptive approach was used to understand the process and challenges of HF-DM. Coded text was categorized into descriptive themes. Interviews with five dyads (n = 10 individuals), SNF nurses and certified nursing assistants (n = 13), and physicians (n = 2) revealed that, among the sample, HF care was not prioritized above other competing health concerns. Staff operated in the challenging SNF environment largely without protocols or educational materials to prompt HF-DM. [Journal of Gerontological Nursing, 48(5), 13-17.].

Low- and High-Intensity Physical Activity Among People with HIV: Multilevel Modeling Analysis Using Sensor- and Survey-Based Predictors.

BACKGROUND: High-intensity physical activity improves the health of people with HIV. Even when people have good intentions to engage in physical activity, they often find it difficult to maintain physical activity behavior in the long term. Two Minds Theory is a neurocognitive model that explains gaps between people's intentions and behaviors based on the operations of 2 independent mental systems. This model predicts that everyday experiences will affect physical activity and that factors outside people's awareness, such as sleep and stress, can have particularly strong effects on physical activity behaviors. OBJECTIVE: We designed this study to test the effects of daily experiences on physical activity among people with HIV, including measures of people's conscious experiences using daily electronic surveys and measures of nonconscious influences using sensor devices. METHODS: In this study, 55 people with HIV wore a Fitbit Alta for 30 days to monitor their physical activity, sleep, and heart rate variability (HRV) as a physiological indicator of stress. Participants also used their smartphones to complete daily electronic surveys for the same 30 days about fatigue, self-efficacy, mood, stress, coping, motivation, and barriers to self-care. Time-lagged, within-person, multilevel models were used to identify the best prospective predictors of physical activity, considering the daily survey responses of people with HIV and sensor data as predictors of their physical activity the following day. We also tested baseline surveys as predictors of physical activity for comparison with daily variables. RESULTS: Different people had different average levels of physical activity; however, physical activity also varied substantially from day to day, and daily measures were more predictive than baseline surveys. This suggests a chance to intervene based on day-to-day variations in physical activity. High-intensity physical activity was more likely when people with HIV reported less subjective fatigue on the prior day (r=-0.48) but was unrelated to actual sleep based on objective sensor data. High-intensity physical activity was also predicted by higher HRV (r=0.56), indicating less stress, lower HIV-related stigma (r=-0.21), fewer barriers to self-care (r=-0.34), and less approach coping (r=-0.34). Similar variables predicted lower-level physical activity measured based on the number of steps per day of people with HIV. CONCLUSIONS: Some predictors of physical activity, such as HRV, were only apparent based on sensor data, whereas others, such as fatigue, could be measured via self-report. Findings about coping were unexpected; however, other findings were in line with the literature. This study extends our prior knowledge on physical activity by demonstrating a prospective effect of everyday experiences on physical activity behavior, which is in line with the predictions of Two Minds Theory. Clinicians can support the physical activity of people with HIV by helping their patients reduce their daily stress, fatigue, and barriers to self-care.

Evaluation framework for selecting wearable activity monitors for research.

BACKGROUND: Wearable devices that support activity tracking and other measurements hold great potential to increase awareness of health behaviors and support the management of chronic health conditions. There is a scarcity of guidance for researchers of all disciplines when planning new studies to evaluate and select technologies appropriate for study purpose, population, and overall context. The aim of this study was to develop and test an evaluation framework to rapidly and systematically evaluate and select consumer-grade wearable devices that serve individual study needs in preparation for evaluations with target populations. METHODS: The wearable evaluation framework was defined based on published literature and past research experiences of the research team. We tested the framework with example case studies to select devices for two different research projects focused on aging-in-place and gestational diabetes. We show how knowledge of target population and research goals help prioritize application of the criteria to inform device selection and how project requirements inform sequence of criteria application. RESULTS: The framework for wearable device evaluation includes 27 distinct evaluation criteria: 12 for everyday use by users, 6 on device functionality, and 9 on infrastructure for developing the research infrastructure required to obtain the data. We evaluated 10 devices from four vendors. After prioritizing the framework criteria based on the two example case studies, we selected the Withings Steele HR, Garmin Vivosmart HR+ and Garmin Forerunner 35 for further evaluation through user studies with the target populations. CONCLUSIONS: The aim of this paper was to develop and test a framework for researchers to rapidly evaluate suitability of consumer grade wearable devices for specific research projects. The use of this evaluation framework is not intended to identify a definitive single best device, but to systematically narrow the field of potential device candidates for testing with target study populations. Future work will include application of the framework within different research projects for further refinement.

Patient Characteristics Are Not Associated With Documentation of Weight and Heart Failure Related Sign and Symptom Assessment in Skilled Nursing Facilities.

OBJECTIVE: Monitoring body weight and signs and symptoms related to heart failure (HF) can alert clinicians to a patient's worsening condition but the degree to which these practices are performed in skilled nursing facilities (SNFs) is unknown. This study analyzed the frequency of these monitoring practices in SNFs and explored associated factors at both the patient and SNF level. DESIGN: An observational study of data from the usual care arm of the SNF Connect Trial, a randomized cluster trial of a HF disease management intervention. The data extracted from charts were combined with publicly available facility data. A linear regression model was estimated to evaluate the frequency of HF disease management conditional on patient and facility covariates. SETTING: Data from 28 SNFs in Colorado. PARTICIPANTS: Patients discharged from hospital to SNFs with a primary or secondary diagnosis of HF. MEASUREMENTS: Patient-level covariates included demographics, New York Heart Association class, type of HF, and Charlson comorbidity index. Facility-level covariates were from Nursing Home Compare. RESULTS: The sample (n = 320) was majority female (66%), white (93%), with mean age 80 ± 10 years and a Charlson comorbidity index of 3.2 ± 1.5. Seventy percent had HF with preserved ejection fraction, mean ejection fraction of 50 ± 16% and 40% with a New York Heart Association class III-IV. On average, patients were weighed 40% of their days in the SNF and had documentation of at least 1 HF-related sign or symptom 70% of their days in the SNF. Patient-level factors were not associated with frequency of documenting weight and assessments of HF-related signs/symptoms. Health Inspection Star Rating was positively associated with weight monitoring (P < .05) but not associated with symptom assessment. CONCLUSIONS AND IMPLICATIONS: Patient-level factors are not meaningfully associated with the documentation of weight tracking or sign/symptom assessment. Monitoring weight was instead associated with the Health Inspection Star Rating.

Design and Evaluation of Low-Fidelity Visual Display Prototypes for Multiple Hospital-Acquired Conditions.

Hospital-acquired conditions such as catheter-associated urinary tract infection, stage 3 or 4 hospital-acquired pressure injury, and falls with injury are common, costly, and largely preventable. This study used participatory design methods to design and evaluate low-fidelity prototypes of clinical dashboards to inform high-fidelity prototype designs to visualize integrated risks based on patient profiles. Five low-fidelity prototypes were developed through literature review and by engaging nurses, nurse managers, and providers as participants (N = 23) from two hospitals in different healthcare systems using focus groups and interviews. Five themes were identified from participatory design sessions: Need for Integrated Hospital-Acquired Condition Risk Tool, Information Needs, Sources of Information, Trustworthiness of Information, and Performance Tracking Perspectives. Participants preferred visual displays that represented patient comparative risks for hospital-acquired conditions using the familiar design metaphor of a gauge and green, yellow, and red "traffic light" colors scheme. Findings from this study were used to design a high-fidelity prototype to be tested in the next phase of the project. Visual displays of hospital-acquired conditions that are familiar in display and simplify complex information such as the green, yellow, and red dashboard are needed to assist clinicians in fast-paced clinical environments and be designed to prevent alert fatigue.

Information Needs of Skilled Nursing Facility Staff to Support Heart Failure Disease Management.

OBJECTIVES: Characterize key tasks and information needs for heart failure disease management (HF-DM) in the distinct care setting of skilled nursing facility (SNF) staff in partnership with community-based clinical stakeholders. Develop design recommendations contextualized to the SNF setting for informatics interventions for improved HF-DM in the SNF setting. METHODS: Semi-structured interviews with fifteen participants (registered nurses, licensed practical nurses, certified nursing aides and physicians) from 8 Denver-metro SNFs. Data coded using a data-driven, inductive approach. RESULTS: Key tasks of HF-DM: symptom assessment, communicating change in condition, using equipment, documentation of daily weights, and monitoring patients. Themes: 1) HF-DM is challenged by a culture of verbal communication; 2) staff face knowledge barriers in HF-DM that are partially attributed to unmet information needs. HF-DM information needs: identification of HF patients, HF signs and symptoms, purpose of daily weights, indicators of worsening HF, purpose of sodium restricted diet, and materials to improve patients' understanding of HF. DISCUSSION AND CONCLUSIONS: HF-DM information needs are not fully supported by current SNF information systems.

Older women's perceptions of wearable and smart home activity sensors.

Introduction: The aim of this study was to characterize perceptions of wearable and smart home technologies of older women using semi-structured interviews.Methods and Procedures: Participants (n = 10) were shown two wearable sensors and a smart home sensor. All participants were 60 years of age or older with the exception of one participant (ages: 57-70,average age: 64.6 years). Sensor function and placement were explained. Participants were asked questions about technology, perceptions of sensors, and thoughts about the use of these types of sensors. Interview transcripts were analyzed to identify themes related to technology acceptance, perceived usefulness, and privacy issues.Main Outcome and Results: Participants perceived wearable and smart home sensors as acceptable for personal activity data collection. In general, wearable sensors were perceived as more useful than smart home sensors because most participants had high levels of activities outside their homes. Participants had few concerns about data sharing. Privacy issues related to perceived risk for break-ins or unwanted disclosure of activity levels.Conclusion: Given the higher proportion of women over men in the older adult population, and some of the aging-related health risks that women face, it is important to understand older women's perceptions of different types of sensor technologies.

Sensor and Survey Measures Associated With Daily Fatigue in HIV: Findings From a Mixed-Method Study.

Fatigue is the most common symptom among people living with HIV (PLWH), but may have many causes. This mixed-method study was designed to characterize PLWH's fatigue experiences and associated self-management behaviors, using Two Minds Theory. Fifty-five PLWH completed daily smartphone surveys on psychological states and fatigue at random times for 30 days and used a Fitbit Alta™ wristband. Within-person multilevel models were used to identify univariate correlates of fatigue. The first 25 participants also completed qualitative interviews about their experiences, and results were compared across methods. Participants had significant fatigue despite well-controlled HIV. Fatigue varied between persons and over time. Fatigue was associated with physical activity, sleep, daily psychological states, and barriers to self-care. PLWH reported new insights into fatigue from self-monitoring. There are potential opportunities for PLWH to improve sleep, activity, or stress management to alleviate fatigue. PLWH were interested in reducing fatigue and willing to use self-monitoring technology.

Usability Testing of a Mobile Clinical Decision Support App for Urinary Tract Infection Diagnosis in Nursing Homes.

The aim of the current study was to conduct usability testing of a mobile clinical decision support (CDS) prototype designed for urinary tract infection (UTI) assessment by nurses in nursing homes (NHs). Usability of the UTIDecide smartphone application (app) was evaluated using cognitive walk-through and think-aloud protocol sessions with nurses (n = 6) at two NH sites. This evaluation was followed by unsupervised field tests lasting ≥1 week with nurses at one site (n = 4) and posttest interviews and administration of the System Usability Scale (SUS). Cognitive walk-through/think-aloud sessions yielded interface design recommendations that were implemented prior to field tests. All test sessions resulted in highly positive perceived usability and usefulness from participants. Average SUS score was 92.5 (n = 3), which equates to an "A" grade for usability. Design recommendations identified for future app versions are: (a) integration of the mobile CDS app with organizational information systems; and (b) expanded features to support assessment of other conditions. [Journal of Gerontological Nursing, 45(7), 11-17.].

Characterizing Workflow to Inform Clinical Decision Support Systems in Nursing Homes.

BACKGROUND AND OBJECTIVES: Clinical decision support systems (CDSS) hold promise to influence clinician behavior at the point of care in nursing homes (NHs) and improving care delivery. However, the success of these interventions depends on their fit with workflow. The purpose of this study was to characterize workflow in NHs and identify implications of workflow for the design and implementation of CDSS in NHs. RESEARCH DESIGN AND METHODS: We conducted a descriptive study at 2 NHs in a metropolitan area of the Mountain West Region of the United States. We characterized clinical workflow in NHs, conducting 18 observation sessions and interviewing 15 staff members. A multilevel work model guided our data collection and framework method guided data analysis. RESULTS: The qualitative analysis revealed specific aspects of multilevel workflow in NHs: (a) individual, (b) work group/unit, (c) organization, and (d) industry levels. Data analysis also revealed several additional themes regarding workflow in NHs: centrality of ongoing relationships of staff members with the residents to care delivery in NHs, resident-centeredness of care, absence of memory aids, and impact of staff members' preferences on work activities. We also identified workflow-related differences between the two settings. DISCUSSION AND IMPLICATIONS: Results of this study provide a rich understanding of the characteristics of workflow in NHs at multiple levels. The design of CDSS in NHs should be informed by factors at multiple levels as well as the emergent processes and contextual factors. This understanding can allow for incorporating workflow considerations into CDSS design and implementation.

Temporal Immediacy: A Two-System Theory of Mind for Understanding and Changing Health Behaviors.

BACKGROUND: Health promotion and chronic disease management both require behavior change, but people find it hard to change behavior despite having good intentions. The problem arises because patients' narratives about experiences and intentions are filtered through memory and language. These narratives inaccurately reflect intuitive decision-making or actual behaviors. OBJECTIVES: We propose a principle-temporal immediacy-as a moderator variable that explains which of two mental systems (narrative or intuitive) will be activated in any given situation. We reviewed multiple scientific areas to test temporal immediacy as an explanation for findings. METHODS: In an iterative process, we used evidence from philosophy, cognitive neuroscience, behavioral economics, symptom science, and ecological momentary assessment to develop our theoretical perspective. These perspectives each suggest two cognitive systems that differ in their level of temporal immediacy: an intuitive system that produces behavior in response to everyday states and a narrative system that interprets and explains these experiences after the fact. FINDINGS: Writers from Plato onward describe two competing influences on behavior-often with moral overtones. People tend to identify with the language-based narrative system and blame unhelpful results on the less accessible intuitive system, but neither is completely rational, and the intuitive system has strengths based on speed and serial processing. The systems differ based on temporal immediacy-the description of an experience as either "now" or "usually"-with the intuitive system generating behaviors automatically in real time and the narrative system producing beliefs about the past or future. DISCUSSION: The principle of temporal immediacy is a tool to integrate nursing science with other disciplinary traditions and to improve research and practice. Interventions should build on each system's strengths, rather than treating the intuitive system as a barrier for the narrative system to overcome. Nursing researchers need to study the roles and effects of both systems.

Developing Mobile Clinical Decision Support for Nursing Home Staff Assessment of Urinary Tract Infection using Goal-Directed Design.

BACKGROUND: Unique characteristics of nursing homes (NHs) contribute to high rates of inappropriate antibiotic use for asymptomatic bacteriuria (ASB), a benign condition. A mobile clinical decision support system (CDSS) may support NH staff in differentiating urinary tract infections (UTI) from ASB and reducing antibiotic days. OBJECTIVES: We used Goal-Directed Design to: 1) Characterize information needs for UTI identification and management in NHs; 2) Develop UTI Decide, a mobile CDSS prototype informed by personas and scenarios of use constructed from Aim 1 findings; 3) Evaluate the UTI Decide prototype with NH staff. METHODS: Focus groups were conducted with providers and nurses in NHs in Denver, Colorado (n= 24). Qualitative descriptive analysis was applied to focus group transcripts to identify information needs and themes related to mobile clinical decision support for UTI identification and management. Personas representing typical end users were developed; typical clinical context scenarios were constructed using information needs as goals. Usability testing was performed using cognitive walk-throughs and a think-aloud protocol. RESULTS: Four information needs were identified including guidance regarding resident assessment; communication with providers; care planning; and urine culture interpretation. Design of a web-based application incorporating a published decision support algorithm for evidence-based UTI diagnoses proceeded with a focus on nursing information needs during resident assessment and communication with providers. Certified nursing assistant (CNA) and registered nurse (RN) personas were constructed in 4 context scenarios with associated key path scenarios. After field testing, a high fidelity prototype of UTI Decide was completed and evaluated by potential end users. Design recommendations and content recommendations were elicited. CONCLUSIONS: Goal-Directed Design informed the development of a mobile CDSS supporting participant-identified information needs for UTI assessment and communication in NHs. Future work will include iterative deployment and evaluation of UTI Decide in NHs to decrease inappropriate use of antibiotics for suspected UTI.