Configuration of Mobile Learning Tools to Support Basic Physical Assessment in Nursing Education: Longitudinal Participatory Design Approach

Background

As many students in higher education are skilled users of mobile technology, mobile learning (mLearning) can be a promising educational strategy to enhance their learning experience. mLearning might also be well suited for nursing students as they navigate between multiple learning contexts in their educational curriculum. As an educational strategy, mLearning may also reduce challenges caused by the theory-practice gap in nursing by supporting skills and knowledge transfer between the university and clinical settings. As the introduction of basic physical assessment skills (B-PASs) into Norwegian bachelor’s degree education in nursing occurred quite recently, there is a lack of competence in supervision and teaching in both university and clinical settings. As such, mLearning appears to be a good strategy to support student B-PAS learning and knowledge transfer across learning contexts.

Objective

This study aims to explore and elicit the perspectives of students regarding the way in which a selection of digital learning resources supports B-PAS learning and application in clinical rotation, which of the selected digital learning resources are beneficial to include in a suite of mLearning tools, and how the selected digital learning resources could support the transfer of skills and knowledge from the academic to clinical context.

Methods

We used a longitudinal participatory design approach to co-design a suite of mLearning tools. The co-design processes took place in several workshops (WSs) over a period of 3 months: 2 WSs with first-year students (n=6), 3 WSs with second-year students (n=6), and 3 WSs with third-year students (n=8). The students evaluated several digital learning resources in both academic and clinical contexts. The digital learning resources included digital simulation with virtual patients, massive open online courses, and multimedia learning material. In the co-design WS, the potential and benefits of these digital learning resources for the learning and application of B-PASs were explored.

Results

The students reported that the digital learning resources stimulated learning in 7 different ways. They also emphasized the importance of including all selected and tested digital learning resources. Moreover, students supported the inclusion of additional learning material, such as multiple-choice tests and written assignments, aimed at providing feedback and contributing to knowledge development.

Conclusions

The co-design processes and collaboration with the nursing students provided insight into how a suite of mLearning tools may support the learning and application of B-PASs and human bioscience knowledge in clinical rotation. From the students’ perspective, one of the strengths of the suite of mLearning tools was the range of content, as this met a broader range of student learning preferences regarding learning B-PASs. The suite of mLearning tools contributes to and supports skills training and knowledge transfer between multiple learning contexts.

Reflection on actions: Identifying facilitators of and barriers to using physical assessment in clinical practice

Current research suggests that nursing students do not apply all sets of physical assessment skills (PAS) learned in their nursing education. The aim of this study was to evaluate third-year nursing students' process of clinical judgment using PAS in clinical rotation. Specific focus was on how the process of clinical judgment affected when the nursing students performed physical assessment, and which types of knowledge were implied in their practice. Ten nursing students performed PAS independently while in clinical rotation; these performances were audiotaped and observed. Shortly after, individual semi-structured stimulated recall interviews (SRI) took place. Regardless of the nursing students' stated level of PAS utilization, self-efficacy or scientific knowledge, clinical judgment was primarily based on contextual factors and personal prerequisites. This study contributes to in-depth knowledge about how nursing students perform physical assessment, how they describe their clinical judgment process and their strategies towards systematically and confidently using PAS. We conclude the paper with pedagogical strategies and learning activities that can facilitate reflection-in-action and reflection-on-action.

Digital Self-Management in Support of Patients Living With Chronic Pain: Feasibility Pilot Study

BACKGROUND

Chronic pain can be complex and taxing to live with, and treatment and support require a multicomponent approach, which may not always be offered or available. Smartphones, tablets, and personal computers are already incorporated into patients' daily lives, and therefore, they can be used to communicate, educate, and support self-management. Although some web-based self-management interventions exist, research examining the evidence and effect of digital solutions supporting self-management for patients living with chronic pain is limited, findings are inconclusive, and new innovative ideas and solutions are needed.

OBJECTIVE

This feasibility pilot study aimed to explore the system use, perceived usefulness, ease of use, and preliminary effects of EPIO, an app-based cognitive-behavioral pain self-management intervention program for patients living with chronic pain.

METHODS

The EPIO intervention was delivered in a blended-care model containing (1) one face-to-face introduction session, (2) nine cognitive behavior-based pain self-management modules, delivered in an app-based format for smartphones or tablets, and (3) one follow-up phone call at 2 to 3 weeks after the introduction session. Patients living with chronic pain (N=50) completed pre-post outcome measures at baseline and 3 months after the introduction session, with registration of system use (ie, log data) until 6 months. The use, perceived usefulness, and ease of use of the EPIO program were examined through system use data, as well as a study-specific use/usability questionnaire and the System Usability Scale (SUS). Outcome measures to test feasibility of use and estimate preliminary effects included the Brief Pain Inventory, health-related quality of life (HRQoL) scale, Hospital Anxiety and Depression Scale, Self-Regulatory Fatigue scale, Pain Catastrophizing Scale, and Chronic Pain Acceptance Questionnaire.

RESULTS

Participants (N=50) had a median age of 52 years (range 29-74 years) at inclusion and were mainly female (40/50, 80%). Thirty-one participants completed at least six of the nine modules within the 3-month study period (62% completion rate). Forty-five participants completed outcome measures at 3 months, and the EPIO program was rated as useful (ie, "totally agree" or "agree"; 39/45, 87%) and easy to use (42/45, 93%), and as having easily understandable exercises (44/45, 98%). The average overall system usability (SUS) score was 85.7, indicating grade A and excellent system usability. Preliminary psychosocial outcome measure estimates showed primarily nonsignificant pre-post intervention improvements at 3 months, but with significant positive effects related to some aspects of HRQoL (bodily pain, P=.02 and change, P=.049).

CONCLUSIONS

 Digital self-management intervention programs may be of use and support for patients living with chronic pain. In this feasibility study, EPIO showed an acceptable program completion rate and was rated as useful and easy to use, with excellent user satisfaction. Program optimization and efficacy testing in a large-scale randomized controlled trial are warranted and in progress.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104.

Exploring patient-centered aspects of home care communication: a cross-sectional study

Background

Communication is a cornerstone in nursing and aims at both information exchange and relationship building. To date, little is known about the naturally occurring communication between older persons and nurses in home care. Communication might heal through different pathways and a patient- or person-centered communication could be important for health and well-being of older persons. However, the delivery of individualized home care is challenged by routines and organizational demands such as time constraints. Therefore, the aim of this study was to explore the patient-centered aspects of home care communication between older persons and registered nurses.

Methods

In total 37 older persons (aged 65 years or older) and eleven RNs participated in 50 audio-recorded home care visits. Roter Interaction Analysis System (RIAS) was used to code verbal communication. A ratio from these codes, establishing the degree of patient-centeredness, was analyzed using a Generalized Linear Mixed Model.

Results

The present home care communication contained more socio-emotional than task-oriented communication and the emotional tone was largely positive. The global affect ratings reflected an overall positive tone (m = 39.88, sd = 7.65), with higher ratings on dimensions of, for example, responsiveness/engagement and interactivity or interest were more frequent than those that may be considered as less-positive emotions (m = 15.56, sd = 3.91), e.g. hurried, dominance or anger. The ratio of the degree of patient-centered communication in the home care visits was an average of 1.53, revealing that the communication could be considered as patient-centered. The length of the visits was the only characteristic significantly associated with the degree of patient-centeredness in the communication, with a peak in patient-centeredness in visits 8–9 min long. Sex, age or procedural focus showed no significant effects on the degree of patient-centeredness.

Conclusion

Overall, the degree of patient-centeredness and a positive emotional tone, which might have a positive outcome on older persons’ health, was high. Longer visits provided a higher degree of patient-centeredness, but no linear increase in patient-centeredness due to length of visit could be observed. The findings can be used for education and training of nurses, and for providing individualized care, e.g. patient- or person-centered care.

Emotional communication in home care: A comparison between Norway and Sweden

OBJECTIVE

Given the free movement of workers across countries, knowledge regarding communication differences between countries is imperative. In this study, we explored and compared the supportive responses of nursing staff to older persons' emotions in home care in Norway and Sweden.

METHODS

The study had an observational, cross-sectional, comparative design, which included 383 audio-recorded home-care visits. Communication was coded using Verona Coding Definitions of Emotional Sequences. Worries and responses were categorised with regard to reference, communicative function and level of person-centredness. Standard statistical tests were used to analyse the data.

RESULTS

The Swedish nursing staff provided space for further disclosure of worry more frequently than the Norwegian nursing staff (75.0 % versus 60.2 %, χ2 = 20.758, p < 0.01). In all, 65 % of the responses were supportive. Multiple logistic regression analyses showed that highly person-centred responses were independently associated with worries phrasing an emotion, OR (95 % CI) 3.282 (1.524-7.067).

CONCLUSION

The level of person-centredness was associated with the way in which older persons expressed their distress. The Swedish nursing staff provided opportunities for further disclosure of worries more frequently than the Norwegian nursing staff.

PRACTICE IMPLICATIONS

Findings of intercultural differences should be incorporated into the training of nursing staff.

Building ground for didactics in a patient decision aid for hip osteoarthritis. Exploring patient-related barriers and facilitators towards shared decision-making

OBJECTIVE

The aim of the present study was to explore patient-related barriers and facilitators towards shared decision-making (SDM) during routine orthopedic outpatient consultations as part of the process of developing a patient decision aid (PDA) for patients with hip osteoarthritis (OA).

METHODS

Consultations comprising nineteen hip OA patients referred to an orthopedic surgeon for treatment decision-making were observed, audio recorded and transcribed. Iterative thematic analysis proceeded, based on a taxonomy of generic patient-related barriers towards SDM grounded in the Theory of Planned Behavior (TPB).

RESULTS

A targeted taxonomy provided a structured overview of 26 factors influencing hip OA patients' intention to engage in SDM. Patients' perceived ability to change the agenda of the visit emerged as seminal factor and was added to the generic taxonomy.

CONCLUSION

Using a TPB-based taxonomy, we were able to identify and structure generic and context specific SDM barriers. Addressing patients' communication self-efficacy should be included as didactic feature in PDAs.

PRACTICE IMPLICATIONS

PDAs for hip OA should be designed for the broad spectrum of decision-making support needs occurring throughout the continuum of the disease. The provided taxonomy may contribute as guidance within implementation strategies that aim to support patients' intentions to engage in SDM.

Fibromyalgia 2016 criteria and assessments: comprehensive validation in a Norwegian population

Background and aims

The ACR1990 criteria of fibromyalgia (FM) have been criticized due to poor reliability of tender points counting (TPC), inconsistent definitions of the widespread pain, and by not considering other symptoms than pain in the FM phenotype. Therefore, several newer self-report measures for FM criteria have emerged. The aim of this study was to translate the fibromyalgia survey questionnaire (FSQ) to Norwegian and validate both the 2011 and the 2016 fibromyalgia survey diagnostic criteria (FSDC) against the ACR1990 criteria.

Methods

One hundred and twenty chronic pain patients formerly diagnosed with fibromyalgia according to the ACR1990 criteria, and 62 controls not diagnosed or where fibromyalgia was not suspected, were enrolled in this study. All responded to a Norwegian version of the FSQ. Also, they had a clinical examination according to ACR1990 fibromyalgia criteria including a counting of significant tender points with an algometer (TPC). The FSQ with the Widespread Pain Index (WPI) and Symptom Severity scale (SSS) subscales, Fibromyalgia Severity (FS) sum score, was examined for correlations with the fibromyalgia impact questionnaire (FIQ) and TPCs. Face-validity, internal consistence, test-retest reliability and construct validity with convergent and divergent approaches were examined and a Receiver Operating Characteristics (ROC) analysis was performed.

Results

The internal consistency of FS measured by Cronbach’s alfa was good (=0.904). The test-retest reliability measures using intra class correlation were respectable for the FS, including WPI and SSS subscales (0.86, 0.84 and 0.87). FS, WPI and SSS correlated significantly with FIQ (0.74, 0.59 and 0.85) and TPC indicating an adequate construct, convergent validity. The medians of FS, WPI and SSS in the fibromyalgia-group were significantly different from the non-fibromyalgia-group indicating good construct, divergent validity. Using the 2011 and 2016 FSDC vs. ACR 1990 as a reference, sensitivity, specificity, positive likelihood ratio (LR +) and negative likelihood ratio (LR−) were identified. The accuracy rate for both 2011 and 2016 FSDC were respectable (84%). ROC analysis using FS revealed a very good Area Under the Curve (AUC) = 0.860.

Conclusion

The current study revealed that the Norwegian versions of FSQ is a valid tool for assessment of fibromyalgia according to the 2011 and 2016 (FSDC).

Nursing staff's evaluation of facilitators and barriers during implementation of wireless nurse call systems in residential care facilities. A cross-sectional study

Background

Traditional nurse call systems used in residential care facilities rely on patients to summon assistance for routine or emergency needs. Wireless nurse call systems (WNCS) offer new affordances for persons unable to actively or consciously engage with the system, allowing detection of hazardous situations, prevention and timely treatment, as well as enhanced nurse workflows. This study aimed to explore facilitators and barriers of implementation of WNCSs in residential care facilities.

Methods

The study had a cross-sectional descriptive design. We collected data from care providers (n = 98) based on the Measurement Instrument for Determinants of Innovation (MIDI) framework in five Norwegian residential care facilities during the first year of WNCS implementation. The self-reporting MIDI questionnaire was adapted to the contexts. Descriptive statistics were used to explore participant characteristics and MIDI item and determinant scores. MIDI items to which ≥20% of participants disagreed/totally disagreed were regarded as barriers and items to which ≥80% of participants agreed/totally agreed were regarded as facilitators for implementation.

Results

More facilitators (n = 22) than barriers (n = 6) were identified. The greatest facilitators, reported by 98% of the care providers, were the expected outcomes: the importance and probability of achieving prompt call responses and increased safety, and the normative belief of unit managers. During the implementation process, 87% became familiar with the systems, and 86 and 90%, respectively regarded themselves and their colleagues as competent users of the WNCS. The most salient barriers, reported by 37%, were their lack of prior knowledge and that they found the WNCS difficult to learn. No features of the technology were identified as barriers.

Conclusions

Overall, the care providers gave a positive evaluation of the WNCS implementation. The barriers to implementation were addressed by training and practicing technological skills, facilitated by the influence and support by the manager and the colleagues within the residential care unit. WNCSs offer a range of advanced applications and services, and further research is needed as more WNCS functionalities are implemented into residential care services.

A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO

Background

Chronic pain conditions are complicated and challenging to live with. Electronic health (eHealth) interventions show promise in helping people cope with chronic illness, including pain. The success of these interventions depends not only on the technology and intervention content but also on the users’ acceptance and adherence. Involving all stakeholders (eg, patients, spouses, health care providers, designers, software developers, and researchers) and exploring their input and preferences in the design and development process is an important step toward developing meaningful interventions and possibly strengthening treatment outcomes.

Objective

The aim of this study was to design and develop a user-centered, evidence-based eHealth self-management intervention for people with chronic pain.

Methods

The study employed a multidisciplinary and user-centered design approach. Overall, 20 stakeholders from the project team (ie, 7 researchers, 5 editors, 7 software developers, and 1 user representative), together with 33 external stakeholders (ie, 12 health care providers, 1 health care manger, 1 eHealth research psychologist, and 17 patients with chronic pain and 2 of their spouses) participated in a user-centered development process that included workshops, intervention content development, and usability testing. Intervention content was developed and finalized based on existing evidence, stakeholder input, and user testing. Stakeholder input was examined through qualitative analyses with rapid and in-depth analysis approaches.

Results

Analyses from stakeholder input identified themes including a need for reliable, trustworthy, and evidence-based content, personalization, options for feedback, behavioral tracking, and self-assessment/registration as factors to include in the intervention. Evidence-based intervention content development resulted in one face-to-face introduction session and 9 app-based educational and exercise-based modules. Usability testing provided further insight into how to optimize the design of the intervention to the user group, identifying accessibility and a simple design to be essential.

Conclusions

The design and development process of eHealth interventions should strive to combine well-known evidence-based concepts with stakeholder input. This study, designing and developing the pain management intervention EPIO, illustrates how a stakeholder-centered design approach can provide essential input in the development of an eHealth self-management intervention for people with chronic pain.

Trial Registration

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104

Pain in persons with chronic venous leg ulcers: A systematic review and meta-analysis

Pain is a serious problem for patients with leg ulcers. Research mainly focuses on dressing‐related pain; however, chronic background pain may be just as devastating. Our main objective was to describe the prevalence and characteristics of wound‐related background pain in persons with chronic venous leg ulcers. We performed a systematic review to synthesise data from quantitative studies. Studies were eligible if they reported original baseline‐ or cross‐sectional data on background pain in chronic venous leg ulcers. The initial search identified 2454 publications. We included 36 descriptive and effect studies. The pooled prevalence of wound‐related background pain (from 10 studies) was 80% (95% CI 65‐92%). The mean pain intensity score (from 27 studies) was 4 (0‐10 numeric rating scale) (95% CI 3.4‐4.5). Other pain characteristics could not be synthesised. We identified few sufficiently high‐quality studies on prevalence and intensity of wound‐related background pain in patients with chronic venous leg ulcers. Four of five persons experience mild to moderate pain. Because of poor quality of pain assessment and report, we believe that the available research does not provide a sufficiently nuanced understanding of background pain in this patient group.

Experiences from Decentralised Radiological Services in Norway - a rural case study

Background

Implementation of the Norwegian government’s Coordination Reform (2012) aims to decentralise health care services from centralised hospitals to local communities. Radiological services in Norway are mainly organised in hospitals, because of the significant financial and human resource demands engendered by the need for advanced technological equipment, and specialised staff. Some selected conventional x-ray services have been decentralised into rural communities. The purpose of this single case study was to highlight experiences from different stakeholders’ of organising decentralised radiological services in a rural area in Norway.

Methods

A qualitative single case study design was adopted, collected data using focus groups with healthcare professionals and managers to obtain stakeholder’s experiences of the radiological services in this rural area. The key emergent themes from the literature, decentralisation, quality, professional roles, organisation and economic consequences were discussed with each focus group. Thematic analysis was used for analyzing the primary data collected.

Results

Four main themes emerged from the focus groups: 1) organisation, 2) quality and safety, 3) funding of radiological services and 4) cooperation between health care professions and health care levels. It was found that the organisation of decentralised radiological services to rural areas is challenging because of the way health services are structured in Norway. The quality of service was found to be inadequate in some areas because of the superficial level of training given to non-radiographic staff. The experience is that the Norwegian funding system hinders an efficient decentralised health care service. Effective cooperation and responsibility between health care professions and levels was challenging. There needs to be improved co-working by clearly defining roles and responsibilities.

Conclusions

A key recommendation for the organisation of rural radiological service was the development of a satellite link with an acute hospital. Quality of the service could be improved and should be given priority. Structural change to the financial system whereby money follows patients, might also facilitate more patientcentred services across healthcare levels. Improved mutual understanding between rural radiological services and hospital specialists and managers is important for a high quality and consistent radiological service to be delivered across Norway.

Implementation Strategies to Enhance the Implementation of eHealth Programs for Patients With Chronic Illnesses: Realist Systematic Review

BACKGROUND

There is growing evidence of the positive effects of electronic health (eHealth) interventions for patients with chronic illness, but implementation of such interventions into practice is challenging. Implementation strategies that potentially impact implementation outcomes and implementation success have been identified. Which strategies are actually used in the implementation of eHealth interventions for patients with chronic illness and which ones are the most effective is unclear.

OBJECTIVE

This systematic realist review aimed to summarize evidence from empirical studies regarding (1) which implementation strategies are used when implementing eHealth interventions for patients with chronic illnesses living at home, (2) implementation outcomes, and (3) the relationship between implementation strategies, implementation outcomes, and degree of implementation success.

METHODS

A systematic literature search was performed in the electronic databases MEDLINE, Embase, PsycINFO, Scopus, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library. Studies were included if they described implementation strategies used to support the integration of eHealth interventions into practice. Implementation strategies were categorized according to 9 categories defined by the Expert Recommendations for Implementing Change project: (1) engage consumers, (2) use evaluative and iterative strategies, (3) change infrastructure, (4) adapt and tailor to the context, (5) develop stakeholder interrelationships, (6) use financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) train and educate stakeholders. Implementation outcomes were extracted according to the implementation outcome framework by Proctor and colleagues: (1) acceptability, (2) adoption, (3) appropriateness, (4) cost, (5) feasibility, (6) fidelity, (7) penetration, and (8) sustainability. Implementation success was extracted according to the study authors' own evaluation of implementation success in relation to the used implementation strategies.

RESULTS

The implementation strategies management support and engagement, internal and external facilitation, training, and audit and feedback were directly related to implementation success in several studies. No clear relationship was found between the number of implementation strategies used and implementation success.

CONCLUSIONS

This is the first review examining implementation strategies, implementation outcomes, and implementation success of studies reporting the implementation of eHealth programs for patients with chronic illnesses living at home. The review indicates that internal and external facilitation, audit and feedback, management support, and training of clinicians are of importance for eHealth implementation. The review also points to the lack of eHealth studies that report implementation strategies in a comprehensive way and highlights the need to design robust studies focusing on implementation strategies in the future.

TRIAL REGISTRATION

PROSPERO CRD42018085539; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=85539.

Revitalizing physical assessment in undergraduate nursing education - what skills are important to learn, and how are these skills applied during clinical rotation? A cohort study

Background

The preparedness of newly graduated registered nurses for a demanding work environment and care practices takes form during nursing education. Norwegian nursing education at one university has implemented a selection of basic physical assessment skills (B-PAS) in the nursing curriculum in order to prepare nursing students for a demanding work environment post-graduation.

Methods

A mixed-method cohort design. We evaluated nursing students’ self-reported use of B-PAS during their clinical rotation using the “Survey of Examination Techniques Performed by Nurses” questionnaire (30 items). In addition, two focus group interviews elicited factors that hinder or facilitate the actual use of B-PAS during clinical rotation. We recruited students from a bachelor’s degree programme for nursing at a Norwegian university. Three hundred and sixty-three of 453 eligible nursing students in the first, second, and third year of the bachelor’s degree programme participated in the study (80%).

Results

ANOVA showed a significant progression (p < 0.016) in students’ self-reported use of B-PAS. Auscultation and percussion skills were graded below the median score of 3, which indicates that these skills were less used throughout the programme. The nursing students highlighted contextual factors for their use of B-PAS when in clinical rotation. Preceptors are important gatekeepers for successful implementation, and there is a need for close collaboration between the university and clinical practice.

Conclusion

Despite the reduced PAS taught in the curricula, there is still a lack of application of such skills in clinical rotations. This study highlights that research should explore how different work environments influence the utilisation of learned skills, and which learning strategies are appropriate or most successful for stimulating clinical reasoning and the extensive use of physical assessment.

Identifying decisions in optometry: A validation study of the decision identification and classification taxonomy for use in medicine (DICTUM) in optometric consultations

OBJECTIVE

The aim of this study was to assess the validity and reliability of the Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM) applied to optometry, to compare decisions in medical and optometric consultations, and to describe decisions in optometry.

METHODS

The study had a cross-sectional design. Data was collected from January to August 2016. Forty video-recorded patient-optometrist consultations were analysed. Clinical decisions were categorised according to DICTUM by two independent coders.

RESULTS

The framework was applied without modification. The inter-rater reliability was moderate, Cohen's kappa 0.57. The mean duration of the consultations was 41 (±9) minutes. In all, 891 clinical decisions were identified, mean 22 (±13) per consultation. Types of decisions were significantly different between optometric and medical consultations (chi-square, p < 0.001). More frequently, optometrists conveyed interpreted test results (27.6% vs 16.7%) and gave advice (23.6% vs 8%), while doctors defined the problem (30.4% vs 24.6%) and decided on treatment (17.8% vs 13.4%).

CONCLUSION

DICTUM is applicable to optometry encounters and may provide valuable insight to different health care settings.

PRACTICE IMPLICATIONS

Descriptive studiesofdecisions in patient-provider consultations is a first step for normative and prescriptive exploration of decision-making processes in health care.

Towards successful digital transformation through co-creation: a longitudinal study of a four-year implementation of digital monitoring technology in residential care for persons with dementia

Background

Implementation of digital monitoring technology systems is considered beneficial for increasing the safety and quality of care for residents in nursing homes and simultaneously improving care providers’ workflow. Co-creation is a suitable approach for developing and implementing digital technologies and transforming the service accordingly. This study aimed to identify the facilitators and barriers for implementation of digital monitoring technology in residential care for persons with dementia and wandering behaviour, and explore co-creation as an implementation strategy and practice.

Methods

In this longitudinal case study, we observed and elicited the experiences of care providers and healthcare managers in eight nursing homes, in addition to those of the information technology (IT) support services and technology vendors, during a four-year implementation process. We were guided by theories on innovation, implementation and learning, as well as co-creation and design. The data were analysed deductively using a determinants of innovation framework, followed by an inductive content analysis of interview and observation data.

Results

The implementation represented radical innovation and required far more resources than the incremental changes anticipated by the participants. Five categories of facilitators and barriers were identified, including several subcategories for each category: 1) Pre-implementation preparations; 2) Implementation strategy; 3) Technology stability and usability; 4) Building competence and organisational learning; and 5) Service transformation and quality management. The combination of IT infrastructure instability and the reluctance of the IT support service to contribute in co-creating value with the healthcare services was the most persistent barrier. Overall, the co-creation methodology was the most prominent facilitator, resulting in a safer night monitoring service.

Conclusion

Successful implementation of novel digital monitoring technologies in the care service is a complex and time-consuming process and even more so when the technology allows care providers to radically transform clinical practices at the point of care, which offers new affordances in the co-creation of value with their residents. From a long-term perspective, the digital transformation of municipal healthcare services requires more advanced IT competence to be integrated directly into the management and provision of healthcare and value co-creation with service users and their relatives.

Emotional communication with older people: A cross-sectional study of home care

The aim of this study was to explore the influence of characteristics of nurses and older people on emotional communication in home care settings. A generalized, linear, mixed model was used to analyze 188 audio-recorded home care visits coded with Verona Coding Definitions of Emotional Sequences. The results showed that most emotional distress was expressed by older females or with female nurses. The elicitation of an expression of emotional distress was influenced by the nurses' native language and profession. Older women aged 65-84 years were given the most space for emotional expression. We found that emotional communication was primarily influenced by sex for nurses and older people, with an impact on the frequency of expressions of and responses to emotional distress. Expressions of emotional distress by older males were less common and could risk being missed in communication. The results have implications for students' and health professionals' education in increasing their knowledge of and attentiveness to the impacts of their and others' characteristics and stereotypes on emotional communication with older people.

Patients' Needs and Requirements for eHealth Pain Management Interventions: Qualitative Study

BACKGROUND

A growing body of evidence supports the potential effectiveness of electronic health (eHealth) interventions in managing chronic pain. However, research on the needs and preferences of patients with chronic pain in relation to eHealth interventions is scarce. Eliciting user input in the development of eHealth interventions may be a crucial step toward developing meaningful interventions for patients for potentially improving treatment outcomes.

OBJECTIVE

This study aimed to explore the experiences of patients with chronic pain with regard to information and communication technology, understand how an eHealth intervention can support the everyday needs and challenges of patients with chronic pain, and identify possible facilitators and barriers for patients' use of an eHealth pain management intervention.

METHODS

Twenty patients living with chronic pain and five spouses participated in individual interviews. Semistructured interview guides were used to explore participants' needs, experiences, and challenges in daily life as well as their information and communication technology experiences and preferences for eHealth support interventions. Spouses were recruited and interviewed to gain additional insight into the patients' needs. The study used qualitative thematic analysis.

RESULTS

The participants were generally experienced technology users and reported using apps regularly. They were mainly in favor of using an eHealth self-management intervention for chronic pain and considered it a potentially acceptable way of gathering knowledge and support for pain management. The participants expressed the need for obtaining more information and knowledge, establishing a better balance in everyday life, and receiving support for improving communication and social participation. They provided suggestions for the eHealth intervention content and functionality to address these needs. Accessibility, personalization, and usability were emphasized as important elements for an eHealth support tool. The participants described an ideal eHealth intervention as one that could be used for support and distraction from pain, at any time or in any situation, regardless of varying pain intensity and concentration capacity.

CONCLUSIONS

This study provides insight into user preferences for eHealth interventions aiming to address self-management for chronic pain. Participants highlighted important factors to be considered when designing and developing eHealth interventions for self-management of chronic pain, illustrating the importance and benefit of including users in the development of eHealth interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104.

An mHealth Intervention for Persons with Diabetes Type 2 Based on Acceptance and Commitment Therapy Principles: Examining Treatment Fidelity

Background

Web-based interventions are becoming an alternative of treatment aimed to support behavioral changes and several advantages over traditional treatments are reported. New ways of delivering an intervention may result in new challenges regarding monitoring of treatment fidelity (TF) which is essential to ensure internal and external validity. Despite the importance of the theme, only a few studies in this field are reported.

Objective

To examine TF of a mobile phone delivered intervention based on Acceptance and Commitment Therapy (ACT) with electronic diaries and written situational feedback for persons with diabetes mellitus type 2, the recommendations from the Behavior Change Consortium (BCC) established by The National Institutes of Health (NHI) were applied. To analyze fidelity, they recommend 5 areas to be investigated (1) design of the study, (2) provider training, (3) delivery of treatment, (4) receipt of treatment, and (5) enactment of treatment. In the current study, these areas were examined based on the analysis of therapists’ adherence to the treatment protocol and participants’ and therapists’ experience with the intervention.

Methods

To investigate the therapists’ adherence to the treatment protocol, a total of 251 written feedback text messages were divided into text segments. Qualitative thematic analyses were then performed to examine how ACT and other therapeutic processes were used in the feedback by the therapists. For the therapists’ and participants’ experience analysis, participants answered a self-reported questionnaire and participated in 2 interviews. The therapists continuously reported their experiences to the researcher responsible for the project.

Results

The results show high adherence to the TF strategies 20/21 (95%) applicable items of the fidelity checklist recommended by NHI BCC were identified in the present study. Measured provider skill acquisition post-training was the only item absent in the fidelity checklist. The results also show high therapists’ adherence to the treatment protocol. All ACT processes (values, committed action, acceptance, contact with the present moment, self as context and cognitive defusion) were found in the coded text segments of the feedback in addition to communication and motivation strategies. For 336/730 (46%) of total possible text segments coded independently by 2 researchers, the interrater reliability measured by Cohen’s kappa was .85. The evaluation of participants’ and therapists’ experience with the intervention was generally positive.

Conclusions

Based on the analyses of therapists’ adherence to the treatment protocol grounded by ACT-principles and participants’ and therapists’ experience with the intervention, the 5 areas of TF recommended by NHI BCC were analyzed indicating a high level of TF. These results ensure an appropriate level of internal and external validity of the study and reliable intervention results and facilitate a precise replication of this intervention concept. Web-based psychological interventions to support people with chronic conditions are becoming increasingly more common. This study supports the results from a previous study which indicated that ACT could be reliably delivered in a written web-based format.

Trial Registration

ClinicalTrials.gov NCT01297049; https://clinicaltrials.gov/ct2/show/NCT01297049 (Archived by WebCite at http://www.webcitation.org/70WC4Cm4T)

A 1-year follow-up of a randomized clinical trial with focus on manual and electric toothbrushes' effect on dental hygiene in nursing homes

OBJECTIVE

A 2-month randomized clinical trial (RCT) study comparing electric and manual toothbrushes used by residents in nursing homes showed significant reduction in plaque score for both groups. The aim of this follow up study was to study if the effect sustained in a longer perspective when toothbrushes were used according to resident's own preference.

MATERIALS AND METHODS

One year after baseline of the RCT-study, 100 participants were re-examined. The simplified oral hygiene index (OHI-S) was used as outcome measure on dental plaque.

RESULTS

The mean age was 86.6, 78.1% had three or more medical diagnoses and 52.2% had moderate to severe cognitive impairment. The mean number of natural teeth was 18.8. After 1 year, mean plaque scores was significantly reduced within the population, from 1.2 to 0.7 (p < .001). A total of 46 participants preferred to use an electric toothbrush and 54 preferred manual. No significant difference in plaque score was found between electric and manual toothbrushes.

CONCLUSION

After 1 year, the improvement in dental hygiene from the RCT study sustained for users of both electric and manual toothbrush. Focus upon tooth brushing seems to be efficient and both manual and electric toothbrushes should be available in nursing homes.

Analyzing Change Processes Resulting from a Smartphone Maintenance Intervention Based on Acceptance and Commitment Therapy for Women with Chronic Widespread Pain

PURPOSE

This study investigated change processes resulting from a randomized controlled trial smartphone-delivered maintenance intervention with daily electronic diaries and personalized written feedback based on acceptance and commitment therapy (ACT) following a rehabilitation program for patients with chronic widespread pain.

METHOD

This study included 48 women who during a 5-week period completed electronic diaries three times daily, totaling 3372 entries. In response to the completed diaries, they received daily feedback from a therapist for 4 weeks (excluding weekends), totaling 799 feedback messages. To analyze the change processes, we explored the associations between feedback and daily ratings of participants' physical activities, positive emotions, pain fear and avoidance, pain acceptance, and self-management. Commitment to physical activities and the participants' evaluation of feedback were also analyzed. Multilevel models were used in the statistical analyses.

RESULTS

Participants' average pain fear and avoidance decreased over the intervention period (mean -0.019, P = 0.05). Self-management, pain acceptance, and positive feelings increased (mean -0.030, P < 0.01; mean -0.015, P < 0.01; and mean -0.011, P = 0.01, respectively). Participants' performance of physical activities decreased slightly over time, but the level of commitment was high and they evaluated the feedback as supportive for staying sufficiently active. No correlation between diary contents and feedback messages was found, even though most of the participants evaluated the feedback as supportive.

CONCLUSION

No support was found for an association between diary content and feedback based on ACT. However, diary measures were consistent with the ACT model and may have influenced positively the change processes.

Exploring physicians' verbal and nonverbal responses to cues/concerns: Learning from incongruent communication

OBJECTIVES

Explore physicians' verbal and nonverbal responses to cues/concerns in consultations with older-patients.

METHODS

Two teams independently coded a sample of Norwegian consultations (n=24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients' verbal emotional expressions were labeled 'Acknowledging of patients' emotional expressions', and 'Distancing from patients' emotional expressions.' Based on type and extent of nonverbal expressiveness, consultations were labeled 'Affective' and 'Prescriptive.' Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed.

RESULTS

Types 1 and 2 consultations were described as 'Congruent,' i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered 'Incongruent,' i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients' needs.

CONCLUSIONS

Frequently physicians' display incongruent behavior in challenging situations. Older patients' may perceive this as either alleviating or increasing distress, depending on their needs.

PRACTICE IMPLICATIONS

Type 3 consultations may shed light on reasons for physicians' incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients' perceptions of incongruent communication should be further explored.

Nursing students' evaluation of a new feedback and reflection tool for use in high-fidelity simulation - Formative assessment of clinical skills. A descriptive quantitative research design

Clinical skills training is an important part of nurses' education programmes. Clinical skills are complex. A common understanding of what characterizes clinical skills and learning outcomes needs to be established. The aim of the study was to develop and evaluate a new reflection and feedback tool for formative assessment. The study has a descriptive quantitative design. 129 students participated who were at the end of the first year of a Bachelor degree in nursing. After highfidelity simulation, data were collected using a questionnaire with 19 closed-ended and 2 open-ended questions. The tool stimulated peer assessment, and enabled students to be more thorough in what to assess as an observer in clinical skills. The tool provided a structure for selfassessment and made visible items that are important to be aware of in clinical skills.

CONCLUSIONS

This article adds to simulation literature and provides a tool that is useful in enhancing peer learning, which is essential for nurses in practice. The tool has potential for enabling students to learn about reflection and developing skills for guiding others in practice after they have graduated.