The role of champions in the implementation of technology in healthcare services: a systematic mixed studies review

BACKGROUND

Champions play a critical role in implementing technology within healthcare services. While prior studies have explored the presence and characteristics of champions, this review delves into the experiences of healthcare personnel holding champion roles, as well as the experiences of healthcare personnel interacting with them. By synthesizing existing knowledge, this review aims to inform decisions regarding the inclusion of champions as a strategy in technology implementation and guide healthcare personnel in these roles.

METHODS

A systematic mixed studies review, covering qualitative, quantitative, or mixed designs, was conducted from September 2022 to March 2023. The search spanned Medline, Embase, CINAHL, and Scopus, focusing on studies published from 2012 onwards. The review centered on health personnel serving as champions in technology implementation within healthcare services. Quality assessments utilized the Mixed Methods Appraisal Tool (MMAT).

RESULTS

From 1629 screened studies, 23 were included. The champion role was often examined within the broader context of technology implementation. Limited studies explicitly explored experiences related to the champion role from both champions' and health personnel's perspectives. Champions emerged as promoters of technology, supporting its adoption. Success factors included anchoring and selection processes, champions' expertise, and effective role performance.

DISCUSSION

The specific tasks and responsibilities assigned to champions differed across reviewed studies, highlighting that the role of champion is a broad one, dependent on the technology being implemented and the site implementing it. Findings indicated a correlation between champion experiences and organizational characteristics. The role's firm anchoring within the organization is crucial. Limited evidence suggests that volunteering, hiring newly graduated health personnel, and having multiple champions can facilitate technology implementation. Existing studies predominantly focused on client health records and hospitals, emphasizing the need for broader research across healthcare services.

CONCLUSIONS

With a clear mandate, dedicated time, and proper training, health personnel in champion roles can significantly contribute professional, technological, and personal competencies to facilitate technology adoption within healthcare services. The review finds that the concept of champions is a broad one and finds varied definitions of the champion role concept. This underscores the importance of describing organizational characteristics, and highlights areas for future research to enhance technology implementation strategies in different healthcare settings with support of a champion.

Educating nursing students for sustainable future rural health-care services: An umbrella review

BACKGROUND

Rural nursing education stands as a way to contribute to a sustainable nurse workforce in rural areas. Different approaches to organizing rural nursing education are described in the existing literature.

OBJECTIVE

To explore scientific reviews about rural nursing education and synthesize current knowledge as "best practice" recommendations for rural nursing education regarding the required organization of rural nursing education programs, what are the competencies required to function as a nurse in rural health-care settings, and the key environmental features for learning in rural nursing education programs.

DESIGN

An umbrella review.

PARTICIPANTS

Nursing students, newly graduated nurses, and clinical supervisors involved in nursing education in rural areas.

DATA SOURCES

A systematic literature search was conducted. Of the 276 review articles found, 93 were screened by title and abstract and 27 were screened in full text. The period searched was 2000-2022, and the literature search was peer-reviewed and published.

REVIEW METHODS

The Joanna Briggs Institute (JBI) methodology for umbrella reviews guided the design, search, and the reporting of the findings of the included reviews. Four reviewers screened for inclusion and exclusion using Covidence in a double blinded process. The analysis was guided by the JBI guidelines for umbrella review syntheses. Two reviewers conducted the analysis.

RESULTS

Sixteen reviews were included; eight scoping reviews, six integrative reviews, one narrative review, and one rapid review. The synthesis of current evidence provides the following "best practice" suggestions: (a) fostering context-sensitive and collaboratively designed education environments is recommended; (b) integrating curricula tailored for the nursing role and rural practice is recommended (c) establishing a supportive learning environment that encourages students' motivation and academic success; and (d) clinical placements in locally developed learning settings address the educational needs required for practice in the rural workforce.

CONCLUSIONS

Rural nursing education needs to be properly aligned with the context and health-care development, to educate nurses who can meet the community's needs today and in the future. A well-functioning collaboration between university faculty and local community stakeholders in a co-creation process stands out as vital to build a sustainable, flexible, rural nursing education program.

TWEETABLE ABSTRACT

Umbrella review: Flexible, co-created education might be "best practice" in rural undergraduate nursing programs.

Exploring facilitation in virtual simulation in nursing education: A scoping review

Objective

To systematically map existing research regarding the reflective feedback in virtual simulation in undergraduate nursing education.

Methods

A scoping review was conducted based on the Arksey and O'Malley framework and the PRISMA-ScR.

Results

We included 41 studies from 15 different countries. The simulation interventions allowed for interaction between the student and the virtual patient, the software, faculty, peers, or a combination of two or more of these. Students valued reflective feedback during and after the simulation.

Conclusions

Our review emphasizes the importance of a human in the loop. Feedback before, during, and after the simulation is possible in virtual simulation where the facilitator can pause the virtual scenario and stimulate reflections during the simulation to obtain deep learning. Virtual simulation provides opportunities to give feedback from the software, such as cues or direct feedback.

Innovation

There is a lack of focus on the feedback process and there is a need to revitalize the role of facilitators in a virtual simulation to determine their relative contribution in this process. Several studies reported the usefulness or the effect of virtual simulation on learning processes, but most lacked emphasis on investigating the significance of including a human in the loop.

Newly graduated nurses use and further development of assessment skills-An in-depth qualitative study

AIMS

To explore in-depth nurses' use and further development of assessment skills in different nursing contexts in the first 2 years after graduation, and factors that influenced their use and development of assessment skills.

DESIGN

The study had explorative qualitative design.

METHODS

Eight nurses who previously had been interviewed about their learning of physical assessment skills in clinical rotation as students participated in this follow-up study. Individual in-depth interviews were conducted, where the nurses spoke freely about their experiences after graduation.

RESULTS

Four prominent features influencing the nurses' use and development of assessment skills were identified: (a) assessment approaches and readiness for practice, (b) the primacy of communication, (c) recognition related to performing assessments, and (d) the influence of organizational factors on their assessment applications.

CONCLUSION

Newly graduated nurses' use of assessment skills is an important part of providing holistic care. This study suggest that assessment skills is not only an assessment task but is central in relationship building and in supporting the professional development of nursing competence.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution, due to study design.

Short-Term Findings From Testing EPIO, a Digital Self-Management Program for People Living With Chronic Pain: Randomized Controlled Trial

BACKGROUND

Chronic pain conditions involve numerous physical and psychological challenges, and while psychosocial self-management interventions can be of benefit for people living with chronic pain, such in-person treatment is not always accessible. Digital self-management approaches could improve this disparity, potentially bolstering outreach and providing easy, relatively low-cost access to pain self-management interventions.

OBJECTIVE

This randomized controlled trial aimed to evaluate the short-term efficacy of EPIO (ie, inspired by the Greek goddess for the soothing of pain, Epione), a digital self-management intervention, for people living with chronic pain.

METHODS

Patients (N=266) were randomly assigned to either the EPIO intervention (n=132) or a care-as-usual control group (n=134). Outcome measures included pain interference (Brief Pain Inventory; primary outcome measure), anxiety and depression (Hospital Anxiety and Depression Scale), self-regulatory fatigue (Self-Regulatory Fatigue 18 scale), health-related quality of life (SF-36 Short Form Health Survey), pain catastrophizing (Pain Catastrophizing Scale), and pain acceptance (Chronic Pain Acceptance Questionnaire). Linear regression models used change scores as the dependent variables.

RESULTS

The participants were primarily female (210/259, 81.1%), with a median age of 49 (range 22-78) years and a variety of pain conditions. Analyses (n=229) after 3 months revealed no statistically significant changes for the primary outcome of pain interference (P=.84), but significant reductions in the secondary outcomes of depression (mean difference -0.90; P=.03) and self-regulatory fatigue (mean difference -2.76; P=.008) in favor of the intervention group. No other statistically significant changes were observed at 3 months (all P>.05). Participants described EPIO as useful (ie, totally agree or agree; 95/109, 87.2%) and easy to use (101/109, 92.7%), with easily understandable exercises (106/109, 97.2%).

CONCLUSIONS

Evidence-informed, user-centered digital pain self-management interventions such as EPIO may have the potential to effectively support self-management and improve psychological functioning in the form of reduced symptoms of depression and improved capacity to regulate thoughts, feelings, and behavior for people living with chronic pain.

TRIAL REGISTRATION

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

Factors associated with changes in students' self-reported nursing competence after clinical rotations: a quantitative cohort study

BACKGROUND

The quality of nursing care in different healthcare contexts can be associated with the level of available nursing competence. Physical assessment skills are vital in nurses' assessment of patient care needs. However, in nursing education, using physical assessment skills is challenging for nursing students who struggle to apply these skills comprehensively in a clinical rotation. Therefore, this study explores changes in nursing competence, factors associated with changes after clinical rotations, and whether a Suite of Mobile Learning Tools supports changes in confident use of basic physical assessment skills.

METHODS

A quantitative cohort study with an explorative pre-and post-test design. During autumn 2019 and spring 2020, 72 s-year nursing students and 99 third-year students participated in the study. The Nurse Professional Competence scale short form was used to investigate students' self-reported changes in nursing competence, and a study-specific questionnaire was used to investigate students' confidence concerning performing physical assessments. The students voluntarily used the Suite of Mobile Learning Tools for the learning of physical assessment. Linear regression analysis was used to identify factors associated with changes in nursing competence after clinical rotation. The STROBE guidelines for cohort studies were followed for study reporting.

RESULTS

After the clinical rotation, both student groups reported changes in nursing competence and confidence in performing physical assessment skills, with statistically significant moderate or large changes in all areas. The Suite of Mobile Learning Tools was evaluated as being useful for learning physical assessment. The regression analysis showed that confidence in performing physical assessment skills, the usefulness of the Suite of Mobile Learning Tools, and a higher nursing competence at the start of clinical rotation were positively associated with overall nursing competence.

CONCLUSION

Basic physical assessment skills are an important component of nursing competence and can be considered one of the pillars of person-centered care, as proposed by the Fundamentals of Care framework. Spaced repetition and access to digital resources are suggested pedagogical approaches to enhance student confidence in the use of assessment skills within academic and clinical contexts.

Registered nurse-patient communication research: An integrative review for future directions in nursing research

AIM

To explore communication research in nursing by investigating the theoretical approaches, methods, content and perspectives in research on real-time registered nurse (RN)-patient communication.

DESIGN

An integrative review of real-time communication between RNs and patients.

DATA SOURCES

Empirical research papers were searched in PubMed, CINAHL Plus and Medline. The results from the database searches were supplemented with results from manual searches in reference lists.

REVIEW METHODS

A total of 1369 articles published between January 1996 and December 2021 were screened, which resulted in the inclusion of 52 articles.

RESULTS

The integration of various theories, such as nursing or communication theories, is weak in most of the included studies. RN-patient communication appears to influence relationship building. Even when nurses strive to meet patients' needs, they often focus primarily on nursing routines and physical care. The topic of the communication varies depending on the situation and different communication styles are used. When a patient-centred approach is adopted, the interpersonal communication becomes quite symmetrical, with complementary roles of nurses and patients. Within a more asymmetric communication context, nurses dominate communication, choose topics and function as instructors. How the nurses communicated subsequently influenced the patients' communication styles and strategies.

CONCLUSION

Communication is multifaceted, contains different strategies and is important for building trust and facilitating patient-centred care. The importance of RNs' communication for interaction and relationship-building seems to be well established within research, but few studies focused on patients' communication with RNs.

IMPACT

This integrative review gives an overview of the width and depth of observational studies on RN-patient communication research. The variety of studies indicates that this area is a less well-grounded field of research. Future research is warranted to support nurses in their communication, especially regarding the exploration of patients' communication and desired communication skills in nurse-patient interactions.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was included in this integrative review.

Understanding the role of positive emotions in healthcare communication - A realist review

AIM

To explore how the expression of positive emotions during the interaction between patients and providers can cultivate the patient-provider relationship.

DESIGN

We conducted a realist review guided by the Realist and Meta-narrative Evidence Syntheses: Evolving Standards.

METHODS

We systematically searched CINAHL, MEDLINE, PsychINFO and Scopus from inception to March 2019. Study selection and data extraction were performed blinded in pairs. From 3146 abstracts blinded in pairs, 15 papers were included and analysed. From each included paper, we extracted contexts, mechanisms and outcomes that were relevant to answer our research questions, creating a configuration between these elements (CMO configuration).

RESULTS

Our findings suggest that in the contexts of person orientation and positive outlook, patient-provider relationships improve by communication conveying and eliciting positive emotions. We found six underlying mechanisms for this that form either direct or indirect pathways between the context and the outcome.

Trust-based service innovation of municipal home care: a longitudinal mixed methods study

BACKGROUND

In Scandinavia, various public reforms are initiated to enhance trust in the healthcare services and the public sector in general. This study explores experiences from a two-step service innovation project in municipal home care in Norway, coined as the Trust Model (TM), aiming at developing an alternative to the purchaser-provider split (PPS) and enhancing employee motivation, user satisfaction, and citizen trust. The PPS has been the prevalent model in Norway since the 1990s. There is little empirical research on trust-based alternatives to the PPS in healthcare. The overall objectives of this study were to explore facilitators and barriers to trust-based service innovation of municipal homecare and to develop a framework for how to support the implementation of the TM.

METHODS

The TM elements were developed through a comprehensive participatory process, resulting in the decision to organize the home care service in small, self-managed and multidisciplinary teams, and trusting the teams with full responsibility for care decisions and delivery within a limited area. Through a longitudinal mixed methods case study design a) patients' expressed values and b) factors facilitating or preventing the service innovation process were explored through two iterations. The first included three city districts, three teams and 80 patients. The second included four districts, eight teams and 160 patients.

RESULTS

The patient survey showed patients valued and trusted the service. The team member survey showed increased motivation for work aligned with TM principles. Both quantitative and qualitative methods revealed a series of facilitators and barriers to the innovation process on different organizational levels (teams, team leaders, system). The key message arising from the two iterations is to keep patients' values in the centre and recognize the multilevelled organizational complexity of successful trust-based innovation in homecare. Synthesizing the results, a framework for how to support trust-based service innovation was constructed.

CONCLUSIONS

Trust-based innovation of municipal homecare is feasible. The proposed framework may serve as a tool when planning trust-based innovation, and as a checklist for implementation and improvement strategies. Further research is needed to explore the validity of the framework and its replicability in other areas of healthcare.

Nursing students' development of using physical assessment in clinical rotation-a stimulated recall study

Background

The overall aim of this study was to explore third-year bachelor nursing students’ stimulated recall reflections on their physical assessment competence development. The choice of learning strategies in nursing education seems to have great impact on nursing students’ use of physical assessment skills while in clinical rotation. There is a need to explore nursing students’ learning processes related to the use of physical assessments.

Methods

Explorative qualitative design using a triangulation of data collection methods. Nine final-year nursing students’ physical assessment performances during patient encounters were audio-taped and observed. Shortly after, an individual stimulated recall interview based on the audio-recorded patient encounter and observation notes was conducted. A two-fold analysis was conducted: 1) analysis of students’ performed assessments, and 2) phenomenological hermeneutical analysis of the stimulated recall interviews.

Results

Nursing students assessments shifted from a checklist approach to a symptom-based, more holistic and person-centred approach, emphasizing conversation as part of their assessments. The nursing students also reported that a safe and stimulating learning environment was a prominent feature for their continuing development. Learning from skilled role models with expectations to them using physical assessment skills facilitated their continuing skills appliance, interprofessional communication and reflective practice.

Conclusions

This study contribute with a novel, comprehensive and in-depth description of what influenced nursing students’ learning processes experiences of using physical assessment skills during clinical rotation. The results reveal the need for targeted course designs by implementing scaffolded learning activities in practical and theoretical courses aimed at strengthening students’ learning of physical assessment skills—building upon and emphasizing their prior knowledge and competence, which may lead to more confident registered nurses and promote patient safety in different health care contexts. We propose using stimulated recall systematically as a novel reflective learning activity in nursing education to foster clinical reasoning and metacognition skills and achieve deep learning.

Engaging with EPIO, a digital pain self-management program: a qualitative study

Background

Chronic pain conditions entail significant personal and societal burdens and improved outreach of evidence-based pain self-management programs are needed. Digital cognitive-behavioral self-management interventions have shown promise. However, evidence is still scarce and several challenges with such interventions for chronic pain exist. Exploring patients' experiences and engagement with digital interventions may be an essential step towards developing meaningful digital self-management interventions for those living with chronic pain.

Objectives

This study aimed to gain insight into the experiences of people with chronic pain when engaging with EPIO, an application (app)-based cognitive-behavioral pain self-management intervention program.

Methods

Participants (N = 50) living with chronic pain received access to the EPIO intervention in a feasibility pilot-study for 3 months. During this time, all participants received a follow-up phone call at 2–3 weeks, and a subsample (n = 15) also participated in individual semi-structured interviews after 3 months. A qualitative design was used and thematic analysis was employed aiming to capture participants’ experiences when engaging with the EPIO intervention program.

Results

Findings identifying program-related experiences and engagement were organized into three main topics, each with three sub-themes: (1) Engaging with EPIO; motivation to learn, fostering joy and enthusiasm, and helpful reminders and personalization, (2) Coping with pain in everyday life; awareness, practice and using EPIO in everyday life, and (3) The value of engaging with the EPIO program; EPIO – a friend, making peace with the presence of pain, and fostering communication and social support.

Conclusions

This qualitative study explored participants’ experiences and engagement with EPIO, a digital self-management intervention program for people living with chronic pain. Findings identified valued aspects related to motivation for engagement, and showed how such a program may be incorporated into daily life, and encourage a sense of acceptance, social support and relatedness. The findings highlight vital components for facilitating digital program engagement and use in support of self-management for people living with chronic pain.

Trial registration

ClinicalTrials.gov NCT03705104.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07963-x.

The value of a redesigned clinical course during COVID-19 pandemic: an explorative convergent mixed-methods study

Background

The COVID-19 lockdown in March 2020 had a significant consequence for nursing students worldwide including limited access to learning situations in clinical rotation. Therefore, this study aims to explore how an innovative redesign of a clinical course in a time of pandemic supported nursing students in learning the fundamentals of care in their first year. The redesign involved the transformation of a traditional hands-on clinical course into a technology-enhanced learning environment.

Design

This was an explorative convergent mixed-methods study using both quantitative and qualitative methods.

Methods

Twenty-four first-year nursing students responded to an online questionnaire with open-ended questions. Two nursing students and one faculty member participated in individual online interviews, and three faculty members participated in an online focus group interview. All the data were collected in June 2020. The quantitative data were analyzed using descriptive statistics and the qualitative data using content analysis. The GRAMMS guideline was applied.

Results

The students achieved the learning outcomes regarding fundamental care, basic physical assessment skills, and clinical reasoning with the help of academic assignments, multimedia learning resources, and virtual patients. Further, six central aspects of the facilitator role in the virtual simulation were identified. The aspect that was considered most valuable involved uncovering the “red thread” between different areas of knowledge in the first year of nursing education; this supported the students to better understand how to think and talk like a nurse.

Conclusion

This study offers insight into how a technology-enhanced clinical course can foster the learning of fundamental nursing care, basic physical assessment skills, and clinical reasoning skills; enhancing students’ preparedness for clinical hours. Virtual patients’ scenarios contributed to integrating different types of knowledge and skills that are important when providing nursing care for patients in clinical practice. This study also highlighted a gap in pedagogical competence among faculty members with regards to facilitating learning in a technology-enhanced learning environment. Study findings suggest promising pedagogical strategies that should be further developed post-pandemic, in response to the call for a renewal of nursing education using more technologically supported learning designs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00872-8.

Effects of Physicians' Information Giving on Patient Outcomes: a Systematic Review

BACKGROUND

Providing diagnostic and treatment information to patients is a core clinical skill, but evidence for the effectiveness of different information-giving strategies is inconsistent. This systematic review aimed to investigate the reported effects of empirically tested communication strategies for providing information on patient-related outcomes: information recall and (health-related) behaviors.

METHODS

The databases MEDLINE, Embase, PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and relevant bibliographies were systematically searched from the inception to April 24, 2020, without restrictions, for articles testing information-giving strategies for physicians (PROSPERO ID: CRD42019115791). Pairs of independent reviewers identified randomized controlled studies with a low risk of selection bias as from the Cochrane risk of bias 2 tool. Main outcomes were grouped into patient information recall and behavioral outcomes (e.g., alcohol consumption, weight loss, participation in screening). Due to high heterogeneity in the data on effects of interventions, these outcomes were descriptively reported, together with studies', interventions', and information-giving strategies' characteristics. PRISMA guidelines were followed.

RESULTS

Seventeen of 9423 articles were included. Eight studies, reporting 10 interventions, assessed patient information recall: mostly conducted in experimental settings and testing a single information-giving strategy. Four of the ten interventions reported significant increase in recall. Nine studies assessed behavioral outcomes, mostly in real-life clinical settings and testing multiple information-giving strategies simultaneously. The heterogeneity in this group of studies was high. Eight of the nine interventions reported a significant positive effect on objectively and subjectively measured patients' behavioral outcomes.

DISCUSSION

Using specific framing strategies for achieving specific communication goals when providing information to patients appears to have positive effects on information recall and patient health-related behaviors. The heterogeneity observed in this group of studies testifies the need for a more consistent methodological and conceptual agenda when testing medical information-giving strategies.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019115791.

Background pain in persons with chronic leg ulcers: An exploratory study of symptom characteristics and management

This exploratory descriptive study aimed to describe characteristics and management of background pain related to chronic leg ulcers. A total of 121 participants were recruited from two wound care clinics using a consecutive sampling method. Data were obtained through screening interview, clinical examination, and questionnaires. The mean average background pain intensity was 4.5 (SD 2.56) (CI 95% 4.0-5.0). Pain interfered mostly with general activity (mean 4.3), sleep (mean 4.1), and walking ability (mean 4.0) (0-10 NRS). The most frequently reported descriptors of background pain were 'tender', 'stabbing', 'aching', and 'hot-burning'. Most of the participants stated that the pain was intermittent. Less than 60% had analgesics prescribed specifically for ulcer related pain, and the respondents reported that pain management provided a mean pain relief of 45.9% (SD 33.9, range 0-100). The findings indicate that ulcer related background pain is a significant problem that interferes with daily function, and that pain management in wound care is still inadequate.

Older persons' expressed worries during nursing care at home: Do health complexity and nature of nursing care in the visit matter?

OBJECTIVE

Older persons receiving home care express more cues and concerns compared to other clinical contexts. Increased health condition complexity requires a corresponding increase in nursing competence. The aim of this study was to explore how complexity of older persons' health and nature of the visit influenced their expressed worries.

METHODS

In this cross-sectional explorative study, we analysed older persons' expressed worries (n = 508) identified by the Verona Coding Definitions of Emotional Sequences (VR-CoDES) in 129 audio-recorded home care visits with older persons (≥65 years), collected in 3 city districts and 1 rural area in Norway.

RESULTS

Expressed worries of 45 older persons were included in the analysis: 18 had low health complexity, 5 moderate and 22 high health complexity. The nature of the visit affected the number of expressed worries, health complexity did not. Most of the worries were expressed during basic nursing care visits and/or medication administration.

CONCLUSION

Findings suggest that home visit type may influence the older persons' expressed worries. The complexity of the older persons' health condition seems to have little impact on the expressed worries.

PRACTICE IMPLICATIONS

Knowledge about communication in different complexity of visits is important when planning care for older persons.

Pain acceptance and its impact on function and symptoms in fibromyalgia

Objectives Fibromyalgia is a chronic widespread pain (CWP) syndrome of unknown etiology with substantial burden of illness and functional impairment. Pain acceptance has emerged as an interesting target of therapy in chronic pain populations, but few studies have yet been done on the effect of pain acceptance on patients with fibromyalgia. The aim of the present study was to examine the relationship between pain acceptance and its impact on function and symptoms in fibromyalgia with both a cross-sectional and longitudinal design. Methods Three hundred and sixty five participants aged 22-70 with fibromyalgia were recruited from the Norwegian Fibromyalgia Association (NFA). They filled out a questionnaire containing the Fibromyalgia Impact Questionnaire (FIQ), measurement of function and symptoms, and Chronic Pain Acceptance Questionnaire (CPAQ), measurement of pain acceptance, in addition to sociodemographic and clinical variables such as degree of fibromyalgia, depression and pain duration (T1 measures). One year after, 87 of the participants filled out the FIQ and clinical measures once again (T2 measures). Unadjusted and adjusted linear regression analyses were performed both for cross-sectional measures at T1 and for longitudinal measures from T1 to T2, with FIQ score as the outcome variable and CPAQ score at T1 as one of the main independent variables. Results Higher CPAQ score was significantly associated with a lower FIQ score at T1, also when adjusting for age, education, work, depression and Fibromyalgianess Score (p<0.01). Lower FIQ score indicate less impact of fibromyalgia on functioning. In addition, two adjusted linear regression models found higher pain acceptance (CPAQ score) at T1 to be associated with lower negative impact of fibromyalgia on function and symptoms (FIQ score) at T2 (p<0.01). Conclusions Higher pain acceptance is associated with better functional level and less symptoms in fibromyalgia, both cross-sectionally and when measurements are separated in time. Further research should include experimental studies with acceptance-based interventions for this patient group.

Nursing students' experiences of virtual simulation when using a video conferencing system - a mixed methods study

OBJECTIVES

There is limited knowledge about students' experiences with virtual simulation when using a video conferencing system. Therefore, the aim of this study was to explore how second-year undergraduate nursing students experienced learning through virtual simulations during the COVID-19 pandemic.

METHODS

The study had an exploratory design with both quantitative and qualitative approaches. In total, 69 nursing students participated in two sessions of virtual simulation during spring 2020, and 33 students answered online questionnaires at session 1. To further explore students' experiences, one focus group interview and one individual interview were conducted using a video conferencing system after session 2. In addition, system information on use during both sessions was collected.

RESULTS

Changes in the students' ratings of their experiences of virtual simulation with the Body Interact™ system were statistically significant. The virtual simulation helped them to bridge gaps in both the teaching and learning processes. Four important aspects of learning were identified: 1) learning by self-training, 2) learning from the software (Body Interact™), 3) learning from peers, and 4) learning from faculty.

CONCLUSIONS

We conclude that virtual simulation through a video conferencing system can be useful for student learning and feedback from both peers and faculty is important.

Tested communication strategies for providing information to patients in medical consultations: A scoping review and quality assessment of the literature

OBJECTIVES

To systematize the scientific knowledge of empirically tested strategies for verbally providing medical information in patient-physician consultations.

METHODS

A scoping review searching for terms related to physician, information, oral communication, and controlled study. Four pairs of reviewers screened articles. For each selected study, we assessed the quality and summarized aspects on participants, study, intervention, and outcomes. Information provision strategies were inductively classified by types and main categories.

RESULTS

After screening 9422 articles, 39 were included. The methodological quality was moderate. We identified four differently used categories of strategies for providing information: cognitive aid (n = 13), persuasive (n = 8), relationship- (n = 3), and objectivity-oriented strategies (n = 4); plus, one "mixed" category (n = 11). Strategies were rarely theoretically derived.

CONCLUSIONS

Current research of tested strategies for verbally providing medical information is marked by great heterogeneity in methods and outcomes, and lack of theory-driven approaches. The list of strategies could be used to analyse real life communication.

PRACTICE IMPLICATIONS

Findings may aid the harmonization of future efforts to develop empirically-based information provision strategies to be used in clinical and teaching settings.

Prevalence and factors associated with ulcer-related pain in persons with chronic leg ulcers-an explorative study

AIMS AND OBJECTIVES

The aims of this study were to explore the prevalence of background pain and identify demographic, clinical and psychosocial factors associated with moderate to severe background pain in persons with leg ulcers.

BACKGROUND

All chronic leg ulcers are potentially painful. Research indicates that 80% of persons with chronic leg ulcers experience wound-related background pain. However, studies on factors associated with pain have small samples and findings are inconclusive.

DESIGN

Exploratory cross-sectional study.

METHOD

This quantitative study recruited persons with chronic leg ulcers (N = 252) from two wound care clinics using consecutive sampling method. Data were obtained through screening interview, clinical examination and questionnaires. Logistic regression with stepwise backwards elimination was used to identify factors associated with moderate to severe background pain. The STROBE checklist for cross-sectional studies was used for reporting this study.

RESULTS

Background pain was reported by 64% of the participants. Inferential statistical analyses suggest that between 58% and 69% of persons with chronic leg ulcers suffer from this type of pain. Factors associated with moderate to severe pain were older age, female gender, reduced sleep quality and diminished health status. In the final model, reduced sleep quality increased the likelihood of having moderate to severe pain in persons with good health status while not in persons with diminished health status.

CONCLUSION

Ulcer-related background pain is common in persons with chronic leg ulcers. Older females reporting insomnia symptoms also had increased risk of moderate to severe ulcer-related background pain. These participants also perceived their health status to be better.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates that ulcer-related background pain and associated factors needs more attention in clinical practice. Furthermore, nurses and other healthcare professionals should integrate biopsychosocial strategies to assess and manage ulcer-related background pain.

Health care providers' experiences of pain management and attitudes towards digitally supported self-management interventions for chronic pain: a qualitative study

BACKGROUND

Chronic pain constitutes a significant burden for the individuals affected, and is a frequent reason why patients seek health care services. While in-person psychosocial interventions can be of support to people living with chronic pain, such interventions are not always accessible. eHealth interventions may provide greater accessibility, but the evidence and use of digital self-management solutions for chronic pain are still limited and the lack of health care provider input in the development process of such solutions a concern. Therefore, the aim of the current study was to investigate health care providers' experiences of treating patients with chronic pain, their attitudes towards, and use of, digital solutions in pain management, and their suggestions for content and design elements for a potential digital pain self-management intervention.

METHODS

Twelve health care providers representing a variety of health care disciplines participated in semi-structured interviews. The interviews were analyzed using thematic analysis.

RESULTS

The material was analyzed into three main themes: [1] Patients with chronic pain and their current use of the health care services, [2] Health care providers' own motivation and impression of patient prerequisites for use of digital self-management interventions, and [3] Suggestions for content and design elements in a digital self-management intervention for people living with chronic pain. The challenges faced by patients living with chronic pain were described as numerous. Despite interest and positive attitudes, few of the health care providers had used or recommended eHealth solutions to their patients. A range of potential content and functionality elements were identified, including aspects of motivation and engagement and providers also emphasized the importance of easy access and positive, personal content to support existing treatment.

CONCLUSIONS

This study offers insights into health care providers' considerations for the potential of digital self-management interventions supporting patients living with chronic pain. Findings indicate the need for change and a more comprehensive treatment approach to pain management. eHealth solutions may contribute to such change, and providers pointed to a need for health care provider involvement, timely support and follow-up as important factors for integrating digital pain self-management interventions into clinical care.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03705104.

Humanoid robots in the care of older persons: A scoping review

The aim was to examine how humanoid robots have been used in the care of older persons and identify possible benefits and challenges associated with such use from older persons' points of view. The study was a scoping review based on Arksey and O'Malley's methodological framework. To identify peer-reviewed and non-peer-reviewed literature, a systematic search of the PubMed, Cinahl and Google Scholar electronic databases was conducted for studies published between 2013 and 2019. The PRISMA-ScR guidelines have served as a guideline. A total of 12 studies were included and resulted in four main categories related to how humanoid robots have been used in care of older persons (domain of use): Supports everyday life, Provides interaction, Facilitates cognitive training and Facilitates physical training. Potential for humanoid robots to be accepted as companions for older persons was seen, but technical issues, such as humanoid robots' slow response time or errors, emerged as key challenges. Older persons' perceived enjoyment of using a humanoid robot might also decrease over time. Validated measurements to estimate the effectiveness of using humanoid robots in the care of older persons are needed.

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.

Mindfulness predicts student nurses' communication self-efficacy: A cross-national comparative study

OBJECTIVES

The aim of this study was to compare student nurses' communication self-efficacy, empathy, and mindfulness across two countries, and to analyse the relationship between these qualities.

METHODS

The study had a cross-sectional design. Data was collected from final year student nurses in Norway and Sweden. Communication self-efficacy, empathy, and mindfulness were reported by questionnaires; Clear-cut communication with patients, Jefferson Scale of Empathy, and Langer 14 items mindfulness scale.

RESULTS

The study included 156 student nurses, 94 (60%) were Swedish. The mean communication self-efficacy score was 119 (95% CI 116-122), empathy score 115 (95% CI 113-117) and mindfulness score 79 (95% CI 78-81). A Mann-Whitney test showed that Swedish students scored significantly higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. When adjusted for age, gender, and country in a multiple linear regression, mindfulness was the only independent predictor of communication self-efficacy.

CONCLUSION

The Swedish student nurses in this study scored higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. Student nurses scoring high on mindfulness rated their communication self-efficacy higher.

PRACTICE IMPLICATIONS

A mindful learning approach may improve communication self-efficacy and possibly the effect of communication skills training.