As organizations adopt electronic health records (EHRs), nurses frequently encounter system barriers and difficulty performing role expectations. This article describes nurses' experiences with unintended consequences emerging from the use of an EHR. In some situations, nurses were positively deviant when encountering unintended consequences relating to EHRs to accomplish patient care or protect patient safety. Nurses engaged in work-arounds to provide patient care when the EHR did not meet their needs, sometimes in positively deviant ways. Qualitative data were collected from 5 open-ended questions at the end of a quantitative survey. Analysis included coding of responses and organization of processes in line with the triangle model, a human factors framework, to identify overarching themes. Five themes emerged: (1) User support after implementation of EHR; (2) User satisfaction with EHR; (3) Communication for patient care, quality, and safety; (4) Effort to complete tasks; and (5) Areas for improvement. Nurses' ability to adopt positive deviance as they experience unintended consequences offers opportunities for organizations to engage nursing perspectives in improving the EHR and engineer it to be more resilient to nursing work.

Background and Objectives Many investigators of Alzheimer’s disease and related dementias (AD/ADRD) are unfamiliar with the embedded pragmatic clinical trials (ePCTs) and the indispensable pilot phase preceding ePCTs. This paper provides a much-needed example for such a pilot phase and discusses implementation barriers and additional infrastructure and implementation strategies developed in preparation for a nationwide AD/ADRD ePCT. Research Design and Methods Two pilot trials were conducted in two hospices sequentially to refine and test Aliviado Dementia Care-Hospice Edition, a complex quality improvement intervention for advanced dementia symptom management. Readiness for the subsequent full-scale ePCT was assessed by three milestones: ≥80% training completion rate (“feasibility”), ≥80% post-training survey respondents indicating intention for practice changes (“applicability”), and at least one Aliviado care plan/assessment instrument administered in ≥75% of dementia patients admitted to home hospice within one-month post training (“fidelity”). Results Participants included 72 interdisciplinary team (IDT) members and 11 patients with AD/ADRD across the pilots. Feasibility, applicability, and fidelity outcomes (92%, 93%, and 100%, respectively) all surpassed the pre-established milestones (80%, 80%, and 75%). Main implementation challenges were related to hospice staff turnover, integration of the Aliviado toolbox materials within the electronic health records, and hospices’ limited research experience and infrastructure. Discussion and Implications This pilot phase demonstrated feasibility, applicability, and fidelity required to proceed to the full-scale ePCT. Our study findings and discussions of additional infrastructure and implementation strategies developed following the pilot phase can inform researchers and clinicians interested in conducting AD/ADRD-related pilot studies for ePTCs or quality improvement initiatives. Clinical Trial Number NCT03681119.

Previous transitional care research has focused on transitions occurring between community and hospital settings. Little is known regarding intrahospital transitions and how they affect care quality. A systematic review was therefore conducted to synthesize the literature regarding clinical outcomes associated with intrahospital transitions. Literature published between January 2003 and December 2018 and indexed in Medline/PubMed, CINAHL, and PsychINFO were reviewed using PRISMA guidelines. Articles were limited to English language and peer-reviewed. Articles were excluded if they focused on transitions occurring from or to the hospital, discharge/discharge planning, or postdischarge follow-up. Data abstraction included study characteristics, sample characteristics, and reported clinical outcomes. Fourteen studies met inclusion criteria, primarily using cross-sectional, cohort, or retrospective chart review quantitative designs. Data were analyzed and synthesized based on outcomes reported. Major outcomes emerging from the articles included delirium, hospital length of stay, mortality, and adverse events. Delirium, hospital length of stay, and morbidity and mortality rates were associated with delayed transfers and transfers to inappropriate units. In addition, increased fall risk and infection rates were associated with higher rates of transfer. Intrahospital transitions represent critical periods of time where the quality of care being provided may be diminished, negatively affecting patient safety and outcomes.

Context. As the aging population grows, the incidence of dementia continues to increase substantially. However, the lack of a significant geriatric health care workforce as well as little dementia training among generalist health care workers leads to suboptimal care for persons living with dementia (PLWD). In particular, few evidence-based interventions exist to improve the quality of dementia care among hospice interdisciplinary teams caring for PLWD. Aliviado Dementia CaredHospice Edition is a quality assurance and performance improvement program that includes training, mentoring, and workflow enhancements, which aims to improve quality of hospice care provided to PLWD and their caregivers.Objectives. To determine the effectiveness of the Aliviado Dementia Care program in increasing dementia symptom knowledge of hospice interdisciplinary team members.Methods. About 53 hospice team members from two diverse hospices, consisting of social workers, chaplains, physicians, and nurses, participated in the Aliviado training program. In this prepost trial, 39 participants completed the Dementia Symptom Knowledge Assessment before and after completion of the program.Results. Paired t-tests showed significant differences before and after Aliviado training in depression knowledge and confidence, as well as behavioral and psychological symptoms of dementia (BPSD) knowledge, confidence, and interventions. The greatest percent change increases were in depression (15.2%) and BPSD (13.3%) confidence as well as BPSD interventions (18.4%). Qualitative feedback consistently emphasized that trainees could now effectively assess their patients for specific symptoms such as pain and agitation. Conclusion.Aliviado is an evidence-based system-level intervention that improves clinical knowledge, attitudes, and confidence in treating PLWD enrolled in hospice.