JMIR Publications

ABSTRACT

Background:

Clinical decision support (CDS) tools embedded in electronic health records (EHRs) in the form of integrated clinical prediction rules (iCPRs) provide a potentially effective intervention to reduce inappropriate antibiotic prescribing for acute respiratory infections (ARIs). Still, their effectiveness has been limited by workflow barriers and low adoption by healthcare providers. Nurses are well-positioned to implement evidence-based protocols using clinical decision support (CDS) tools. In a multicenter randomized controlled trial, a nurse-led implementation strategy for ARI iCPRs was evaluated for use in primary care and urgent care settings.

Objective:

After trial completion, this study examined nurse and nurse leader perspectives on the sustainability of an EHR-integrated clinical decision support tool for antibiotic stewardship and explored factors influencing its potential long-term integration into ambulatory nursing practice.

Methods:

We interviewed 22 nurses and nurse leaders from clinics that participated in the clinical trial. Two semi-structured interview guides, one for nurses and one for nursing leadership, were developed to understand the barriers and facilitators to implementing a decision-aid tool for nurses and to elicit challenges specific to nursing interactions with the CDS tool. Interviews were recorded and transcribed. Using thematic content analysis and iterative coding, our team collaboratively identified emerging themes related to sustainability and refined the results with consensus.

Results:

Five themes emerged: 1) importance of staffing stability and capacity; 2) impact of dedicated clinic resource availability; 3) variable nurse readiness with CDS-guided clinical care; 4) influence of openness to change and a nurse-supportive clinic culture; and 5) ongoing need for training and support. Specific recommendations for future actions were also noted.

Conclusions:

Our findings revealed specific barriers and facilitators to the sustainability of a CDS tool from the nursing perspective that can inform further implementation of nurse-led delegation protocols in the ambulatory setting. Future solutions should consider mapping physical workflows, scheduling specific to nurse visits, continuing education, and treating cough and sore throat as two distinct processes.