Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety.

Importance: Emergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety. Objective: To explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care. Design, Setting, and Participants: In this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022. Main Outcomes and Measures: Themes and subthemes of nursing perspectives on EHR behavioral flags were identified. Results: This study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19-related strain and burnout). Conclusions and Relevance: In this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.

"The new normal has become a nonstop crisis": a qualitative study of burnout among Philadelphia's harm reduction and substance use disorder treatment workers during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic worsened the ongoing overdose crisis in the United States (US) and caused significant mental health strain and burnout among health care workers (HCW). Harm reduction, overdose prevention, and substance use disorder (SUD) workers may be especially impacted due to underfunding, resources shortages, and chaotic working environments. Existing research on HCW burnout primarily focuses on licensed HCWs in traditional environments and fails to account for the unique experiences of harm reduction workers, community organizers, and SUD treatment clinicians. METHODS: We conducted a qualitative secondary analysis descriptive study of 30 Philadelphia-based harm reduction workers, community organizers, and SUD treatment clinicians about their experiences working in their roles during the COVID-19 pandemic in July-August 2020. Our analysis was guided by Shanafelt and Noseworthy's model of key drivers of burnout and engagement. We aimed to assess the applicability of this model to the experiences of SUD and harm reduction workers in non-traditional settings. RESULTS: We deductively coded our data in alignment with Shanafelt and Noseworthy's key drivers of burnout and engagement: (1) workload and job demands, (2) meaning in work, (3) control and flexibility, (4) work-life integration, (5) organizational culture and values, (6) efficiency and resources and (7) social support and community at work. While Shanafelt and Noseworthy's model broadly encompassed the experiences of our participants, it did not fully account for their concerns about safety at work, lack of control over the work environment, and experiences of task-shifting. CONCLUSIONS: Burnout among healthcare providers is receiving increasing attention nationally. Much of this coverage and the existing research have focused on workers in traditional healthcare spaces and often do not consider the experiences of community-based SUD treatment, overdose prevention, and harm reduction providers. Our findings indicate a gap in existing frameworks for burnout and a need for models that encompass the full range of the harm reduction, overdose prevention, and SUD treatment workforce. As the US overdose crisis continues, it is vital that we address and mitigate experiences of burnout among harm reduction workers, community organizers, and SUD treatment clinicians to protect their wellbeing and to ensure the sustainability of their invaluable work.

Using the National Incident Management System to Prepare Physicians for Rapid Responses: A Pilot Study.

OBJECTIVE: The study objective was to determine the feasibility of training physicians in the principles of the National Incident Management System (NIMS) and Incident Command System (ICS) as applied to in-hospital rapid responses and to assess physicians' attitudes regarding rapid responses. METHODS: This was an educational pilot study. Resident physicians completed a pre-survey, followed by online training in the principles of NIMS and ICS, a knowledge test, and a post-survey. RESULTS: The number of residents who participated was 22. In the pre-survey, most (20/22) did not have a working understanding of NIMS/ICS. Participants (21/22) agreed that residents should have more training in resource organization. On the knowledge test, the median score was 9.5/10. In the post-survey, participants felt more comfortable clearing extra resources from the scene (P < 0.001) and that it would be easier to keep track of resources (P < 0.001). Most indicated that they had a working understanding of NIMS/ICS (P < 0.001) and felt more comfortable establishing command using NIMS/ICS (P < 0.001). All agreed that they would consider using an NIMS/ICS-based structure on their next rapid response. CONCLUSIONS: Training physicians in the principles of NIMS/ICS as they pertain to rapid responses is feasible and appears to change residents' attitudes about rapid responses.

"We have to be uncomfortable and creative": Reflections on the impacts of the COVID-19 pandemic on overdose prevention, harm reduction & homelessness advocacy in Philadelphia.

The COVID-19 pandemic and ensuing service delivery interruptions had serious impacts on people who use drugs (PWUD) and people experiencing homelessness, including instability in the drug supply, decreased access to substance use disorder (SUD) treatment and harm reduction supplies, increased substance use and relapse due to stress and isolation, inability to properly isolate and quarantine without stable housing, and risk of COVID-19 spread in congregate living spaces. At the same time, many have noted a potential opportunity for rapid change in health, housing, and drug policy despite previous stagnation-referred to as a "punctuated equilibrium" by Baumgartner and Jones-in response to the pandemic. The pandemic forced some important policy interventions in the United States at both national and local levels, including eviction moratoriums and loosening of drug policy related to substance use treatment. However, to what extent some of these changes will be sustained past the current COVID-19 crisis is still unclear, as is how drug and housing related policy shifts have impacted the work of frontline overdose prevention, substance use treatment, and homelessness advocacy workers. In this qualitative study, we used semi-structured interviews to assess how Philadelphia's harm reduction advocates, community organizers, and SUD treatment clinicians have responded to the overdose and homelessness crises during COVID-19, and how they predict the pandemic and ensuing policy changes will impact the future of overdose prevention, harm reduction efforts, and homelessness advocacy. We interviewed 30 eligible participants during July and August 2020. The analysis of these data yielded three themes: 1/"None of it should be new to anybody": COVID-era issues impacting PWUD and people experiencing homelessness are extensions of existing problems; 2/"An opportunity to actually benefit in some way from this crisis": Possibility for innovation and improved care for PWUD and people experiencing homelessness; and 3/"Nothing we've tried has worked, so we have to be uncomfortable and creative": The uncertain path forward. Despite the many barriers that participants faced to promoting the health and well-being of marginalized communities during the pandemic, they also believed that the pandemic presented an important opportunity for positive policy change that has the potential to promote drug user health into the future, including a continuation of loosened federal restrictions on substance use disorder treatment, legalization of safe consumption spaces, safe supply of substances, and progressive, creative housing solutions.

Telehealth for opioid use disorder treatment in low-barrier clinic settings: an exploration of clinician and staff perspectives.

BACKGROUND: The majority of individuals with opioid use disorder (OUD) face access barriers to evidence-based treatment, and the COVID-19 pandemic has exacerbated the United States (US) opioid overdose crisis. However, the pandemic has also ushered in rapid transitions to telehealth in the USA, including for substance use disorder treatment with buprenorphine. These changes have the potential to mitigate barriers to care or to exacerbate pre-existing treatment inequities. The objective of this study was to qualitatively explore Philadelphia-based low-barrier, harm-reduction oriented, opioid use disorder (OUD) treatment provider perspectives about and experiences with telehealth during the COVID-19 pandemic, and to assess their desire to offer telehealth to patients at their programs in the future. METHODS: We interviewed 22 OUD treatment prescribers and staff working outpatient programs offering OUD treatment with buprenorphine in Philadelphia during July and August 2020. All participants worked at low-barrier treatment programs that provide buprenorphine using a harm reduction-oriented approach and without mandating counseling or other requirements as a condition of treatment. We analyzed the data using thematic content analysis. RESULTS: Our analysis yielded three themes: 1/ Easier access for some: telehealth facilitates care for many patients who have difficulty attending in-person appointments due to logistical and psychological barriers; 2/ A layered digital divide: engagement with telehealth can be seriously limited by patients' access to and comfort with technology; and 3/ Clinician control: despite some clinic staff beliefs that patients should have the freedom to choose their treatment modality, patients' access to treatment via telehealth may hinge on clinician perceptions of patient "stability" rather than patient preferences. CONCLUSIONS: Telehealth may address many access issues, however, barriers to implementation remain, including patient ability and desire to attend healthcare appointments virtually. In addition, the potential for telehealth models to extend OUD care to patients currently underserved by in-person models may partially depend on clinician comfort treating patients deemed "unstable" via this modality. The ability of telehealth to expand access to OUD care for individuals who have previously struggled to engage with in-person care will likely be limited if these patients are not given the opportunity to receive treatment via telehealth.

Academic careers and the COVID-19 pandemic: Reversing the tide.

The COVID-19 pandemic halted research operations at academic medical centers. This shutdown has adversely affected research infrastructure, the current research workforce, and the research pipeline. We discuss the impact of the pandemic on overall research operations, examine its disproportionate effect on underrepresented minority researchers, and provide concrete strategies to reverse these losses.