ABSTRACT
BACKGROUND: Extended foster care programs help prepare transitional-aged youth (TAY) to step into adulthood and live independent lives. Aspiranet, one of California's largest social service organizations, used a social care management solution (SCMS) to meet TAY's needs. OBJECTIVE: We aimed to investigate the impact of an SCMS, IBM Watson Care Manager (WCM), in transforming foster program service delivery and improving TAY outcomes. METHODS: We used a mixed methods study design by collecting primary data from stakeholders through semistructured interviews in 2021 and by pulling secondary data from annual reports, system use logs, and data repositories from 2014 to 2021. Thematic analysis based on grounded theory was used to analyze qualitative data using NVivo software. Descriptive analysis of aggregated outcome metrics in the quantitative data was performed and compared across 2 periods: pre-SCMS implementation (before October 31, 2016) and post-SCMS implementation (November 1, 2016, and March 31, 2021). RESULTS: In total, 6 Aspiranet employees (4 leaders and 2 life coaches) were interviewed, with a median time of 56 (IQR 53-67) minutes. The majority (5/6, 83%) were female, over 30 years of age (median 37, IQR 32-39) with a median of 6 (IQR 5-10) years of experience at Aspiranet and overall field experience of 10 (IQR 7-14) years. Most (4/6, 67%) participants rated their technological skills as expert. Thematic analysis of participants' interview transcripts yielded 24 subthemes that were grouped into 6 superordinate themes: study context, the impact of the new tool, key strengths, commonly used features, expectations with WCM, and limitations and recommendations. The tool met users' initial expectations of streamlining tasks and adopting essential functionalities. Median satisfaction scores around pre- and post-WCM workflow processes remained constant between 2 life coaches (3.25, IQR 2.5-4); however, among leaders, post-WCM scores (median 4, IQR 4-5) were higher than pre-WCM scores (median 3, IQR 3-3). Across the 2 study phases, Aspiranet served 1641 TAY having consistent population demographics (median age of 18, IQR 18-19 years; female: 903/1641, 55.03%; race and ethnicity: Hispanic or Latino: 621/1641, 37.84%; Black: 470/1641, 28.64%; White: 397/1641, 24.19%; Other: 153/1641, 9.32%). Between the pre- and post-WCM period, there was an increase in full-time school enrollment (359/531, 67.6% to 833/1110, 75.04%) and a reduction in part-time school enrollment (61/531, 11.5% to 91/1110, 8.2%). The median number of days spent in the foster care program remained the same (247, IQR 125-468 years); however, the number of incidents reported monthly per hundred youth showed a steady decline, even with an exponentially increasing number of enrolled youth and incidents. CONCLUSIONS: The SCMS for coordinating care and delivering tailored services to TAY streamlined Aspiranet's workflows and processes and positively impacted youth outcomes. Further enhancements are needed to better align with user and youth needs.
ABSTRACT
OBJECTIVE: Using the case of barcode medication administration (BCMA), our objective is to describe the challenges nurses face when informatics tools are not designed to accommodate the full complexity of their work. MATERIALS AND METHODS: Autonomy is associated with nurse satisfaction and quality of care. BCMA organizes patient information and verifies medication administration. However, it presents challenges to nurse autonomy. Qualitative fieldwork, including observations of everyday work and interviews, was conducted during the implementation of BCMA in a large academic medical center. Fieldnotes and interview transcripts were coded and analyzed to describe nurses' perspectives on medication safety. RESULTS: Nurses adopt orienting frames to structure work routines and require autonomy to ensure safe task completion. Nurses exerted agency by trusting their own judgment over system information when the system did not consider workload complexity. Our results indicate that the system's rigidity clashed with adaptive needs embodied by nurses' orienting frames. DISCUSSION: Despite the fact that the concept of nurse as knowledge worker is foundational to informatics, nurses may be perceived as doers, rather than knowledge workers. In practice, nurses not only make decisions, but also engage in highly complex task-related work that is not well supported by process-oriented information technology tools. CONCLUSIONS: Information technology developers and healthcare organization managers should engage and better understand nursing work in order to develop technological and social systems to support it.
