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1. JOURNAL CLUB Komal Antil Master of Sciences in Nursing (Neurosciences Nursing) All India Institute of Medical Sciences, New Delhi

2. ARTICLE -1 The effects of continuous care model using a smartphone application on adherence to treatment and self-efficacy among patients with multiple sclerosis AUTHORS :- Seyed Mojtaba Kazemi, Mahnaz Rakhshan, Mozhgan Rivaz and Sadegh Izadi JOURNAL :- BMC Medical Informatics and Decision making (2022) Impact Factor(2023) : 3.298 H-index (2023) : 90

3. 20XX Multiple Sclerosis (MS) is the most prevalent chronic, inflammatory, destructive, and progressive demyelinating disease of the central nervous system .( Oost W et.al 1 ) Dealing with chronic diseases usually requires long- term treatment plans to empower patients include Disease-Modifying Therapies (DMTs) supportive care rehabilitation symptom management ( Kapica-Topczewska K 8 ) Adherence to DMTs is essential to maximize the beneficial effects of MS treatment and reduce the number of clinical relapses . ( Verdugo RM et.al 9 ) BACKGROUND

4. Multimedia software-based education can improve knowledge and compliance with treatment regimens. ( Xiao Q.et.al 26 ) Educational software programs provide valuable information, to improve the disease process that allows patients to access the required information upon request. ( Sheikh A. et. al 23 ) Recommended treatment regimen often takes place at home and outside the scope of medical care in patients with MS. ( Bove R.et.al 20 ) By providing remote healthcare services increases the access of patients with mobility or geographical limitations. ( Robb JF.et.al 21 ) Need of the study

5. To determine the effects of Continuous Care Model (CCM) using a smartphone application on adherence to treatment and self-efficacy among MS patients. AIM OF THE STUDY

6. Not mentioned in the article OBJECTIVE

7. Not mentioned in the article HYPOTHESIS

8. REVIEW OF LITERATURE AUTHOR / YEAR STUDY FINDINGS Verdugo RM, Herráiz ER, Fernández-Del Olmo R, Bonet MR, García MV (2019) Adherence to disease-modifying treatments in patients with multiple sclerosis in Spain The adherence rate is acceptable. It is widely known that treatment satisfaction is related to adherence . In our study, patients' level of satisfaction was higher with oral treatments. However, oral administration showed a greater lack of adherence . The main cause of lack of adherence was forgetfulness . In relation to other variables, cognitive status and family support showed a correlation with treatment adherence.

9. REVIEW O F LITERATURE AUTHOR / YEAR STUDY FINDINGS Golan D, Sagiv S, Glass-Marmor L, Miller A. (2020) Mobile phone-based e-diary for assessment and enhancement of medications adherence among patients with multiple sclerosis. Substantial and clinically important disagreement between methods of medication adherence evaluation was noted. Smartphone reminders did not significantly improve the MPR of DMDs.

10. METHODOLOGY RESEARCH APPROACH QUANTITATIVE STUDY RESEARCH DESIGN Quasi experimental study with pre-test/ post-test design SETTING MS Association affiliated to Shiraz University of Medical Sciences POPULATION Adults who had relapsing–remitting MS SAMPLING TECHNIQUE Convenience sampling SAMPLE SIZE 72 ; intervention group(n=36) and control group(n=36) RANDOMISATION Block randomization with the block size of four using the Random Allocation Software

11. METHODOLOGY VARIABLES DEPENDENT VARIABLE Adherence to treatment and self efficacy among patients INDEPENDENT VARIABLE Effects of Continuous care model using a smartphone application

12. The study sample size was estimated according to a similar study and considering α=0.05, β=0.2, and attrition rate of 15%. Total sample size calculated = 72 Intervention group (n=36), Control group (n=36) SAMPLE SIZE CALCULATION

13. Patient suffering from relapsing–remitting MS, not being in the recurrence phase Patient aging 18–45 years Patient having the history of MS for at least six months. Patient having mild to moderate disability (EDSS 0-5-5) Patient being able to use smartphones Patient having an Android smartphone INCLUSION CRITERIA

14. Patient suffered from other types of MS (primary progressive, secondary progressive and progressive relapsing) Patients who are unwilling to continue cooperation. Incomplete attendance in educational interventions Patients who have severe disease complications Patients with known psychophysical disorders EXCLUSION CRITERIA

15. TOOLS S.No Tools Purpose No.of items Validity Reliability 1. Demographic Information Form Provide Demographic Characteristics about patient’s population 2parts: Demographic Characteristics Disease related information 2. MS Treatment Adherence Questionnaire Self-report tool for identifying barriers to adherence amongst MS patients taking DMTs. 30 items divided into three subscales: DMT-Barriers DMT-Side Effects DMT-Coping Strategies. Convergent validity (r=0.5) Divergent validity (r=0.3) Cronbach’s alpha coefficients ranging from 0.40 to 0.86. 3. MS Self Efficacy Scale Measuring self efficacy in function maintenance and control over MS from patient’s perspectives 14 items divided into four dimensions independence and activity (five items) concerns and interests (four items) personal control (three items) social confidence (two items). Divergent validity(r = − 0.74). Cronbach’s alpha=0.9

16. Intervention (Development of the smartphone application) Educational materials on MS were extracted from authentic resources (i.e., textbooks, literature, etc.) and were evaluated and revised by two experts in the field of nursing and one neurologist. The educational content included the description of MS (i.e., pathophysiology, clinical manifestations, assessment and diagnosis, pharmacologic therapies, management of the disease, nutrition, pregnancy, exercise, etc.), COVID-19 and its prevention among MS patients , and self-management programs . Then, based on educational materials, electronic contents, images, animations, and audio and video clips were produced and designed in form of an installable application on electronic devices using an Android Studio program on the Android platform. Extraction of educational material Description of MS Production and Designing of Application MS APPLICATION

17. Initially, the written informed consent form and the questionnaires were completed by both groups in the MS Association before the intervention. Then, the CCM using an Android-based interactive smartphone application was performed for the patients in the intervention group for 4 months (control group only received the routine care) This model consisted of four steps including: Orientation Sensitisation Control Evaluation METHOD OF DATA COLLECTION

18. It includes: explaining the aims making a relationship with the clients explaining the study protocol collaboration to take part in the study involvement of the clients and their families in care. First stage (orientation)

19. For this purpose, a 30–45-min session was held with the presence of the patients and their families at the clinic to identify the patients’ problems accurately motivate them to participate explain the importance of continuous care determine their expectations from each other express the need for continuation of the cooperation until the end of the study. At the end of the orientation session, the demographic information form, MS-TAQ, and MSSS were completed. First stage (orientation)

20. Interventions were performed in this stage during two months In doing so, sensitizing the clients to accept responsibility for their health was emphasized by evaluating their educational needs Overall, the patients became familiar with the process of the disease its complications DMTs adherence to treatment self-management programs possible questions were addressed through the MS App. This multimedia app could be easily installed on Android mobile phone s . Second stage ( Sensitization stage)

21. This phase consisted of assessment and continuity of care Continuous care consultations and care needs were followed daily and weekly through a part of the MS App that was designed for this purpose. The telephone number of the researcher was given to the patients, as well. Third stage ( Control stage)

22. In this stage, the effects of the interventions and follow-ups were evaluated using the scales for measuring and comparing adherence to treatment and self-efficacy. In addition, the patients in the intervention group were requested to take part in an online survey and express their satisfaction with the implementation of the virtual CCM. At the end of the study, the MS App was made available to all the patients in the MS Association, Shiraz, Iran. Fourth stage ( Evaluation stage)

23. This study was conducted in accordance with the Helsinki Declaration and was approved by the Research Ethics Committee of Shiraz University of Medical Sciences (Approval No. IR.SUMS.REC.1399.201) . Furthermore, the control group participants were provided with the designed programs and trainings at the end of the research. ETHICAL CONSIDERATION

24. 20XX presentation title The data were analyzed by the SPSS 22 software at the significance level of p<0.05. Kolmogorov–Smirnov test showed the normal distribution of the data related to adherence to treatment and self-efficacy (p>0.05). The data were analyzed using descriptive indices such as mean and Standard Deviation (SD) and inferential statistics including Chi-square, Fisher’s exact test, independent t-test, repeated measures ANOVA, and LSD post-hoc test. DATA ANALYSIS

25. RESULTS

26. DIS CUSSION AUTHOR/YEAR STUDY/METHOD FINDINGS PRESENT STUDY Xia L. (2018) The effects of continuous care model of information-based hospital-family integration on colostomy patients: a randomized controlled trial No statistically significant differences were found in demographic information between the experimental and control groups. In comparison with the control group, subjects in the experimental group had less anxiety and could better cope with anxiety, had a better self-efficacy and quality of life scores, and had fewer complications. The patients in the experimental group were shown to be more satisfied with the care model. In agreement with present study reports shows significant improvement

27. DIS CUSSION AUTHOR/YEAR STUDY/METHOD FINDINGS PRESENT STUDY Shakery M, Mehrabi M, Khademian Z. (2021) The effect of a smartphone application on women’s performance and health beliefs about breast self-examination: a quasi-experimental study. Access to the smartphone application enhanced the participants' performance and health beliefs regarding BSE in the areas of perceived susceptibility, self-efficacy, and health motivation. Therefore, we recommend using the same smartphone application to improve women's performance and health beliefs regarding BSE. In agreement with present study reports shows significant improvement

28. STUDY STRENGTHS As per author As per Presenter 1. I nnovation in applying continuous care for the MS patients during the COVID-19 pandemic. 1. Standardised tools were used in the study and mentioned each tool’s reliability and validity. 2. R educed the risk of spread of the viral infection among patients , healthcare providers, and clinicians,a and increased patient satisfaction. 2. Researcher explained the intervention very nicely. 3. L onger intervention time can achieve better outcomes remains unknown. 3. Researcher check the normal distribution. 4. Though COVID-19 was there, researcher continued the data collection via online mode. 5. Researcher used interactive multimedia for the patients.

29. STUDY LIMITATIONS As per Author As per Presenter 1. Specific type of MS (relapsing–remitting), which might increase the likelihood of bias in the data. Patient were recruited via convenience sampling. 2. Selection of samples within the age range of 18–45 years. 2. Patient did not do the item analysis for the tools. 3. Technology is more likely to be embraced by the younger generation , thus limiting its applicability in older individuals . 3. Patient did not correlate the factors among each other.

30. STUDY LIMITATIONS As per Author As per Presenter 4. Adherence to treatment was measured using self-report scale that did not directly assess adherence and had a weak correlation (r=0.5) with the missed dose ratio. 4. In place of Quasi- experimental study, research should do the Randomised Controlled Trial. 5. Time-consuming design of the application, the outbreak of COVID-19 that prolonged the sampling process, and the short follow-up period (two months) due to the limited research time.

31. Multimedia application can enhance the outcomes as well as patient’s satisfaction so this approach can be used for nurses, healthcare providers, and clinicians & can also be used to provide contain care in other interventions for MS patients. IMPLICATIONS

32. The results demonstrated that implementing the CCM using the MS App led to improvements in treatment adherence and self-efficacy among the MS patients. Thus, it can be concluded that providing care with an interactive multimedia application can enhance the outcomes as well as patient satisfaction, especially during the COVID- 19 pandemic. CONCLUSION

33. Oost W , Talma N, Meilof JF, Laman JD. Targeting senescence to delay progression of multiple sclerosis. J Mol Med. 2018;96(11):1153–66. Kapica-Topczewska K, Collin F, Tarasiuk J, Chorąży M, Czarnowska A, Kwaśniewski M, Brola W, Bartosik-Psujek H, Adamczyk-Sowa M, Kochano- wicz J. Clinical and epidemiological characteristics of multiple sclerosis patients receiving disease-modifying treatment in Poland. Neurol Neuro- chir Pol. 2020;54(2):161–8. Verdugo RM, Herráiz ER, Fernández-Del Olmo R, Bonet MR, García MV. Adherence to disease-modifying treatments in patients with multiple sclerosis in Spain. Patient Prefer Adher. 2019;13:261. Sheikh A, Anderson M, Albala S, Casadei B, Franklin BD, Richards M, Taylor D, Tibble H, Mossialos E. Health information technology and digital inno- vation for national learning health and care systems. Lancet Digit Health. 2021;3:e383–96. Bove R, Rowles W, Zhao C, Anderson A, Friedman S, Langdon D, Alexan- der A, Sacco S, Henry R, Gazzaley A. A novel in-home digital treatment to improve processing speed in people with multiple sclerosis: a pilot study. Mult Scler J. 2020;27(5):778–89. Robb JF, Hyland MH, Goodman AD. Comparison of telemedicine versus in-person visits for persons with multiple sclerosis: a randomized crosso- ver study of feasibility, cost, and satisfaction. Mult Scler Relat Disord. 2019;36:101258. Xiao Q, Wang J, Chiang V, Choi T, Wang Y, Sun L, Wu Y. Effectiveness o mHealth interventions for asthma self-management: a systematic review and meta–analysis. Nurs Inform. 2018;2018:144–5. REFERENCES

34. The associations of psychological burnout and time factors on medication errors in rotating shift nurses in Korea: A cross sectional descriptive study AUTHORS :- Cheongin Im, Suyoung Song, Kyoungja Kim JOURNAL:- Wiley Nursing Open (2023) Impact Factor: 2.60 Indexing: Pubmed ARTICLE-2

35. Medication errors are defined as ‘ any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer ’ ( Walsh et al., 2017) . A high level of psychological burnout not only adversely affects the health of workers but also directly affects their job performance .( Kakemam et al., 2021; Montgomery et al., 2021; Sullivan et al., 2022) For nurses, psychological burnout of nurses affects their vigilance and reduces their alertness. (Dall'Ora et al., 2020) BACKGROUND

36. To understand the relationship between psychological burnout, time factors and medication errors in nurses working in hospitals. OBJECTIVES OF THE STUDY

37. Not mentioned in the article HYPOTHESIS

38. REVIEW OF LITERATURE AUTHOR / YEAR STUDY FINDINGS Darawad, M. W., Nawafleh, H., Maharmeh, M., Hamdan-Mansour, A. M., & Azzeghaiby, S. N. (2015). The relationship between time pressure and burnout syndrome: A cross-sectional survey among Jordanian nurses. Burnout was found to be common among Jordanian nurses, and time pressure is a precursor of this phenomenon, giving rise to the consequences on both patients’ and nurses’ health. Healthcare administrators have to modify the nursing work environment to be less stressful and more appealing to overcome the causes of nurses’ burnout.

39. REVIEW OF LITERATURE AUTHOR / YEAR STUDY FINDINGS Min, A., Min, H., & Hong, H. C. (2019). Work schedule characteristics and fatigue among rotating shift nurses in hospital setting: An integrative review. The reviewed studies provided mixed results regarding the associations between work schedule characteristics and nurse fatigue. However, quick returns and days called to work on days off were consistent factors contributing to nurse fatigue. More evidence is needed to arrive at a definitive conclusion about such relationships.

40. METHODOLOGY RESEARCH APPROACH QUANTITATIVE STUDY RESEARCH DESIGN Cross-sectional survey design SETTING 2 tertiary university hospitals in metropolitan cities in South Korea POPULATION Licensed staff nurses working 8-h shifts. SAMPLING TECHNIQUE Convenience sampling SAMPLE SIZE 207

41. A minimum sample size of 207 was calculated with G*power program assuming multiple regression analysis , α = 0.05, a medium effect size of 0.15, 0.90 power, 10 factors, and 20% drop out rate. SAMPLE SIZE CALCULATION

42. The inclusion criteria were (1) Bedside nurses with assignment to patient care (2) The adult care nurses (3) Nurses working in a general ward or intensive care unit (ICU), working in 8 h, 3h shift system. INCLUSION CRITERIA

43. The exclusion criteria were : (1) nurses with <3 months of nursing career (to rule out the adaptation periods of new nurses) (2) nurses working in management roles. EXCLUSION CRITERIA

44. The questionnaire used for this study was 41 items, including Demographic items (14 items) Maslach Burnout Inventory (22 items) Time pressure perception measurement (5 items) Objective time pressure (5 items) Medication error measurement (9 items) The questionnaire was pilot tested with 7 clinical nurses to ensure the readability and accuracy of the meaning of each item of measurements prior to distribution. TOOLS FOR DATA COLLECTION

45. TOOLS S.No Tools Purpose No.of items Reliability 1. General and hospital-related characteristics Provide Demographic Characteristics about patient’s population 14 items 2. Maslach Burnout Inventory (MBI) Used to measure the psychological burnout of hospital nurses. MBI consists of 22 items divided into three sub-domains: emotional exhaustion (nine items) depersonalization (five items) personal accomplishment (eight items) Internal consistency reliabilities (Cronbach's α) of each sub-domain were 0.87, 0.88 and 0.89

46. TOOLS S.No Tools Purpose No.of items Reliability 3. Time pressure perception meas- urement M easure the subjective time pressure perception of hospital nurses. 5 items with no sub domains. Internal consistency reliabilities (Cronbach's α) in a previous study was over 0.90 4. Objective work time characteristics Measure the objective work time characteristics, information on rest time whilst on duty, meal time during duty and overtime during the last week was collected. Participants were asked to write precise time (minutes) during the last shift (rest times, meal times) during the previous week (over time).

47. TOOLS S.No Tools Purpose No.of items Reliability 5 Medication error measurement for Korean nurses developed by Park and Lee To measure the medication error It comprises nine items: For each item, subjects were asked to indicate the frequencies of medication error they experienced during the last 3 months. The nurses' responses were scored using the following scale: 1 point (one time), 2 point (twice), 3 point (three times), 4 point (four times) and 5 points (more than five times). If no medication error was experienced over 3 months, a score of 0 was assigned. The higher sum value signifies higher frequencies of medi- cation errors. Internal consistency reliabilities (Cronbach's α) in a previous study was = 0.77 (Park & Lee, 2019). In the current study, Cronbach's α was 0.78.

48. Data were collected during December 2021 in ten hospital units , including six general wards and four intensive care units. Each unit was provided with questionnaires for the nurses to complete. The researcher explained the research purpose and ethical considerations in each unit during the day and evening shift changes . The questionnaire required 10–15 min to complete. Completed questionnaires were returned in sealed envelopes to maintain confidentiality. DATA COLLECTION

49. The general characteristics, psychological burnout and time factors were analysed using descriptive statistics The general characteristics, were analysed using the Mann–Whitney U tes t and the Kruskal–Wallis test. The associations between the major research variables and medication errors were analysed with the zero-inflated negative binomial regression DATA ANALYSIS

50. RESULTS

51. Table 1 : Nurse’s General characteristics and differences in medication errors (N=200)

52. Table 2: Descriptive statistics for psychological burnout, time factors and medication errors (N = 200)

53. Table 3 : Correlations between general characteristics, time factors, psychological burnout and medication errors (N=200)

54. Table 4 : Relationship between medication errors and psychological burnout, time factor (N=200) Logit model shows zero inflated negative binomial regression model likelihood-ratio test was done to identify the model fit and it appeared appropriate (Chi-square value: 26.07, p < 0.001). The final zero-inflated negative binomial regression model's AIC value was 500.52 compared with the zero-inflated Poisson regression model ’ AIC: 524.58 revealing the appropriateness of the model.

55. DISCUSSION AUTHOR/YEAR STUDY/METHOD FINDINGS PRESENT STUDY Poghosyan, L., Clarke, S. P., Finlayson, M., & Aiken, L. H. (2010) Nurse burnout and quality of care: Cross-national investigation in six countries. Across countries, higher levels of burnout were associated with lower ratings of the quality of care independent of nurses' ratings of practice environments. These findings suggest that reducing nurse burnout may be an effective strategy for improving nurse-rated quality of care in hospitals. In agreement with present study.

56. DISCUSSION AUTHOR/YEAR STUDY/METHOD FINDINGS PRESENT STUDY Perlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., & Feeley, D. (2017). IHI framework for improving joy in work Joy in work is more than just the absence of burnout or an issue of individual wellness. In agreement with present study.

57. STRENGTH OF THE STUDY As per the author As per the Presenter Not mentioned 1. Confidentiality of the participants were maintained. 2. Tools were pilot tested before implementation. 3. All tools were tested for reliability and validity before implementation. 4. Researcher compared with binomial regression model with poisson regression model that reveals the appropriateness of the model

58. LIMITATIONS OF THE STUDY As per the author As per the presenter 1. This study had limited external validity because nurses working at two tertiary university hospitals with similar characteristics were conveniently sampled to control for possible other exogenous variables, such as the number of nurses to patients, severity of patients and regulations of hospitals, which may affect medication errors. 1. Pilot testing conducted on 7 people only. 2. Unlike objective time factors, subjective time pressure did not show significant association with the dependent variables. Further research should be considered, using subjective time pressure measures with higher specificity, sensitivity, and measurement error. 2. Researcher mentioned ‘ N ’ for sample, though ‘ N ’ meant for population and ‘ n ’ for sample.

59. For medication safety, nurse managers should provide appropriate administrative support to nurses to cope with psychological burnout of nurses. Work time management should also be considered as human factors to satisfy the needs of nurses, such as securing meal times and maintaining a low level of weekly overtime. IMPLICATIONS

60. Higher psychological burnout, shorter meal time during duty and longer weekly overtime were associated with an increased likelihood of medication error of nurses working in tertiary university hospitals. CONCLUSION

61. Article 1: Use of interactive multimedia is effective in engaging patients in care and improving their disabilities. Article 2: Managerial support and favourable working environment should be provided to the nursing staff that may influence the negative consequences of patient safety, caused by nurse’s psychological burnout. TAKE HOME MESSAGE

62. Walsh, E. K., Hansen, C. R., Sahm, L. J., Kearney, P. M., Doherty, E., & Bradley, C. P. (2017). Economic impact of medication error:A systematic review: Economic impact of medication error. Pharmacoepidemiology and Drug Safety, 26(5), 481–497. https://doi. org/10.1002/pds.4188 Kakemam, E., Chegini, Z., Rouhi, A., Ahmadi, F., & Majidi, S. (2021). Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: A cross-sectional on- line survey among nurses. Journal of Nursing Management, 29(7), 1974–1982. Montgomery, A. P., Azuero, A., Baernholdt, M., Loan, L. A., Miltner, R. S., Qu, H., Raju, D., & Patrician, P. A. (2021). Nurse burnout pre- dicts self-reported medication administration errors in acute care hospitals. Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality, 43(1), 13–23. https://doi. org/10.1097/JHQ.0000000000000274 REFERENCES

63. SUPPLEMENTARY INFORMATION

64. ARTICLE 1 The effects of continuous care model using a smartphone application on adherence to treatment and self-efficacy among patients with multiple sclerosis

65. ‹#› TOOL 1: MS-TAQ Adherence Questionnaire

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68. ‹#› MS APPLICATION

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73. ARTICLE 2 The associations of psychological burnout and time factors on medication errors in rotating shift nurses in Korea: A cross sectional descriptive study

74. ‹#› TOOL 2: Maslach Burnout Inventory

75. THANKS Do you have any questions ? Credits for Presentation: Ms. Tarika Sharma For Query: [email protected]