Employing a User-Centered Design to Engage Mothers in the Development of a mHealth Breastfeeding Application Breastfeeding has numerous health benefits; however, many mothers do not continue breastfeeding to the recommended 6 months of age. Breastfeeding support after discharge from the hospital is often lacking in the communities with the greatest need. Therefore, the Mother's Milk Connection mHealth application was designed to improve breastfeeding duration and access to support. This article describes a user-centered design process to engage mothers in the development of the Mother's Milk Connection application. Two phases of stakeholder and user studies were conducted. Phase 1 involved concept generation, prototype development, and usability testing. Phase 2 focused on prototype redesign and usability testing. We used a descriptive mixed-method approach with data collected using a demographic questionnaire, System Usability Scale, exit survey, and focus groups. Final features of the Mother's Milk Connection application included resources and education, peer support, automated activity tracking, and professional support via video conference. Stakeholder and user engagement indicated the integration of four distinct features is acceptable for use as a comprehensive mHealth intervention to improve access to breastfeeding support. mHealth has the potential to be a useful strategy for providing breastfeeding support, and a clinical trial regarding the efficacy of the Mother's Milk Connection application is needed. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Phase 1 of this project was supported by grant R24HS022140 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Phase 2 was supported by funding from University of Missouri Institute for Clinical and Translational Science. Corresponding author: Urmeka T. Jefferson, PhD, RN, S416 Sinclair School of Nursing, University of Missouri, Columbia, MO 65211 (jeffersonu@missouri.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Development and Evaluation of a Quick Response Code–Based Nursing Education Program for Operating and Recovery Room Nurses The purpose of this study was to develop and evaluate the effectiveness of a quick response code–based nursing education program to improve the competence of operation and recovery room nurses. An experimental methodological design was used to develop a quick response code–based nursing educational program and analyze its effects and nurses' satisfaction with its use. The quick response code–based nursing education program was developed in five steps based on the ADDIE model: analysis, design, development, implementation, and evaluation. The program was built on smartphones, and a Web site was linked to it. After testing the program for 40 days, nurses' attitudes toward various medical devices were significantly less negative. Nurses were able to use a large number of medical devices and were highly satisfied and willing to engage with the quick response code–based nursing educational program. In the context of nursing education, introducing educational content using quick response codes helps to improve nurses' knowledge and competence in providing high-quality nursing care and medical services. Corresponding author: Eun Kyoung Yun, PhD, RN, College of Nursing Science, Kyung Hee University, 26, Kyungheedae-Ro, Dongdaemun-Gu, Seoul, Republic of Korea (ekyun@khu.ac.kr). The authors have disclosed they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Author Contributions: Study design: E.K.Y., E.W.P.; data collection and analysis: E.K.Y., E.W.P.; manuscript writing: E.K.Y., E.W.P., H.L. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Improved Patient Flow and Provider Efficiency After the Implementation of an Electronic Health Record Electronic health records are used widely across the nation in many different types of healthcare facilities. Electronic health record systems can provide more accurate and complete information about a patient's health, improve patient safety, and improve patient care. The purpose of this project is to evaluate a provider efficiency and workflow program at a hospital-owned, freestanding urgent care system after implementation of an electronic health record. A retrospective, longitudinal approach was used to evaluate the implementation of an electronic health record system among six freestanding urgent care clinics. The logic model was used as a guiding framework to determine whether provider efficiency and patient flow were improved. Data were collected from participants via an online survey, electronic health record data review, paper chart review, and direct observation of providers. An evaluation of a provider efficiency program using door-to-triage, door-to-provider, door-to-discharge, and average length of stay at each urgent care clinic was collected. The results indicate improvement in all areas after implementation of the electronic health record in all six urgent care settings. The average length of stay decreased from 109 minutes in 2014 to 73 minutes in 2016. The authors have disclosed they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Lesley Pyron, DNP, APRN, FNP-BC, Capstone College of Nursing, The University of Alabama, 650 University Boulevard East, Box 870358, Tuscaloosa, AL 35487 (lesrn2np@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Perceptions and Experiences of Hospital Nurses During Transition to an Electronic Handover Informatics System An effective patient transfer, or handover, among healthcare professionals can help prevent communication-related medical errors, and a reliable electronic handover informatics system can standardize the handoff process. Adapting to a new handover system may cause stress for nurses. This descriptive qualitative study aimed to explore the perceptions and transition experiences of hospital nurses in adopting and adapting to a new handover informatics system. Thirty-eight nurses at a medical center in Taiwan participated in the study from December 2016 to January 2017. The researcher conducted five focus group interviews and analyzed all responses using content analysis. Results showed three major themes: “Perceptions of challenges and barriers related to the transition to a new handover informatics system,” “Perceptions of benefits and strategies to the transition to a new handover informatics system,” and “Suggestions for successful implementation of a new handover informatics system.” Five subthemes emerged from the first theme, and six subthemes emerged from the second theme. The results of this study could enhance our understanding of nurses' perceptions and experiences with transition to a new handover informatics system and could provide a reference for hospitals to develop individualized strategies to facilitate the implementation of a handover informatics system. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. This research work was supported by research grants from Kaohsiung Medical University Hospital (KMUH104-M401), Taiwan. Corresponding author: Shu-Yuan Lin, PhD, RN, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Rd, Siamin District, Kaohsiung City 807, Taiwan (m845008@kmu.edu.tw). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effect of Web-Based Preoperative and Postoperative Patient Care Education on Nursing Students: A Randomized Controlled Study This study examined the effect of Web-based preoperative and postoperative patient care education among undergraduate nursing students. This was an experimental, randomized controlled study. The study included 305 nursing students (experimental group: n = 155, control group: n = 150), who were assessed with the following instruments: the Preoperative and Postoperative Care Knowledge Test, Preoperative and Postoperative Care Skill Control List, Clinical Decision Making in Nursing Scale, and Nursing Student Clinical Performance Evaluation Scale. t Tests and χ2 tests were used to evaluate the data. There was no statistically significant difference between the students' posttest knowledge levels, clinical performance assessment, or clinical decision-making scores. The experimental group was found to perform the skills of “check patient's documents and prophylactic antibiotics when going to surgery” (χ2 = 4.88; P = .02), “controls the surgical safety checklist (before surgery) before going to surgery” (χ2 = 10.41; P = .00), and “observes surgical site/dressing (χ2 = 7.77; P = .00)” at a statistically significantly higher level. The education provided in the Web-based education was equivalent to that provided in traditional education. Thus, Web-based education appears to be a useful tool to educate student nurses in preoperative and postoperative patient care. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Hale Turhan Damar, PhD, RN, Nursing Faculty, Dokuz Eylul University, Inciralti, Balçova, Turkey 35340 (hale.turhan1986@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Recruitment and Retention of Asian Americans in Web-Based Physical Activity Promotion Programs: A Discussion Paper Web-based interventions that promote physical activity have been tested in various populations and proven effective. However, information on recruiting and retaining ethnic minorities in these interventions is limited. This study discusses practical issues in recruitment and retention of Asian Americans using three strategies: (1) only Web-based intervention (Group 1), (2) one with Fitbit Charge HR (Group 2), and (3) one with Fitbit Charge HR and office visits (Group 3). Recruitment and retention rates, minutes of weekly research team meetings, and the researchers' memos were collected. Retention rates were analyzed using descriptive statistics, and the minutes and memos were content analyzed following Weber's methods. Retention rates varied by the end of the first (12% in Group 3, 36.9% in Group 2) and third month (0% in Group 3, 36.9% in Group 2). The practical issues were (1) difficulties in recruitment across strategies, (2) the necessity of using community consultants/leaders across strategies, (3) subethnic differences across strategies, (4) timing issues across strategies, (5) Fitbit as a facilitator with several hindrances, and (6) office visits as an inhibitor. Fitbits with user guidelines and community consultants'/leaders' involvement are proposed for future Web-based interventions to promote physical activity in Asian Americans. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. The study was funded by the University Research Foundation grant and the Dr Dorothy Mereness Endowed Research Fund at the University of Pennsylvania and the Chang Gung Medical Research Foundation (grant NMRPF3G0141/0051 and ZZRPF3C0011) and Ministry of Science and Technology (MOST 105-2511-S-255-001,106-2511-S-255-001, 106-2511-S-255-003-MY3). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Hsiu-Min Tsai, PhD, RN, FAAN, Chang Gung University of Science and Technology, No. 261, Wenhua 1st Rd, Guishan Dist, Taoyuan, Taiwan 333 (hsiumin2011@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Comparative Cost of Virtual Reality Training and Live Exercises for Training Hospital Workers for Evacuation Adoption of virtual reality technology may be delayed due to high up-front costs with unknown returns on that investment. In this article, we present a cost analysis of using virtual reality as a training tool. Virtual reality was used to train neonatal intensive care workers in hospital evacuation. A live disaster exercise with mannequins was also conducted that approximated the virtual experience. Comparative costs are presented for the planning, development, and implementation of both interventions. Initially, virtual reality is more expensive, with a cost of $229.79 per participant (total cost $18 617.54 per exercise) for the live drill versus $327.78 (total cost $106 951.14) for virtual reality. When development costs are extrapolated to repeated training over 3 years, however, the virtual exercise becomes less expensive with a cost of $115.43 per participant, while the cost of live exercises remains fixed. The larger initial investment in virtual reality can be spread across a large number of trainees and a longer time period with little additional cost, while each live drill requires additional costs that scale with the number of participants. This study was supported by the Agency for Health Research and Quality through grant R18 HS23149. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Sharon L. Farra, PhD, RN, CNE, CHSE, Wright State University College of Nursing and Health, 3640 Colonel Glenn Hwy, Dayton OH 45435 (sharon.farra@wright.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Technology-Supported Interventions for Pregnant Women: A Systematic Review Technology is deeply embedded in daily life; thus, more pregnant women seek information through the Internet and incorporate the use of technological devices during their pregnancies. This systematic review aimed to examine to what extent and how technology-supported interventions were developed and delivered to pregnant women, as well as intervention effects on the targeted outcomes. Electronic data were collected from MEDLINE, CINAHL, and Scopus. Among the 11 selected studies, most were pilot studies to test the feasibility, acceptability, or preliminary effects of technology-supported interventions. The studies included both women with healthy pregnancies and pregnancies complicated by factors including preterm labor, smoking, and alcohol abuse. Most were conducted in the US, and most participants were white or African American. Interventions were primarily developed by research teams and focused on mental health issues including depression, anxiety, and stress. Interventions incorporated the use of technology including computers, mobile phones, and audiovisual aids. The overall interventions were reported to be feasible, acceptable, and beneficial in all the selected studies. Based on the review of literature, suggestions were provided for future research including the need for careful selection of intervention topics and objectives to target women who can benefit more from technology-supported interventions. Corresponding author: Yaelim Lee, PhD, RN, 84 Heukseok-ro, Dongjak-gu, Seoul, Korea 06974 (ylcaregiver@gmail.com). This research was supported by the National Research Foundation of Korea in 2018 (2017R1C1B5075221). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluation of Nursing Practice in Patients With HIV/AIDS With the Omaha System Electronic-Based Information Program: A Retrospective Study The Omaha System is a standardized health care terminology that has been used in many different settings for nursing care worldwide for more than 20 years. In Turkey, it has been used mainly in nursing education and research. In this context, the purpose of this study was to examine paper-based nursing care plans of inpatients with HIV/AIDS according to the Omaha System and to assess the clinical suitability of the Omaha System. The study has a descriptive-retrospective design and was carried out at the Department of Infectious Diseases and Clinical Microbiology in a hospital. The sample consisted of 30 patients with HIV/AIDS who were chosen randomly from patients hospitalized between January 2007 and April 2017. Nursing care plans were reevaluated and encoded according to the Omaha System. The five most frequently diagnosed problems were oral health (27.2%), neuromusculoskeletal function (20.2%), communicable/infectious condition (19.4%), skin condition (13.2%), and circulation (5.7%). A total of 4409 nursing interventions were applied to solve the problems, and almost 74% of the interventions were categorized in the surveillance. Among the targets, physical signs/symptoms were indicated for more than 68% (3.026). The results confirmed the clinical suitability of the Omaha System. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Ozlem Koseoglu Ornek, PhD, RN, Department of Nursing, Faculty of Health Sciences, Istanbul Bilgi University, Dolapdere Kampus, Haciahmet Mahallesi, Pir Hüsamettin Sokak, No. 20, 34440 Beyoğlu, Istanbul, Turkey (ozlem.koseoglu@bilgi.edu.tr; ozlem.koseoglu62@gmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Sequential Two-Stage Network and Thematic Analysis for Exploring an Interdisciplinary Care Approach in Nursing Homes Since various groups of older adults with different conditions and levels of function coexist in nursing homes, it is necessary to develop integrated care strategies through collaboration among experts across related fields. The purposes of this study are to identify the regularity of information sharing in managing daily function for older adults, with a special focus on interdisciplinary cooperation, and to explore a practical care strategy for nursing home residents. The collaborative methods of network and thematic analysis were done by conducting in-depth interviews with 33 interdisciplinary experts working at seven nursing homes. This study proposed three relationships and three themes as interrelated key factors for providing interdisciplinary care to the elderly at various levels of function based on the experiences accumulated by the practitioners. First, independent sharing is required to make professional judgments about how daily function in older adults changes from reported baselines. Second, practitioners accurately judge clinical situations and supplement experts' judgments through partial sharing. Finally, all interdisciplinary consensus through complete sharing achieves the ultimate goal of maintaining remaining function in older adults. These findings can be the first step in developing practical care guidelines for interdisciplinary use, and the results can be used to develop integrated assessment and intervention strategies. Corresponding author: Sung Ok Chang, PhD, RN, College of Nursing, Korea University, 145 Anam-ro, Seongbuk-Gu, Seoul, Republic of Korea 02841 (sungok@korea.ac.kr). This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2015R1D1A1A01057258). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.