{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T19:09:06Z","timestamp":1782846546624,"version":"3.54.5"},"reference-count":30,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Nursing"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Clinical decision support (CDS) tools embedded in electronic health records in the form of integrated clinical prediction rules provide a potentially effective intervention to reduce inappropriate antibiotic prescribing for acute respiratory infections. However, their effectiveness has been limited by workflow barriers and low adoption by health care providers. Nurses are well positioned to implement evidence-based protocols using CDS tools. In a multicenter randomized controlled trial, a nurse-led implementation strategy for acute respiratory infection integrated clinical prediction rules was evaluated for use in primary care and urgent care settings.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This study aimed to examine nurse and nurse leader perspectives on the sustainability of an electronic health record\u2013integrated CDS tool for antibiotic stewardship and explored factors influencing its potential long-term integration into ambulatory nursing practice beyond the clinical trial.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We interviewed 22 nurses and nurse leaders from 37 clinics across 3 academic medical centers that participated in the clinical trial. Two semistructured 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.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n 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 2 distinct processes.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/83567","type":"journal-article","created":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T00:20:06Z","timestamp":1768954806000},"page":"e83567-e83567","source":"Crossref","is-referenced-by-count":0,"title":["Barriers and Enablers for Sustaining Nurse-Led Use of Clinical Decision Support Tools for Antibiotic Stewardship: Qualitative Study"],"prefix":"10.2196","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5653-2282","authenticated-orcid":false,"given":"Victoria L","family":"Tiase","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-3292-9853","authenticated-orcid":false,"given":"Aurie D","family":"Tovar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-4302-9476","authenticated-orcid":false,"given":"Natalie","family":"Henning","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-5863-5411","authenticated-orcid":false,"given":"Mariana","family":"Braga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-4218-6825","authenticated-orcid":false,"given":"Keelin","family":"McHugh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-8586-9955","authenticated-orcid":false,"given":"Lynn","family":"Xu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-6987-6297","authenticated-orcid":false,"given":"Haddy","family":"Bah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2635-8999","authenticated-orcid":false,"given":"Alice","family":"Yuroff","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2545-8504","authenticated-orcid":false,"given":"Rachel","family":"Hess","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2099-0852","authenticated-orcid":false,"given":"Devin M","family":"Mann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7287-6816","authenticated-orcid":false,"given":"David","family":"Feldstein","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6063-1523","authenticated-orcid":false,"given":"Elizabeth R","family":"Stevens","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2026,3,10]]},"reference":[{"issue":"6","key":"R1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0306195","article-title":"Ambulatory antibiotic prescription rates for acute respiratory infection rebound two years after the start of the COVID-19 pandemic","volume":"19","author":"Stevens","journal-title":"PLoS One"},{"issue":"1","key":"R2","doi-asserted-by":"publisher","DOI":"10.1186\/s13012-017-0567-y","article-title":"Design and implementation of electronic health record integrated clinical prediction rules (iCPR): a randomized trial in diverse primary care settings","volume":"12","author":"Feldstein","journal-title":"Implement Sci"},{"issue":"1","key":"R3","doi-asserted-by":"publisher","DOI":"10.1136\/bmjhci-2019-100088","article-title":"Using normalisation process theory to understand workflow implications of decision support implementation across diverse primary care settings","volume":"26","author":"Mishuris","journal-title":"BMJ Health Care Inform"},{"key":"R4","doi-asserted-by":"publisher","DOI":"10.1186\/1748-5908-6-109","article-title":"Rationale, design, and implementation protocol of an electronic health record integrated clinical prediction rule (iCPR) randomized trial in primary care","volume":"6","author":"Mann","journal-title":"Implement Sci"},{"issue":"Suppl 2","key":"R5","doi-asserted-by":"publisher","first-page":"788","DOI":"10.1007\/s11606-020-06096-3","article-title":"Impact of clinical decision support on antibiotic prescribing for acute respiratory infections: a cluster randomized implementation trial","volume":"35","author":"Mann","journal-title":"J Gen Intern Med"},{"key":"R6","doi-asserted-by":"publisher","DOI":"10.1177\/2055207619827716","article-title":"Adaptive design of a clinical decision support tool: what the impact on utilization rates means for future CDS research","volume":"5","author":"Mann","journal-title":"Digit Health"},{"issue":"2","key":"R7","doi-asserted-by":"publisher","first-page":"113","DOI":"10.7326\/M13-2567","article-title":"Effects of nurse-managed protocols in the outpatient management of adults with chronic conditions: a systematic review and meta-analysis","volume":"161","author":"Shaw","journal-title":"Ann Intern Med"},{"issue":"1","key":"R8","doi-asserted-by":"publisher","first-page":"82","DOI":"10.1111\/jnu.13001","article-title":"Nurses\u2019 perceptions of the design, implementation, and adoption of machine learning clinical decision support: a descriptive qualitative study","volume":"57","author":"Wieben","journal-title":"J Nurs Scholarsh"},{"key":"R9","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijnurstu.2025.105142","article-title":"Promoting nurse participation in hospital antimicrobial stewardship: a realist review","volume":"169","author":"Luo","journal-title":"Int J Nurs Stud"},{"key":"R10","doi-asserted-by":"publisher","DOI":"10.2196\/54996","article-title":"Barriers to implementing registered nurse\u2011driven clinical decision support for antibiotic stewardship: retrospective case study","volume":"8","author":"Stevens","journal-title":"JMIR Form Res"},{"key":"R11","doi-asserted-by":"publisher","DOI":"10.2196\/55316","article-title":"Snowball group usability testing for rapid and iterative multisite tool development: method development study","volume":"9","author":"Dauber-Decker","journal-title":"JMIR Form Res"},{"issue":"1","key":"R12","doi-asserted-by":"publisher","DOI":"10.1186\/s12911-023-02368-0","article-title":"Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial","volume":"23","author":"Stevens","journal-title":"BMC Med Inform Decis Mak"},{"issue":"6","key":"R13","doi-asserted-by":"publisher","first-page":"204","DOI":"10.1136\/ebmed-2014-110054","article-title":"Longitudinal adoption rates of complex decision support tools in primary care","volume":"19","author":"McCullagh","journal-title":"Evid Based Med"},{"issue":"10","key":"R14","doi-asserted-by":"publisher","first-page":"2793","DOI":"10.1007\/s10067-019-04643-w","article-title":"Factors influencing implementation of a computerized, individualized, culturally tailored lupus decision aid in lupus clinics: a qualitative semi-structured interview study","volume":"38","author":"Qu","journal-title":"Clin Rheumatol"},{"issue":"1","key":"R15","doi-asserted-by":"publisher","DOI":"10.1186\/s13012-022-01245-0","article-title":"The updated consolidated framework for implementation research based on user feedback","volume":"17","author":"Damschroder","journal-title":"Implement Sci"},{"issue":"2","key":"R16","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","journal-title":"Qual Res Psychol"},{"key":"R17","unstructured":"Dedoose. URL: www.dedoose.com [Accessed 19-02-2026]"},{"key":"R18","doi-asserted-by":"crossref","unstructured":"Booth A Hannes K Harden A Noyes J Harris J Tong A . COREQ (consolidated criteria for reporting qualitative studies). In: Moher D Altman DG Schulz KF Simera I Wager E , editors. Guidelines for Reporting Health Research A User\u2019s Manual. John Wiley & Sons; 2014:214-226. [doi: 10.1002\/9781118715598.ch21] ISBN: 9780470670446","DOI":"10.1002\/9781118715598.ch21"},{"issue":"1","key":"R19","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-020-05434-9","article-title":"The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review","volume":"20","author":"Cowie","journal-title":"BMC Health Serv Res"},{"issue":"2","key":"R20","doi-asserted-by":"publisher","first-page":"192","DOI":"10.1177\/1049731513505778","article-title":"A systematic review of strategies for implementing empirically supported mental health interventions","volume":"24","author":"Powell","journal-title":"Res Soc Work Pract"},{"issue":"3","key":"R21","first-page":"126","volume":"34","author":"Haas","journal-title":"Nurs Econ"},{"issue":"7","key":"R22","doi-asserted-by":"publisher","DOI":"10.1001\/jamahealthforum.2023.1809","article-title":"Physician and nurse well\u2011being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety","volume":"4","author":"Aiken","journal-title":"JAMA Health Forum"},{"issue":"16","key":"R23","doi-asserted-by":"publisher","first-page":"1987","DOI":"10.1001\/jama.288.16.1987","article-title":"Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction","volume":"288","author":"Aiken","journal-title":"JAMA"},{"key":"R24","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijnsa.2022.100064","article-title":"Outpatient nurse staffing relationship with organizational, nurse and patient outcomes: a scoping review","volume":"4","author":"Adynski","journal-title":"Int J Nurs Stud Adv"},{"key":"R25","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2025.02.024","article-title":"Effect of virtual nursing implementation on emergency department efficiency and quality of care","volume":"91","author":"Khairat","journal-title":"Am J Emerg Med"},{"key":"R26","unstructured":"Webster JS King HB Toomey LM et al. Understanding quality and safety problems in the ambulatory environment: seeking improvement with promising teamwork tools and strategies. In: Advances in Patient Safety: New Directions and Alternative Approaches (Volume 3: Performance and Tools). Agency for Healthcare Research and Quality (US); 2008:211-223. URL: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK43683\/ [Accessed 19-02-2026]"},{"issue":"8","key":"R27","doi-asserted-by":"publisher","first-page":"1667","DOI":"10.1093\/jamia\/ocab064","article-title":"Barriers to using clinical decision support in ambulatory care: do clinics in health systems fare better?","volume":"28","author":"Shi","journal-title":"J Am Med Inform Assoc"},{"key":"R28","unstructured":"Nursing Informatics Scope and Standards of Practice. 2nd ed. American Nurses Association; 2015. URL: https:\/\/www.homeworkforyou.com\/static_media\/uploadedfiles\/1729564993_4793663__166..pdf [Accessed 19-02-2026] ISBN: 9781558105805"},{"issue":"1","key":"R29","doi-asserted-by":"publisher","DOI":"10.1186\/s12911-025-02945-5","article-title":"Practical applications of methods to incorporate patient preferences into medical decision models: a scoping review","volume":"25","author":"Fusiak","journal-title":"BMC Med Inform Decis Mak"},{"issue":"3","key":"R30","doi-asserted-by":"publisher","first-page":"102397","DOI":"10.1016\/j.outlook.2025.102397","article-title":"Top-of-license practice for registered nurses: a scoping review","volume":"73","author":"Hlebichuk","journal-title":"Nurs Outlook"}],"container-title":["JMIR Nursing"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/nursing.jmir.org\/2026\/1\/e83567","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T18:17:45Z","timestamp":1782843465000},"score":1,"resource":{"primary":{"URL":"https:\/\/nursing.jmir.org\/2026\/1\/e83567"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,10]]},"references-count":30,"URL":"https:\/\/doi.org\/10.2196\/83567","relation":{},"ISSN":["2562-7600"],"issn-type":[{"value":"2562-7600","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,10]]},"article-number":"v9i6e83567"}}