Catherine McCabe

Ethics education constitutes a fundamental component of nursing development, shaping practitioners capable of sound moral judgment, responsible action, and ethically grounded clinical decision-making. Despite long-standing written ethical codes within the nursing profession, substantial gaps persist between theoretical instruction and real-world practice, leading to fragmented moral competence among nursing students and nurses. This discussion paper synthesizes evidence from the “Promoting a Morally Competent Nurse” project, insights derived from an international blended intensive program to examine the multifaceted challenges that hinder effective nursing ethics education, and expert contributions. Identified challenges include complexity of ethics theories; inconsistencies in the nursing curricula; the misalignment between formal and hidden curriculum; lack of resources and time dedicated to ethics education; inconsistencies in the training methods; and issues related to ethical leadership. The paper argues that cultivating moral competence requires more than the transmission of theoretical knowledge -it demands experiential learning, role modelling, and ethically supportive environments. A roadmap is proposed outlining complementary roles for academic nurses and nurse managers in strengthening ethics education across educational and clinical settings. Enhancing ethical leadership, harmonizing curricula, and investing in educator preparation are critical steps toward building an ethically resilient nursing workforce The paper concludes that ethical competence is not a static achievement but a lifelong developmental process that must be nurtured through intentional, coordinated, and context-sensitive strategies.

Objective: Nurse-led virtual outpatient clinics are now a familiar component of healthcare delivery across many disciplines, including cancer care, orthopedics, rheumatology, and gastroenterology. However, establishing a nurse-led virtual clinic is challenging for nursing management, particularly regarding resources. We aimed to investigate nursing practices and processes and patient experiences in relation to virtual outpatient clinics. Methods: This was a cross-sectional, descriptive study using mixed data collection methods. Patients (n = 324) from 4 specialist clinics completed the Virtual Clinics Patient Satisfaction Questionnaire (VCSQ) survey. Five Nurse Specialists participated in a focus group interview. Results: Most participants (86.3%) reported being satisfied/very satisfied with the virtual clinics, particularly those that were nurse-led. Nurse specialists identified electronic health records (EHRs) and additional IT and administrative support as important for efficiency and effectiveness of the clinics. Conclusions: Nurse-led virtual clinics can be an effective and efficient way to provide care to patients. Nurse managers need to ensure supportive structures are in place, for example, dedicated administrators, IT support and infrastructure, education/training, and relevant policies/procedures. The success of nurse-led virtual services requires key infrastructure to support nursing staff and sustain this service.

Background: Digital health interventions for self-management have reported improvement in medication adherence, but further studies have reported that this is not sustained. Clarity is needed on the effectiveness of digital health interventions (DHIs) for medication adherence and the characteristics of successful DHIs. Objective: This review aimed to evaluate the effectiveness of DHIs versus standard care in supporting medication adherence in community-based adults. Methods: Studies of DHIs that included community-based adults (18 + years) that required prescribed medications and either used, or have access to, technology to manage their illness were included for review. A literature search was conducted across eight key databases. Studies were pooled in statistical meta-analysis using a random effects model. Pooled results were estimated by subgroup analyses defined by study design, intervention duration and intervention type (platform). Results: Thirteen studies were included in the final meta-analysis ( N = 1320). There was no statistically significant effect of DHIs on medication adherence. Subgroup analyses showed no increase in medication adherence observed in the intervention group. However, a small significant increase in medication adherence was observed in the control group in studies of 6-month duration. Conclusions: The impact of DHIs on medication adherence is unclear. More rigorous clinical evidence is required to understand the impact of DHIs on medication adherence over longer durations, and further studies exploring the impact of platform type on medication adherence are required, with consideration given to the potential of Artificial Intelligence (AI)-driven diagnostics and analytics in the future.

Background: Chronic obstructive pulmonary disease (COPD) negatively impacts clinical health outcomes, resulting in frequent exacerbations, increased hospitalizations, reduced physical activity, deteriorated quality of life, and diminished self-efficacy. Previous studies demonstrated that a self-management program tailored for adults with COPD improves self-management decisions, resulting in a positive effect on clinical health outcomes. Limitations of these studies include issues regarding heterogeneity among interventions used, patient population characteristics, outcome measures, and longitudinal studies. Limited studies focused on the use of a comprehensive self-management program using a smartphone app for adults with COPD over 12 months. Objective: This study aimed to explore the effectiveness of a smartphone app self-management program and monthly phone calls compared with standard respiratory outpatient care on clinical health outcomes in adults with COPD. Methods: This was a 3-arm parallel pilot randomized controlled trial (RCT) that included 92 participants. Participants were randomized into intervention arm 1, which included a self-management smartphone app and monthly phone calls (n=31); intervention arm 2, which included a self-management smartphone app (n=31); and arm 3, which was standard respiratory outpatient care (n=30). All arms received standard respiratory outpatient care. The primary outcome was a binary indicator equal to 1 if participants reported attendance to a general practitioner (GP) and or a hospital setting as a result of an exacerbation and 0 otherwise. This indicator was recorded at 6 months and 12 months from the baseline. Secondary outcomes included engagement, breathlessness, physical activity, health-related quality of life, and self-efficacy. Results: There was a statistically significant difference (P=.03), indicating fewer exacerbations in the intervention arm 2 compared with the control arm at 6 months in the hospital setting. The intervention arms had a statistically significant difference indicating a lower risk of developing an exacerbation at 6 months in both the GP (P=.01) and hospital setting (P=.006) compared to the control arm. Furthermore, intervention arm 1 demonstrated a statistically significant difference in exercise capacity at 6 and 12 months (P=.02 and P=.03). The intervention arm 2 illustrated a statistically significant difference in step count (P=.009) compared to the control arm. The majority of participants (60%, 33/55) used the app over the 12-month period. Conclusions: This study demonstrated that a smartphone app self-management program had a positive effect on clinical health outcomes for participants with COPD in comparison to standard respiratory outpatient care. This study illustrated benefits such as reduced exacerbations resulting in fewer hospitalizations, improved exercise capacity, and physical activity among the intervention arms. This was a single-center study, which was limited in power to demonstrate significant effects on all measured outcomes but paves the way for a larger, fully powered multicenter trial exploring the effect of a smartphone app self-management program on clinical health outcomes in adults with COPD. Trial Registration: ClinicalTrials.gov NCT05061810; https://clinicaltrials.gov/study/NCT05061810

Digital health interventions (DHIs) have the potential to improve health care and health promotion. However, there is a lack of guidance in the literature for the development, refinement, and prioritization of key performance indicators (KPIs) for the evaluation of DHIs. This paper presents a 4-stage process used in the Gravitate Health project based on stakeholder consultation and consensus for this purpose. The Gravitate Health consortium, which comprises private and public partners from across Europe and the United States, is developing innovative digital health solutions in the form of Federated Open-Source Platform and G-lens to present users with individualized digital information about their medicines. The first stage of this was the consultative process for the development of KPIs involving stakeholder (Gravitate Health project leads) consultations at the planning stages of the project. This resulted in the formation of an extensive list of KPIs organized into 7 categories. The second stage was conducting a scoping review, which confirmed the need for extensive stakeholder consultation in all stages of the KPI development, refinement, and prioritization process. The third stage was a period of further consultation with all consortium members, which resulted in the elimination of 1 category of KPIs. The fourth stage involved using the Delphi technique for refining and prioritizing the remaining 6 categories of KPIs. It is unusual to use this methodology in a nonresearch exercise, but it provided a clear consultative framework and structure that facilitated the achievement of consensus within a large consortium of 250 members on a substantial list of KPIs for the project. Consortium members ranked the relevance and importance of each KPI. The final list of KPIs provides substantial indicators sensitive to the needs of a broad group of stakeholders that are being used to capture real-world data in developing and evaluating DHIs.

Aim: To explore (a) how nurses can be supported in developing their moral competence and (b) which tools should be used, according to the perspective of patient representatives. Background: Nurses must provide morally competent care. Examining how moral competence can be developed requires a comprehensive approach that includes patients and their representatives to complement the perspective of professionals (e.g., educators). Methods: A descriptive qualitative multinational study in 2023 as part of the Promoting a Morally Competent Nurse (PROMOCON) project. A purposive sample of 35 patient representatives as members or chairs of patient organisations representing different diseases or health issues in Belgium, Cyprus, Finland, Greece, Ireland and Italy. Data were collected through focus group interviews and analysed using a thematic and content analysis approach. The checklist of the Consolidated Criteria for Reporting Qualitative Research was followed. Results: The development of nurses’ moral competence can be supported at three different levels, namely (1) at the societal level: “Recognition of the nursing profession”; (2) at the organisational level: “Building organisations based on ethically sound premises”; and (3) at the level of individual relationships: “Working on oneself to achieve moral competence in relation to oneself and others”. To support the development of morally competent nurses, various educational measures, infrastructures and social tools were recommended. Conclusion: In this area, a systematic approach is required that includes multicomponent strategies and is complemented by practical tools. Implications for Nursing Management: This is the first study to address the question of how to support the development of a morally competent nurse from the perspective of patients’ representatives. The list of strategies and tools that have emerged can be considered by societies, professional organisations and academic institutions as well as national health services and the private sector to take concrete action.

UNSTRUCTURED Digital health interventions (DHIs) have the potential to improve health care and health promotion. However, there is a lack of guidance in the literature for the development, refinement, and prioritization of key performance indicators (KPIs) for the evaluation of DHIs. This paper presents a 4-stage process used in the Gravitate Health project based on stakeholder consultation and consensus for this purpose. The Gravitate Health consortium, which comprises private and public partners from across Europe and the United States, is developing innovative digital health solutions in the form of Federated Open-Source Platform and G-lens to present users with individualized digital information about their medicines. The first stage of this was the consultative process for the development of KPIs involving stakeholder (Gravitate Health project leads) consultations at the planning stages of the project. This resulted in the formation of an extensive list of KPIs organized into 7 categories. The second stage was conducting a scoping review, which confirmed the need for extensive stakeholder consultation in all stages of the KPI development, refinement, and prioritization process. The third stage was a period of further consultation with all consortium members, which resulted in the elimination of 1 category of KPIs. The fourth stage involved using the Delphi technique for refining and prioritizing the remaining 6 categories of KPIs. It is unusual to use this methodology in a nonresearch exercise, but it provided a clear consultative framework and structure that facilitated the achievement of consensus within a large consortium of 250 members on a substantial list of KPIs for the project. Consortium members ranked the relevance and importance of each KPI. The final list of KPIs provides substantial indicators sensitive to the needs of a broad group of stakeholders that are being used to capture real-world data in developing and evaluating DHIs.

BACKGROUND Chronic obstructive pulmonary disease (COPD) negatively impacts clinical health outcomes, resulting in frequent exacerbations, increased hospitalizations, reduced physical activity, deteriorated quality of life, and diminished self-efficacy. Previous studies demonstrated that a self-management program tailored for adults with COPD improves self-management decisions, resulting in a positive effect on clinical health outcomes. Limitations of these studies include issues regarding heterogeneity among interventions used, patient population characteristics, outcome measures, and longitudinal studies. Limited studies focused on the use of a comprehensive self-management program using a smartphone app for adults with COPD over 12 months. OBJECTIVE This study aimed to explore the effectiveness of a smartphone app self-management program and monthly phone calls compared with standard respiratory outpatient care on clinical health outcomes in adults with COPD. METHODS This was a 3-arm parallel pilot randomized controlled trial (RCT) that included 92 participants. Participants were randomized into intervention arm 1, which included a self-management smartphone app and monthly phone calls (n=31); intervention arm 2, which included a self-management smartphone app (n=31); and arm 3, which was standard respiratory outpatient care (n=30). All arms received standard respiratory outpatient care. The primary outcome was a binary indicator equal to 1 if participants reported attendance to a general practitioner (GP) and or a hospital setting as a result of an exacerbation and 0 otherwise. This indicator was recorded at 6 months and 12 months from the baseline. Secondary outcomes included engagement, breathlessness, physical activity, health-related quality of life, and self-efficacy. RESULTS There was a statistically significant difference (P=.03), indicating fewer exacerbations in the intervention arm 2 compared with the control arm at 6 months in the hospital setting. The intervention arms had a statistically significant difference indicating a lower risk of developing an exacerbation at 6 months in both the GP (P=.01) and hospital setting (P=.006) compared to the control arm. Furthermore, intervention arm 1 demonstrated a statistically significant difference in exercise capacity at 6 and 12 months (P=.02 and P=.03). The intervention arm 2 illustrated a statistically significant difference in step count (P=.009) compared to the control arm. The majority of participants (60%, 33/55) used the app over the 12-month period. CONCLUSIONS This study demonstrated that a smartphone app self-management program had a positive effect on clinical health outcomes for participants with COPD in comparison to standard respiratory outpatient care. This study illustrated benefits such as reduced exacerbations resulting in fewer hospitalizations, improved exercise capacity, and physical activity among the intervention arms. This was a single-center study, which was limited in power to demonstrate significant effects on all measured outcomes but paves the way for a larger, fully powered multicenter trial exploring the effect of a smartphone app self-management program on clinical health outcomes in adults with COPD. CLINICALTRIAL ClinicalTrials.gov NCT05061810; https://clinicaltrials.gov/study/NCT05061810

Background: Digital health interventions offer new methods for delivering healthcare, with the potential to innovate healthcare services. Key performance indicators play a role in the evaluation, measurement, and improvement in healthcare quality and service performance. The aim of this scoping review was to identify current knowledge and evidence surrounding the development of key performance indicators for digital health interventions. Methods: A literature search was conducted across ten key databases: AMED – The Allied and Complementary Medicine Database, CINAHL – Complete, Health Source: Nursing/Academic Edition, MEDLINE, APA PsycINFO, EMBASE, EBM Reviews – Cochrane Database of Systematic Reviews, EBM Reviews – Database of Abstracts of Reviews of Effects, EBM Reviews – Health Technology Assessment, and IEEE Xplore. Results: Five references were eligible for the review. Two were articles on original research studies of a specific digital health intervention, and two were overviews of methods for developing digital health interventions (not specific to a single digital health intervention). All the included reports discussed the involvement of stakeholders in developing key performance indicators for digital health interventions. The step of identifying and defining the key performance indicators was completed using various methodologies, but all centred on a form of stakeholder involvement. Potential options for stakeholder involvement for key performance indicator identification include the use of an elicitation framework, a factorial survey approach, or a Delphi study. Conclusions: Few articles were identified, highlighting a significant gap in evidence-based knowledge in this domain. All the included articles discussed the involvement of stakeholders in developing key performance indicators for digital health interventions, which were performed using various methodologies. The articles acknowledged a lack of literature related to key performance indicator development for digital health interventions. To allow comparability between key performance indicator initiatives and facilitate work in the field, further research would be beneficial to develop a common methodology for key performance indicators development for digital health interventions.