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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000418927.60847.44
iNurse

Tablet Technology for Nurses

Duffy, Megen BA, BSN, RN, CEN

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Author Information

Megen Duffy is an RN in an ED in the Midwest. Her blog, Not Nurse Ratched, can be found at http://notratched.net. The author has disclosed no potential conflicts of interest, financial or otherwise.

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Abstract

A guided tour of uses, potential uses, and pitfalls, plus a closer look at two leading contenders.

Mobile technology has become ubiquitous. Smartphones have become affordable, and tablet computers and electronic book readers (e-readers) have become both more affordable and easier to use—no more dinking with a stylus on a finicky Windows tablet screen. They're popular with nurses, too. According to a Springer Publishing survey from September 2011, 75% of the more than 1,100 nurses who responded said they owned either a tablet or a smartphone, and approximately 42% owned a dedicated e-reader (61% of whom chose some version of the Amazon Kindle).1 The population in general is becoming more comfortable with the idea of reading pixels instead of paper. According to a survey by the Pew Internet and American Life Project, one in five American adults said they'd read an e-book in the previous year (February 2011 to February 2012), and of these, a surprising 74% said they'd read e-books for research, close to the 80% who read for pleasure.2

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Figure. Photo by Ari...
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I would guess that everyone reading this column has heard of the iPad. Many readers may even have one, and those who don't probably want one. According to the April Apple Inc. earnings report, Apple sold almost 12 million iPads during the financial quarter ending March 31.3 That's a lot of iPads. The Samsung Galaxy Tab is probably closest to the iPad in terms of market penetration, but other tablets are either in development, like the Windows Surface or Google Nexus, or already exist, like the Kindle Fire. (Although the Kindle Fire is an e-reader rather than a tablet, it's discussed here because it has enough additional functionality to be grouped with tablets; however, since it wasn't released until mid-November 2011, no available survey data break down use of the Kindle Fire versus the iPad.)

But why all this interest in tablets?

Tablets are mobile. Laptops are portable, but tablets are truly mobile technology. An iPad or e-reader can be slipped into a purse (or small gadget bag), and the battery lasts so long that packing a charger and an extra cord is unnecessary unless an overnight visit is involved, and maybe not even then. Tablets also cut down drastically on the amount of stuff in said purse or bag. Anyone who has ever experienced back strain from hauling books around will appreciate the ability to consolidate an entire library into a device smaller and lighter than a single textbook.

Tablets are convenient. Nurses are always short on time, and as a group we are acutely interested in anything that will simplify our lives and give us a little more free time. We are people who structure our professional lives around efficiency and timeliness. Therefore, we are the perfect audience for tablet computing. Tablets are a lightweight way to do everything in one (portable) spot: check your calendar; check your e-mail; check your to-do list; read your blogs, Twitter, and Facebook; and read the latest issues of many nursing journals.

Tablets versus smartphones. It's tempting to view the iPad as a giant iPhone that doesn't make phone calls, and in some ways it is, but important differences distinguish tablets from smartphones. As portable as tablets are, smartphones are more so, and tablets may have Internet connectivity only when Wi-Fi is available. Smartphones are “always on,” unless the user disables Internet connectivity. The screens on smartphones are much smaller than those on tablets, so much so that it can be nearly unworkable to read much text on them. Certainly it would be untenable to view PDF files or read long research articles on a smartphone, whereas doing the same on a tablet is pleasurable. Conversely, storing reference materials on a tablet may not be as useful as storing them on a smartphone, because the tablet will not fit in a scrubs pocket whereas the smartphone will. Furthermore, as popular as tablets are, smartphones are even more so.

This column will cover the use, both current and potential, and possible pitfalls, of tablet computing and smartphones in general, focusing on Apple and Android devices because these are the most common among nurses—with 44% owning the Apple iPhone and iPod Touch, 22% the Apple iPad, and 30% Android devices (the nurses' survey did not separate Android platform use between smartphones and tablets as it did with the Apple data).1 The column will also include device reviews for the iPad and Kindle Fire, by popular consensus the two most common tablets currently in use.

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USES FOR TABLETS

Tablets have untapped potential for use by nurses (and like other medical bloggers before me,4, 5 I will speculate on some of these possible uses later in this article), but they are already far from useless, and tablet users and app developers are constantly inventing new uses.

Current uses. As mentioned earlier, tablets are a boon for busy, mobile nurses who need to be connected. And unless you are a self-employed nurse who stays at home working on a computer, that category probably includes you. Smartphones are helpful for keeping track of e-mail, appointments, task lists, and so on, but because of their small screen size, they reach a limit of usefulness fairly quickly. The larger screen on a tablet makes a world of difference in doing the online things that, for most of us, have become daily necessities.

Activities of daily electronic living. For example, my job requires me to check my work e-mail regularly, and I'm responsible for knowing and implementing the information communicated via that medium. Before that, my nursing school required the same, and had I not had nearly constant connectivity, I would have shown up for classes that had been cancelled, turned in late papers because I missed a changed due date, or failed to read the correct assignment for a lecture. Similarly, nurse managers and educators expect nurses to receive electronic communications quickly.

Social media. Nurses are also increasingly involved in social media, whether for personal or professional use, and tablets ease participation in these online activities. It's simply easier on the eyes to read blogs or any large amount of text on a larger screen.

Keeping up with professional articles. Perusal of nursing Web sites, blogs, and Twitter feeds generally nets a slew of articles that one would like to read … someday. Everyone has a favorite method of storing these away (I call mine my “good intentions file”; other people just bookmark sites and forget them), but owning a tablet makes it significantly more likely that you will actually read these articles later because you can send them to a variety of visually clean and pleasing applications. Options for saving blog posts and other Web pages include, most popularly, Instapaper (www.instapaper.com) and Readability (www.readability.com). Anything can be sent to Evernote (http://evernote.com), but it is such a comprehensive system that a review of it is beyond the scope of this article. It's worth learning how to use, however. Interested readers can purchase the worthy Evernote Essentials guide at http://nerdgap.com/landing/evernote-essentials.

For articles formatted as PDFs (reflecting the physical appearance of the journal versus the HTML layout used on the Web), the previously described options will not work. AJN now has an attractive iPad app (go to the iTunes store and search for “AJN iPad app”). Other journals have downloadable articles, if not entire issues, usually in PDF files that are easy to read with inexpensive (around $5) iPad apps. The most popular is GoodReader for iPad, which is now $4.99. It's a must-have for reading just about any format you throw at it, and it also allows annotation. It syncs with remote servers of various kinds, and the real techie will find many other goodies hidden in the preferences.

Kindle Fire users are more crippled when it comes to easily reading PDF files, because reading a journal-sized PDF file on the 7-inch screen involves more pinching and zooming than reading. However, Amazon has a utility called Send to Kindle (www.amazon.com/sendtokindle) available for the PC and the Mac. It shuttles PDFs, text files, and other file formats to the registered Kindle of your choice; and sooner rather than later, the file will appear on your carousel. This is not as seamless a process as it is on an iPad, and the sending is best done from an actual computer; however, it creates attractive Kindle-compatible files and allows easy reading, storage, highlighting, and annotation on the Kindle Fire.

Reading for fun (shhhh …). The iPad doubles as a stellar e-book reader. With the free Kindle app, it syncs with the Amazon Kindle store and opens nearly everything a Kindle would. I say nearly everything because it doesn't support books borrowed from the Kindle Owners' Lending Library and has some other esoteric limitations that most readers will probably never care about. The Fire, obviously, is primarily an e-book reader. The iPad can also use the iBooks app, free from the App Store, so that books will sync between the iPad and an iPhone that's also running iBooks. Although some e-books cost as much as and sometimes more than their paper counterparts, it's possible to find many cheap or free e-books. Just run a Google search for “free Kindle books” or “free e-books” and bask in the abundance.

Medical applications. Tablets are useful for viewing medical references, although smartphones are more so because they are smaller (again, the iPad will not fit in your pocket). For lengthy texts, though, the tablet screen wins out. Either a smartphone or tablet can be used to view Web pages on any platform, but also hundreds of medical applications exist for both the iOS (iPad and iPhone) and Android (used on the Kindle Fire and many smartphones) operating systems. According to the Springer Publishing nurses' survey, nearly half of the respondents who owned smartphones or tablets had downloaded medical applications.1 Medical apps can help you look up current-to-the-minute drug information (in the survey, the most common application downloaded, by far, was Epocrates); translate what you need to say into Spanish; convert units/hour to mL/hour; supply information on your patient's extremely rare genetic condition; show you the most current advanced cardiac life support algorithms; convert adult to pediatric dosages; and even track your continuing education credits.

For the Luddite nurses out there, downloading and using medical references probably seem daunting, but there are definite advantages to consider before discarding the idea. Electronic databases can constantly be kept current, whereas traditional paper reference books are out of date as soon as they're printed. This is particularly the case for drug references. New medications erupt onto the market constantly, and existing ones are routinely removed or are associated with newly listed adverse effects and warnings. Also, information on a smartphone is portable. If you are at the bedside and your patient asks a question about a medication you're about to administer, which seems more patient friendly: whipping out your electronic reference and answering the question instantly with absolutely current information, or leaving the room, hunting down the drug reference—which may or may not be near the Pyxis, where it should be—and then returning to the bedside with a giant tome to answer the question?

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EDUCATION

Mobile technology can also be used to educate both patients and nurses. My nursing school started requiring personal digital assistants the semester after I graduated, and other nursing schools are doing the same, mostly iPhones or iPod Touches.6 Although reading textbooks would be tedious on such a small device, using the smaller device to locate a reference can be extraordinarily convenient. Nursing students carry around notoriously large stacks of textbooks, and moving them all onto one slim device is a compelling idea. Nursing students have just as much need for medication data and other clinical information as practicing nurses.

In more technical usage, nurse educators are using their iPads for audiovisual presentations. With AirPlay, a built-in technology that sends audio and video to other devices, and an Apple TV (or a VGA adaptor), nurses can create a presentation using the Apple Keynote application from the iPad.

There's also a huge potential for tablets in patient education. Medical professionals hand out pamphlets and printouts like there's no tomorrow, but I wonder how many patients actually read them. What if we could whip out an iPad at the bedside and show the patient full-color illustrations and even videos to illustrate our teaching? Companies are already marketing customizable iPad apps, and hospitals have created mobile applications to provide maps and other patient information.7 These are but the tip of the iceberg.

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ELECTRONIC MEDICAL RECORDS

The availability of more user-friendly devices to access electronic medical records (EMRs) would bring a smile to many a nurse's face. Currently we labor on often-broken Windows tablets, use heavy CareMobile bar scanners, and drag around COWs (computers on wheels). iPads and iPod Touches would solve many of the problems with these devices (unreliability, heft, battery issues, stylus issues, and user interface issues, to name but a few). The workflow of the future may involve arriving at work, checking out an iPad (or one of the tablets currently in development by Google, Microsoft, and others, if they prove themselves worthy), and receiving up-to-the minute laboratory results and new orders, all in a more portable and user-friendly package.

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PRODUCTIVITY

Mobile technology is generally seen as a means of consumption, but it can also be used for productivity. Using the iPad's on-screen keyboard for any length of time is cumbersome for all but the most dedicated users, but with an external Bluetooth keyboard, the iPad can become a laptop for many writers. Affordable iPad applications sync with Microsoft Office and the Apple iWork suite, and a keyboard simplifies tasks such as responding to a large number of e-mails. Entering text on the Kindle Fire, conversely, is extremely laborious, and the Fire is not realistically a productivity device.

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PITFALLS

Nurses may find their use of mobile devices curtailed because of concerns about professionalism, patient privacy, and use of non–hospital-approved reference information. Brent Thompson, PhD, RN, who blogs at http://nursingeducator.blogspot.com, has compellingly addressed for nursing students the pitfalls associated with the use of mobile technology in the clinical setting, and the same arguments apply for practicing nurses.8 Ironically for nursing students required by their schools to use mobile devices, some hospitals still forbid their use. Such students may find themselves in the untenable position of being required to use a device they are not allowed to use. Here the past butts heads with the future, with no possible compromise.

Patient privacy. The concern most frequently bandied about concerning tablets and smartphones is, predictably, patient privacy. Two main issues enter the fray here: the first is our old friend the Health Insurance Portability and Accountability Act (usually just called HIPAA); the second are those inherent in extremely portable devices that contain EMR information. Hospitals are leery of allowing nurses to run around with devices that take pictures and allow on-the-spot posting to the world at large, and they are right to be. Some nurses have posted inappropriate information from their smartphones while they were at work (see the September 2011 iNurse column, “Patient Privacy and Company Policy in Online Life,” for examples).9

Nurses have, however, also posted such information when not at work, and as Thompson points out, nurses can violate HIPAA in many ways.8 Disallowing mobile devices takes only one possible mode out of contention. The EMR issue is stickier. Information technologists have not yet widely “HIPAA-fied” the iPad, and until that capability exists, patient data cannot be kept on these devices. This barrier may soon be broken, however, as I've heard that at least one project for using the iPod Touch as a medication scanner (to replace the common Windows Mobile barcode scanners, for example) is close to being tested at a clinical site, and medical students report using iPads to access patient data.

Professionalism. Does using a tablet or smartphone distance you from your patient? Opinions run wild; data, not so much. On one side are clinicians stating that a tablet throws up much less of a barrier than a laptop, but on the other side are those stating that a tablet throws up more of a barrier than pen and paper. For example, a medical student blogs the following10:

In the instances where I've tried to use my iPad during patient interviews, I've felt like it was a barrier between me and the patient. I could sense that my patients felt like I wasn't completely paying attention to them. Truth be told, I wasn't. I was too busy making sure that the lines I scrawled or notes I pecked were accurate.

A physician who feels differently blogs this5:

Even if the doctor uses a laptop that allows them to sit directly in front of the patient, the screen acts as a physical barrier between the two…. A doctor can actively engage the patient while writing or typing on a tablet, no different than they would with a notepad or chart in front of them.

The only available study on this topic involved physicians, and it found that patients had largely positive reactions to tablet technology.11

Another professionalism issue arises when someone sees a medical professional using a mobile device and assumes that she or he is texting or playing a game rather than looking up a medication or lab value. This issue may simply take time to resolve as increasing numbers of health care employees use these devices. When nurses use mobile devices at the bedside, it's appropriate to tell the patient what we are doing to eliminate confusion.

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ACCURACY

If we use a hospital-purchased paper drug reference, we are reasonably sure that we have a fallback if our information turns out to be wrong. If we use our own electronic reference, how can we, or our employers, know that it is accurate? Thus runs the argument of some worried paper-only nurses. In return, I would ask how we know that any information is accurate. Just because something is in print does not guarantee accuracy. On the contrary, electronic references can correct errors with an automatic over-the-air update, whereas paper volumes take a year or more to publish a correction. However, it is not an insurmountable task for hospital educators and pharmacists to tell nurses which drug reference to use at that facility, if this is a concern.

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A CLOSER LOOK AT TWO RIVALS

If you already own a tablet, you can stop reading. But if you can't wait to get one, read on. This is a snapshot of my opinions on the iPad and Kindle Fire because it's likely that most people today will be deciding between these two. I own both and use them regularly. For more in-depth reviews, check the Web, where potential buyers can find detailed specifications for processor speed, pixel counts, screen resolutions, and battery times. But I stopped caring about those things a long time ago. What are the devices like to use in real life? That is the question I answer here.

Apple iPad. I have the new iPad (which starts at $499) and had the first two generations as well. At first I saw little difference between the new iPad and the iPad 2, but then I looked at someone else's iPad 2 and felt as if I were going blind. In other words, the improved screen quality makes a huge difference. Even so, until I used the updated iPad, I was not bothered by the original or second-generation iPad screens.

The iPad has a 10-inch screen. That's both good, because it allows easier reading of some types of information, and bad, because larger means heavier. The newest version also has a truly beautiful screen because of the much-touted retina display. This makes photos, games, and text all nicer to look at.

Apps. One advantage of the iPad is that more apps exist for it. Even a casual virtual stroll through the iOS app store will reveal a broader and deeper selection compared with the Android store. Depending on how specific your needs are, this could matter to you. The iPad is in the Apple “ecosystem,” meaning that it often syncs with iPhone versions of the same applications, thus creating time-saving productivity solutions. This allowed me, for example, to write small portions of this article on my iPhone during short breaks at work and then continue on my iPad or even MacBook later.

The iPad also has some bells and whistles that the Fire lacks, such as Bluetooth, cellular data, and GPS capabilities. The iPad 2 and new iPad also have front and rear cameras, and the resolution of the new iPad camera is high enough to take decent photos.

Storage. Finally, you can fit a lot of stuff on an iPad. They come in various storage flavors up to 64 gigabytes. If you plan to haul around a lot of media—in particular, high-definition movies that look beautiful on the retina screen—the iPad is the better choice.

Kindle Fire. The Fire ($199) is cheaper than the iPad. Much cheaper. At least a few hundred dollars cheaper, depending on which iPad model you buy. It's also smaller and lighter.

These two points deserve their own paragraph, because if you pick up a Fire and then pick up an iPad, you will probably initially shrug off the weight difference. iPads weigh 21 to 23 ounces, give or take, and the Fire weighs 14.6 ounces. How much difference can 6 or 7 ounces make? Your mileage may vary, but I bought a Fire in the first place because I read a lot, often for hours a day, and the iPad actually made my wrists and neck hurt. The Fire, with its 7-inch screen, feels more like a book and is a more manageable size and weight for long-term viewing. Its size also makes it much more stowable. It can go into a regular purse (or small gadget bag), whereas the iPad requires more of a messenger-style bag.

Storage. As mentioned previously, the Fire falls short in the storage department; at only 8 gigabytes, it has half the smallest amount of storage available on an iPad. However, it provides compensations. If you are a heavy Amazon user, and especially if you've already owned a Kindle, you will appreciate the tight Amazon integration on the Fire. Although storing videos on the Fire would kill off the available gigabytes rather quickly, the Fire streams from Amazon Video on Demand like a champ. The Fire also allows some Kindle-only functions via the Kindle app that are not supported on the iPad, most notably the use of the Kindle Lending Library.

Apps and browsers. The Fire, which uses the Android operating system, has available to it applications from the Amazon Appstore for Android, many of which are identical or similar to their iOS counterparts (you can play Angry Birds on a Fire, too). However, they fail to pass muster compared with the polish of and available choices for iPad apps. The Fire browser, Silk, is unrewarding as well. It's possible but not enjoyable to browse the Web with it. In fact, that's my experience with many of the non–media-related Fire functions: they are possible to use, but more effort than they're worth.

Productivity is all but impossible on a Fire. With no Bluetooth capability, no external keyboard is possible, and the onscreen keyboard is infuriating. I have skinny fingers and still fat-finger the keyboard. I don't even like to type in user names and passwords. The Fire is far more of a consumption-only device than the iPad.

Which one is for you? It all comes down to this: which one is better? I declined to make that decision and have both. Why? Because I am genetically incapable of not buying new gadgets to play with, and because I use them for different things. If I weren't such an avid reader, the iPad would easily suffice, but as it is I probably use my Fire more hours in a given week than either my iPad or laptop. I am one of those people who cannot stand to be caught without a book, and I remain delighted that I can carry so many with me on a single book-sized device that is small enough and light enough to put in a regular purse. And because the Fire does have additional capabilities, I have the option of Googling something or checking Facebook and Tumblr while I'm away from home.

However, I also read a lot of things that are not books (blogs, journal articles, and so on), and I prefer the iPad for keeping up with those. Programs such as Flipboard on the iPad make it my preferred consumption device, even over my laptop. I have a Bluetooth keyboard for it that I snap on the front and take with me when I travel, and it is a huge advantage to have a laptop, e-reader, and media player all in one relatively lightweight package that runs for 10 hours on a battery charge. I also take a lot of photos, and the iPad has a larger, prettier display for looking at photos; is immediately integrated with the photos I've taken on my iPhone via the new Photo Stream technology; and allows immediate transfer of photos from my camera via the iPad Photo Connection Kit.

Price may ease your decision, since the iPad costs a lot more than the Fire. But first- and second-generation iPads can be found relatively cheaply on eBay and Craigslist because people like me must have the newest one, and we have to get rid of our old (less than a year old) ones somehow. I know some very geeky, technically minded people who are still happily using their original iPads, and unless you are drooling over the camera, the retina screen, or both, you may be happy with an older model as well.

Performance-wise, I have read dozens of articles touting the benefits of the processor in one tablet over that in another, but I can't tell the difference unless I try to play a highly graphics-intensive game (I forgot to mention: these devices are fun, too) on an older iPad. The Fire is laggier in general than the iPad, but not enough to irritate me into not using it, and I have a relatively low irritation threshold with gadgets.

A final tip. If possible, find friends who own iPads and Fires and spend some time reading on both and doing the sorts of activities you would like to do on your tablet. Otherwise, do your research, and enjoy your new tablet.

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REFERENCES

1. The Springer Publishing 2011 nursing ebook and smartphone survey. New York; 2011 Sep. http://springerpub.com/content/downloads/Springer-Publishing_2011_Nursing_eBook-Smartphone_Survey.pdf.

2. Rainie L, et al. The rise of e-reading. Pew Research Center; Washington, DC; 2012 Apr 5. http://libraries.pewinternet.org/2012/04/04/the-rise-of-e-reading.

3. Apple Inc Apple reports second quarter results. Cupertino, CA; 2012 Apr 24. http://www.apple.com/pr/library/2012/04/24Apple-Reports-Second-Quarter-Results.html.

4. The Nerdy Nurse. 7 Reasons why nurses need a tablet: Amazon Kindle Fire, iPad2, or Nook Tablet. 2011 Dec 4. http://thenerdynurse.com/2011/12/7-reasons-why-nurses-need-a-tablet-amazon-kindle-fire-ipad2-or-nook-tablet.html.

5. Ahn D Evolution of tablet devices for the hospital. 2011 Feb. http://www.kevinmd.com/blog/2011/02/evolution-tablet-devices-hospital.html.

6. Versel N Nursing school adds mobility into the curriculum. 2011 Jul 14. http://mobihealthnews.com/11884/nursing-school-adds-mobility-into-the-curriculum.

7. Boston Children's Hospital. For patients and families: introducing Boston Children's MyWay mobile app. 2012. http://childrenshospital.org/patientsfamilies/Site1393/mainpageS1393P474.html.

8. Thompson BW We must keep student access to handhelds in clinical. 2012 April 23. http://nursingeducator.blogspot.com/2012/04/we-must-keep-student-access-to.html.

9. Duffy M. Patient privacy and company policy in online life Am J Nurs. 2011;111(9):65–9

10. Chamessian A How a medical student uses an iPad for patient care and education. 2011. http://www.kevinmd.com/blog/2011/10/medical-student-ipad-patient-care-education.html.

11. Strayer SM, et al. Patient attitudes toward physician use of tablet computers in the exam room Fam Med. 2010;42(9):643–7

© 2012 Lippincott Williams & Wilkins, Inc.

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