WHITLOW, MALINDA LEE DNP, RN, FNP-BC; DRAKE, EMILY PhD, RN; TULLMANN, DOROTHY PhD, RN; HOKE, GEORGE MD; BARTH, DENISE MSN, RN
In the past few years, there has been an increase in the use of Smartphones such as the Apple iPhone, Blackberry, and Android. These communication devices are now being integrated into hospital settings (eg, University of Denver Medical Center in Colorado, St. Agnes Healthcare in Baltimore, Maryland, Trillium Health Centre in Ontario Canada, and Royal Victoria Hospital in Northern Ireland).1–4 Pagers and many other communication devices will likely continue to have a role in healthcare communications; however, most paging devices do not allow for immediate two-way communication between the provider and the bedside nurse, especially when a patient experiences an acute change in clinical condition.5
Healthcare providers are highly mobile, and the need for fast, accurate messaging remains crucial to maintain patient safety at all times. Forrester Consulting found that 65% of nurses surveyed spent from 20 minutes to more than 1 hour per day trying to reach other medical staff, which adds up to less time for patients over the course of a day.6 Smartphones also allow risk officers and others to review audit trails and to track when messages are sent, received, and answered. “Audit trails are key for Joint Commission regulations, staff accountability for messages sent and/or received, and to detect process issues and unacceptable lag times between communications.”7(p4)
Using Smartphone technology at the bedside has the potential to improve patient care and safety, increase nurse and physician satisfaction, and increase efficiency, allowing more time to be spent with patients. This quality improvement initiative demonstrated how the integration of a Smartphone can help address the continued gap in communication among bedside nurses and physicians.
The Donabedian Model on Patient Safety provided a structure and process to eliminate or minimize risks of healthcare-associated injury, involving communication practices at the bedside between the nurse and physician, before they have an adverse event impact on the outcomes of care.8 Critical language is very important when the nurse relays crucial information to the provider. When the steps of the Donabedian Model on patient safety were used to address the process of improving communication between the nurse and physician, it helped to understand the flow of creating change with current practice. Integrating this model into the process and flow of improving nurse and physician communication, with the use of a Smartphone, helped validate the importance of structured communication at the bedside.
The DeLone and McLean Information Systems Success Model helped synthesize basic elements of health information and communication technology used by nurses and physicians.9 The DeLone and McLean Information Systems Success Model uses six dimensions (ie, system quality, information quality, service quality, use, user satisfaction, and net benefit) that can be used to evaluate an information system’s success or effectiveness.10
Integrating the Donabedian on Patient Safety and DeLone and McLean Information Systems Success Model helped guide the implementation of this project aimed at improving interprofessional communication at the bedside.
QUALITY IMPROVEMENT PROJECT
The questions that guided the project were as follows: (1) What is the effect of the use of a Smartphone on the quality of interprofessional communication as compared with standard procedures involving the paging system on a general medicine unit? (2) What is the effect of the use of a Smartphone on the response time between nurses and physicians?
A quasi-experimental pretest/posttest comparison design was used to evaluate the impact of using Smartphones at the bedside on the quality of interprofessional communication and measure the response time between nurses and physicians with the use of a Smartphone compared with the usual paging device. Smartphones were provided to nurses and physicians on a 26-bed medical unit during a 2-month study period. Data were collected using Nurse-Physician Communication Questionnaires and Time and Motion data collection tools. Baseline data were gathered from a convenience sample of general medicine nurses (n= 61) and physicians (n = 44) before the implementation of the Smartphone. Postimplementation data were gathered from a sample of nurses (n = 29) and physicians (n = 11) who participated in the pilot. A similar general medicine unit was used as a comparison group and continued to use the usual paging device. Institutional review board approval was obtained prior to the implementation of the project.
SETTING AND SAMPLE
The project was conducted at the University of Virginia Health System (UVAHS) in Charlottesville, VA, on an inpatient general medicine unit. The UVAHS includes a 604-bed academic medical center with 53 designated general medicine beds. Part of the third floor (3West) is a 26-bed general medicine unit and one of two general medicine units within the hospital. The average length of stay on the general medicine units is approximately 5.77 days. The study sample included the registered nurses (RNs) (n = 35) and general medicine physicians (n = 20) rotating through the 3West study unit during the 2-month pilot period. The second, 27-bed, general medicine unit (3Central), also on the third floor, served as the comparison group, and the staff on this unit continued to use the usual paging device during the pilot period.
The staff nurses consist of RNs who had received an associate, bachelor’s, or master’s education. According to information provided by conversations with the nurses, the average age of the nursing staff on the general medicine unit ranges from 19 to 62 years. The nurses and physicians (ie, interns) who completed the postimplementation questionnaire consisted mostly of women (85%) and had a mean (SD) age of 34.33 (12.549) years, and most were well educated, being first-year medical residents and bachelor’s-prepared nurses (64%). Full demographic data are presented in Table 1.
Fifteen Apple iPhone 4 Smartphone devices (Apple, Cupertino, CA) were provided to the nurses and physicians on the general medicine unit. Baseline data were collected prior to implementation through the use of modified communication questionnaires and time and motion data collection tools developed by Spurck et al.1 Then, the Smartphone project was implemented over a 2-month period. Near the end of the 2-month period, evaluation data were collected, repeating the questionnaires and time and motion data. Verbal consent regarding the use of the Nurse-Physician Communication Questionnaire and Time and Motion data collection was obtained from the author (P. Spurck, personal communication, December 11, 2012).
Protecting Patient Safety
The Smartphones were checked for encryption for safety and regulation factors to determine compatibility with cardiac devices (ie, telemetry and pacemakers). The Smartphones were password protected, and each nurse and physician received training regarding the appropriate use of the Apple iPhone 4, including information about the Health Insurance Portability and Accountability Act, Health Information Technology for Economic and Clinical Health Act, Electronic Protected Health Information, and The Joint Commission regulations. The RN or physician was not able to transmit patient electronic information via the device because the Smartphone did not link to the electronic medical record (EPIC) software. Messages could contain sensitive patient details (ie, health records, room numbers, medical record numbers, and the last name of the patient); therefore, the physicians and nurses were reminded about the importance of not allowing messages to be viewed by anyone other than the intended recipient. The RNs and physicians were notified that the Smartphones were programmed to lock down after a short period of time when the phone is in an idle mode. Some of the Smartphone’s features (ie, camera and e-mail access) were disabled to help protect patient-sensitive data during the study period. MobileIron (MobileIron, Mountain View, CA), an encrypted device management software, was also installed on each device.
Quality of communication was measured using a modified Nurse-Physician Communication Questionnaire, an 8-item (RN) and 7-item (physician) instrument modified from Spurck et al,1 with the option to provide comments at the end of the questionnaire. This online questionnaire was e-mailed to the 3West nurses and physicians preimplementation and postimplementation. They were asked to respond to a series of statements that addressed communication effectiveness on a 5-point Likert-type scale, with 1 for “never” and 5 for “always.”
Response time was measured using the Time and Motion data collection sheet also modified from Spurck et al.1 The number, frequency, duration, and personnel involved with all incoming and outgoing pages were captured with the use of a stopwatch and documented on the data collection sheet. These were observations of real-time minutes spent by the clerical staff to locate the nurse for a returned call and/or page, time of nurse to travel to a phone for a returned page, time of interruption of patient care, missed pages, and time medicine staff spent on hold waiting to speak to a nurse about a returned page. The primary investigator and research assistant performed time and motion data collection by shadowing the nurses and physicians during day shift (from 7 am to 3 pm) to observe the greatest number of staff interactions.
SPSS version 20 (IBM Corp, Armonk, NY11) was used for statistical analysis. Descriptive statistics were used to explore the data. The mean and standard deviation from the Communication Questionnaire ratings on the Likert-scale items (1 = never to 5 = always) were compared across the physician and nurse groups. Normality of the distribution was assessed, and since the preimplementation and postimplementation questionnaire data were skewed, a Wilcoxon signed-rank test was used to assess differences in preimplementation and postimplementation questionnaire scores. The level of significance for this exploratory study was set at α = .05. Frequencies and percentages were calculated for descriptive categorical variables (gender and education) and means and standard deviations for the continuous variable (age). Descriptive time and motion data captured in minutes are displayed graphically.
Quality of Communication Preimplementation
Baseline questionnaires were completed by the 3Central/3West general medicine nurses (n = 61) and general medicine resident physicians (n = 44), with a response rate of 76.2% and 48.8%, respectively. Before the study, both nurses and physicians reported a significant dissatisfaction with the current one-way paging device at baseline (P = .000) (Table 2). Nurses reported significant interruptions in patient care, frequent wait times at the nurses’ station waiting on a returned call, and frequently having to leave patients to answer a phone call with the use of a one-way pager. Physicians reported significant wait times on hold waiting for the nurse to answer a return page and they also reported that the nurse is frequently unavailable for the returned phone call.
Preimplementation Nurse and Physician Comments
Our current system lacks any way of knowing if pages are being received and solutions are being worked on unless MD calls the front desk so repeat pages can be annoying to MDs and time consuming for RNs—it’s difficult to be readily available for receiving calls since patient care & needs continue and it’s unclear if a response to a page will be immediate, a few minutes, or half an hour. In some urgent situations it’s more important to stay at the bedside than leave the patient to answer a call (having a 2-way device would make it possible to do both). (Anonymous written nurse response on preimplementation questionnaire, January 22, 2013)
A two-way communication system would not only be helpful for me to return pages from nursing and other clinical staff, but would also be helpful in communicating brief messages/instructions to the nurse that do not require a response. Currently the only way we can do that now is contact the nurse in person or calls the floor and hope the nurse is available, can be found, or is not in an isolation room. This is very time consuming for trying to communicate simple requests. (Anonymous written physician response on postimplementation questionnaire, January 26, 2013)
Quality of Communication Postimplementation
Postimplementation questionnaires were completed by the 3West nurses (n = 29) and general medicine interns (n = 11) who rotated to the medicine service during the 2 months of the pilot project (response rates, 82.5% and 55%, respectively). Nursing responses indicated a statistically significant difference on all items of the questionnaire after implementation of the Smartphones (Table 3). The most significant improvements were the reduced wait times at the nurses’ station for a returned call (P = .001), reduced time away from their patient to answer a phone call (P = .021), and fewer interruptions during patient care (P = .002). The physicians also reported a statistically significant difference on all items of the questionnaire except the items related to finding the nurse for a return page or the nurses’ availability for a return call. Specific means, standard deviations, and Z and P values from the analysis of the nurse-physician communication questionnaires are also displayed in Table 3.
Postimplementation Nurse and Physician Comments
Love, love, love the phones. Two-way communication is great for us nurses, but it is the patients who really benefit. When we communicate as an interdisciplinary team patient outcomes and satisfaction with our care increases. (Anonymous written nurse response on postimplementation questionnaire on June 10, 2013)
The two-way iPhones were incredibly helpful for 2-way communication (especially for clarification of orders, simple questions) and reduced both the nurse-to-physician and physician-to-nurse time spent waiting. I especially liked it during rounds when I could return pages and answer questions without being disruptive. I think it decreased a lot of the frustration we all experience trying to get in touch with one other. Hope this gets extended to all of the units! (Anonymous written physician response on postimplementation questionnaire on April 22, 2013)
Response Times Preimplementation and Postimplementation
On the days that time and motion data were collected, the patient census began with 26 patients, and the nursing staff consisted of seven RNs and one or two health unit coordinators. The patient census for the physicians’ teams was between five and eight patients per intern during data collection. The preimplementation and postimplementation time and motion results showed significant improvement in communication efficiency (Figure 1). Some of the compelling results included the following:
* Time spent for clerical staff to locate a nurse decreased from 14 minutes to 3 minutes per day, for a 79% decrease.
* Time of the nurse to travel to answer a phone call decreased from 79 minutes to 0 minutes per 12-hour shift, for a 100% decrease.
* Time callers spent on hold when using the device decreased from 8 minutes to 0 minutes per call, for a 100% decrease.
* Nurse time away from patient care decreased from 86 minutes to 5 minutes per 12-hour shift, for a 94% decrease.
* Physician time away from a task decreased from 28 minutes to 15 minutes per day, for a 54% decrease.
Limitations and Lessons Learned
Overall, this project did improve quality. In addition, some lessons were learned, and limitations noted related to compatibility, functionality, and user resistance. For example, the Apple iPhone 4 was unable to link to the medical center’s current patient call bell system or bed alarm alerting staff that their patient was getting out of bed. The unit secretaries were taught about this limitation and were encouraged to send a text message to the nurses’ Smartphone if a patient was requesting the nurse’s presence or if a bed alarm was activated. The patient care assistants continued to use the usual paging device, which was linked to the call bell system, and they continued to receive direct alerts to account for any potential missed communication and to prevent any compromise to patient care.
During the pilot project, the Smartphones functioned well, and remarkably, none of the phones were damaged or lost (paging devices were available as a back-up if needed). In the future, we suggest having a few additional phones available and adding insurance to each device. A few of the Smartphone chargers were missing or damaged when left plugged into the USB ports of the desktop computers and a few nurses reported that their Smartphone battery life was less than 50% when they received their phone from the previous nurse, which could increase the risk of missing phone calls and or text messages due to time spent charging the device. Future considerations could include purchasing extra battery packs to allow for more than 12 hours of continuous use.
Similar to findings in other studies,1 gathering data from the physicians proved to be a challenge. The physicians and the text paging operators were reluctant to make the project phones the physicians’ direct pager due to concerns that emergent text messages might not be transmitted successfully to the devices. Although there was no mention of messages not being received on the nurses’ Smartphones, because of this hesitation, the physicians continued to use their one-way pager and many stopped using their Smartphones within a week. The physicians who continued to use the Smartphones during their rotations found the phones to be very feasible. It should be noted that these physicians had patients on several units within the medical center and only the study unit nurses carried Smartphones. This may have negatively affected the physicians’ responses to the question regarding the nurses’ availability for a returned page.
Our findings were similar to the results of Spurck et al,1 and implementation of the Smartphones proved to be highly successful and feasible with the nursing staff. Nurse and physician time savings were documented, and the time efficiency to patient care translated to improved workflow of the nursing staff, which allowed for improvement in nurse-physician collaboration, overall improving patient care.
IMPLICATIONS FOR PRACTICE AND RESEARCH
Smartphones can connect the bedside nurse and physician in a timely manner and allow for an immediate response and limit the need for overhead paging, which can be disruptive to the patient’s necessary rest times. Messages between nurses and physicians are sent every second of the day in today’s hospitals, and most are related to the care and safety of patients. Often, the messages are urgent and require the staff to act quickly (eg, a patient is having signs and symptoms of a heart attack or stroke). Critical messages need to be sent in ways that do not impede patient care or increase the time required for effective communication so that acute changes in a patients’ condition can be handled expeditiously. Immediate feedback from the physician to nurse could help minimize a delay in treatment and prevent adverse events by allowing the nurse to remain at the bedside with the patient and continue to perform nursing duties without interruptions.
This project also aligns with the American Association of Colleges of Nursing12 doctor of nursing practice essentials II, IV, and VI by providing examples of how the use of a Smartphone can account for quality healthcare and safety and how nurses and physicians provide leadership within a healthcare system related to the use of information technology and communication networks and allowed interprofessional teams to create communication change within the UVAHS infrastructure.
The findings of this project suggest that attrition may be explained, in part, by the hesitation of some nurses and physicians to use advanced technology, for communication purposes, when a Smartphone replaces the usual paging device for fear of missing a call. Furthermore, the findings also have implications for additional teaching strategies aimed at minimizing the hesitancy of replacing one-way pagers with two-way devices at the bedside between nurses and physicians. It would be necessary to track patient safety, response time to patient care, and nurse/physician satisfaction when two-way devices are the sole means of communication between bedside nurses and physicians and when one-way pagers are no longer in use.
Future research could examine the feasibility of the use of a Smartphone with a larger sample and with other services or units to validate its feasibility across specialties within the medical center. Additional data could be collected to document outcomes in patient safety, patient satisfaction, and cost savings related to the use of two-way communication devices. Further research regarding improvements in nurse-physician relationships during the implementation of two-way communication devices could also be conducted.
Using Smartphones at the bedside successfully improved nurse and physician satisfaction; reduced time spent waiting on calls, allowing more time to be spent with patients; and may have helped improve patient care and safety. This project demonstrated the feasibility and positive impact that Smartphones at the bedside can have on interprofessional communication and response times, and because of the project’s success, the devices are currently being implemented on additional acute care units throughout the UVAHS.
© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.