Smartphones have steadily become an integral part of our lives.1 In healthcare, the slogan “there's an app for that”2 can relate to applications (apps) for medication references, laboratory values, diagnoses, anatomy displays, and more. As of September 2015, it was estimated that the number of medical apps surpassed 165 000.3 With this vast array and advanced level of technology, mobile health is now accessible to 77% of American adults, with higher rates among individuals with higher levels of education (eg, nurses).4 In particular, nurses can access medical information, video chat with other practitioners, and send text messages from their smartphones.5–7 Using smartphones, nurses reported increased satisfaction with the quality of communication, reduced wait times for return calls, reduced time away from patients to answer a call, and fewer patient care interruptions after the implementation of smartphone use on general medicine inpatient units.8 Smartphones also offer a variety of basic tools in one device. Standard apps such as flashlights, alarm clocks and timers, and calculators can be useful in patient care areas. Coupled with the ability to call, text, e-mail, and stream live video with coworkers and other healthcare professionals, smartphones have the potential to become indispensable in healthcare.8
With patient safety and quality as a priority for healthcare systems and providers, the need for fast, accurate, and accessible information regarding all aspects of patient care has increasingly become a best practice.6,9 As such, some hospital systems use smartphones, with the assistance of third-party software, to securely access, record, and transfer sensitive patient information such as questions about patient treatments, records of real-time waveform confirmation, and bedside alarms.5,8–10 However, the use of smartphones in acute care settings remains controversial, and policies regarding smartphone use vary.11,12 The purposes of this study were to determine (1) the current rates of personal smartphone use by nurses in acute care settings, (2) nurses' preferences regarding the use of smartphone functionality at work, and (3) nurse perceptions of the benefits and drawbacks of smartphone use at work. The research questions were the following:
- Does nurses' use of smartphones in acute care settings differ by age category or role?
- What are nurses' preferences regarding the use of smartphone functionality in acute care settings?
- Are there differences in use by age category or role?
- What are nurses' perceptions of the benefits and drawbacks of using smartphones in the acute care setting?
- Are there differences in perceptions by age category or role?
This study was based on an anonymous, online cross-sectional survey of nurses across six acute care medical-surgical inpatient facilities within an urban healthcare system located in southern United States. All facilities equip each patient room with computers connected to internal and external networks, allowing patients and nurses access to relevant medical information through different e-portals. The study was approved by the university-affiliated healthcare system's institutional review board.
A convenience sample of approximately 2000 nurses, who were at least 18 years old and employed in the six medical-surgical inpatient facilities, was invited to participate. A total of 760 survey submissions were received. Participants self-identifying as nonnurses (eg, patient care assistants, maintenance) and those who did not report their professional role were excluded from analyses, resulting in 735 total nurse respondents (approximately 37%).
Data were collected using SurveyMonkey (SurveyMonkey Inc, Palo Alto, CA) during 3 consecutive weeks in August 2015. All employees identified through each inpatient facility's emailing list as nurses (both point of care and non–point of care) received weekly scripted emails inviting participation. In addition, flyers were placed in areas frequented by nurses (eg, nurses' lounges and bathrooms), research team members verbally informed nurses about the study using scripted messaging, and announcements were placed in newsletters and intranet pages.
Data were collected using a questionnaire specifically developed for this study. The instrument was based on the work of Moore and Jayewardene,13 with input on modifications from the current Nursing Research Council members throughout the healthcare system. Demographic information collected included participant age category, current role (ie, [point-of-care] registered nurse, [point-of-care] licensed practical nurse, [non–point-of-care] leadership nurses), and personal smartphone ownership. Participants were then asked whether they currently use, would like to use, or did not want to use specific smartphone functions in acute care settings. A list of smartphone functions addressing communication (ie, texting, calling, emailing) between coworkers, other departments, and other healthcare providers; access for patient and provider education (ie, medication, procedure, diagnostic testing apps); general announcement or translator apps; and standard apps (ie, flashlight, calculator, calendar, alarm/reminder, music) were provided with an opportunity for participants to make additions. The final section of the survey addressed participant perceptions of the benefits and drawbacks of having smartphones widely used in acute care settings on 14 items using a 5-point Likert-type scale (1, strongly disagree; 2, disagree; 3, don't know; 4, agree; and 5, strongly agree). Items addressed potential barriers to smartphone use, such as introducing error and distracting staff, and potential benefits of smartphone use, such as improving efficiency and care quality.13 The survey took approximately 10 minutes to complete.
Data Management and Analysis
Data were downloaded from SurveyMonkey to Microsoft Excel 2010 (Microsoft, Redmond, WA) and then uploaded to IBM SPSS Statistics version 24 (IBM, Armonk, NY) for analysis. To succinctly determine nurses' preferences for using smartphone functionality in acute care settings, response options were dichotomized as (1) currently using/would like to use smartphone functionality in acute care settings and (2) not wanting to use smartphone functionality in acute care settings. Response options to the 14 items assessing participant perceptions of the benefits of, and drawbacks to, having smartphones widely used in acute care settings were categorized into three groups for ease of analysis and interpretation. The three groups were “strongly disagree/disagree,” “don't know,” and “agree/strongly agree.”
Data were initially analyzed descriptively to determine percentages of participants who owned, carried, and used smartphones in acute care settings. χ2 Analysis was performed to address differences by age group and role with cell standardized residual significance set to greater than 2.0.14 Significance level was set a priori to P < .05.
Of the 734 respondents who indicated their age category, 22.3% were between 18 and 30 years old, 26.6% were between 31 and 40 years old, 22.9% were between 41 and 50 years old, and 28.2% were older than 51 years (Table 1). Most respondents were point-of-care nurses (n = 569, 77.4%). The remaining non–point-of-care nurse respondents (n = 166, 22.6%) included managers, care managers, educators, and advanced practice nurses.
Nurses' Use of Smartphones in Acute Care Settings
Most (97.7%, n = 716) of the respondents indicated that they owned a smartphone. Most who owned a smartphone reported carrying their smartphones at work (92.7%, n = 663), and 84.8% of these respondents (n = 562) indicated that they used their smartphones in acute care settings (Table 1). Comparisons by age category revealed that significantly more respondents older than 50 years reported not having a smartphone (χ2 = 12.2, df = 3, P = .007). Significantly more respondents older than 50 years who owned a smartphone indicated that they did not carry a smartphone at work compared with those 18 to 30 years old (χ2 = 13.4, df = 3, P = .004). In addition, significantly more participants older than 50 years who carried a smartphone at work indicated that they did not use their smartphones in acute care settings compared with those 31 to 40 years old (χ2 = 19.1, df = 3, P < .001). No statistical significances were noted between point-of-care and non–point-of-care nurses.
Use of Smartphone Functions
To assess participant preferences regarding smartphone functionality, participants were asked whether they used/would like to use specific smartphone functions in acute care settings (Table 2). More than 90% indicated that they used/would like to use a smartphone to access medical information concerning medications, procedures, diseases, or diagnostic criteria. More than 75% of the participants indicated that they used/would like to use smartphone calculators, texting and calling abilities, medical apps, patient education information, and flashlight functions. Fewer than half of the participants indicated that they used/would like to use smartphones for music or announcement sharing functions.
Comparisons of participants' preference to use/like to use smartphone functionality by age and role revealed that, compared with those 51 years and older, significantly more participants between the ages of 18 and 30 years used/would like to use medical apps (χ2 = 71.4, df = 3, P < .001), the flashlight (χ2 = 38.2, df = 3, P ≤ .001), alarms (χ2 = 36.9, df = 3, P < .001), announcements (χ2 = 24.3, df = 3, P < .001), and music (χ2 = 26.3, df = 3, P < .001). Compared to participants between the ages of 18 and 30 years, significantly fewer participants older than 50 years indicated that they used/would like to use smartphones for patient education (χ2 = 44.5, df = 3, P < .001) and translator apps (χ2 = 38.4, df = 3, P < .001). There were no statistically significant differences between point-of-care and non–point-of-care nurses.
Nurses' Perceptions of the Benefits and Drawbacks of Using Smartphones
Participants were asked about their perceptions of the benefits and drawbacks of having smartphones widely used in acute care settings. More than 75% of the participants indicated that they agreed/strongly agreed that smartphones would improve access to information, be easy to use, improve communication, and improve efficiency (Table 3). While few drawbacks were noted by participants, more than one-third (36%) did not know whether smartphones would upset patients or families and approximately 30% did not know whether smartphones would introduce more error. Approximately 30% of the participants indicated that they agreed/strongly agreed that smartphones would distract staff.
Exploration of the responses by age category revealed that significantly more participants older than 50 years, compared with those 18 to 30 years old, disagreed/strongly disagreed that smartphones improved efficiency (54.2% vs 8.5%, respectively; χ2 = 45.5, df = 6, P < .001) or improved clinical decision-making (41.8% vs 10.4%, respectively; χ2 = 21.5, df = 6, P = .001). Significantly more participants older than 50 years, compared with those 18 to 30 years old, agreed/strongly agreed that smartphones would get in the way of patient care (51.4% vs 12.1%, respectively; χ2 = 40.3, df = 6, P ≤ .001) and wasted time (44.2% vs 8.7%, respectively; χ2 = 26.5, df = 6, P ≤ .001). The graph in Figure 1 displays average responses by age group for each of these items, illustrating differences in responses by age group.
Exploration of differences between point-of-care and non–point-of-care nurses revealed that significantly more nurses in non–point-of-care roles agreed/strongly agreed that, if smartphones were widely used in acute care settings, these would upset patients and families (32.5% vs 19.6%, respectively; χ2 = 12.0, df = 6, P = .002) and distract staff (39.6% vs 27.4%, respectively; χ2 = 9.03, df = 6, P = .011). There were no other significant differences by role.
Most nurses (76.6%) in the six-facility acute care, urban healthcare system who responded to the survey indicated that they have, carry, and use personal smartphones in acute care settings. These findings are similar to other studies in which most physicians15–19 and nurses15,20,21 had and used smartphones in their work settings. Most participants preferred to use/would like to use all the smartphone's communication and app functions, except for email, announcements, and music. Medically related apps were also identified as commonly used smartphone functions by physicians, surgical residents, nurses, and nursing students.13,15–17,20,22 It was surprising that only approximately half of the participants indicated that they use/would like to use their smartphones for email. Possible explanations for this relatively low percentage are the substantial number of work-related emails received by nurses and the requirement to register personal electronic devices through a third party. This system allows for secure, internal email transfer, but the facility licensing agreement authorizes the periodic monitoring and eventual purging of the device's content by the facility upon the employee's termination.
Analysis of written comments revealed several themes. First, nurses commented on the ability to use smartphone technology to improve communication among nurses, physicians, and other healthcare providers with whom they interacted during their shifts. For example, nurses desired telephone numbers of supervisors, physicians, and different departments throughout the facility preprogrammed into their smartphones. This was suggested to save time when retrieving the number for a specific individual or department.
Smartphone technology could potentially make internal communication easier for nurses, but communication regarding the transfer of care could also be improved among the discharging nurse, outside vendors, facilities, insurance companies, and home health agencies. Nurses in this study made comments related to the need “to contact/communicate with home health, durable medical equipment (DME) companies to ensure [the patient's] needs are met for a timely discharge.”
Another use noted by nurses was for patient education. Respondents reported that patients and families seek information from nurses for a variety of reasons including clarity about procedures and/or medications, contact information for providers, and directions to local venues. Tools that are part of smartphone functionality can enhance the patient experience and save time for nurses by providing educational tools “in the nurses' hands,” although consideration is needed regarding the legitimacy of the information obtained through third-party sources.
Apart from the functions addressed in the survey, several participants commented on additional uses not included in the survey. Similar to the findings of Bautista and Lin21 regarding nurses in the Philippines, comments by participants addressed the ability to use the smartphone's camera to record photos and videos to facilitate communication between those at the bedside and those who needed to see—not simply hear—the details of patient information. This included electrocardiograms, wounds, radiology imagery, and procedural equipment. Another recurring comment was for personal and family security. Participants reported the use of global positioning system tracking to verify their child's arrival at home after school, as well as the use of their phone as the primary contact for aging parents. Some participants also expressed feeling safer with a smartphone when walking to their cars at night if they left the hospital alone. Finally, some extremely unique uses were identified by a few participants. Two individuals used their smartphones for spell check, and one used it to facilitate communication, “I once had a patient type a message for me that couldn’t verbalize their message.” In all, some individuals advocated for more smartphone integration, suggesting the use of smartphones to “scan the patient's arm bands as well as medications,” while others protested smartphone use, stating: “Even if we receive the approval to use our smartphones in acute-care settings, I still may not do it.”
Findings from this study concerning the benefits and drawbacks of smartphone use in acute care settings were similar to those of other studies.13,21 Improving access to information was consistently seen as a primary benefit in both studies, and participants in both studies identified staff distraction as the primary drawback of smartphones in acute care settings. McBride12 defined smartphone distraction in acute care settings as an interruption in the clinician's primary task (eg, medication administration, clinical rounds) initiated by smartphone use. The interruption might be initiated externally (eg, from a patient or clinician) or internally (eg, personal Internet use). Personal use of smartphones and other mobile devices by nurses includes checking for or sending personal calls, emails, or texts; accessing news, social networking, or shopping sites; and playing online games.21,23 Choi et al24 attributed internally initiated interruptions to smartphone addiction, a phenomenon associated with anxiety when not holding one's smartphone and an inability to reduce smartphone use. It is interesting to note that at least one-quarter of the participants in our study indicated that they did not know whether smartphone use would improve quality care, clinical decision-making, safety, and patient satisfaction; introduce more errors; waste time; distract staff; or upset patients and families. Therefore, additional studies are needed to determine the impact of nurses' use of smartphones in acute care settings on patient care and patient satisfaction.
This is the first study to explore differences in smartphone use by age group and nursing role. While few differences by role were found, several differences by age group were identified. Participants older than 50 years were less likely to own, carry, or use a smartphone in acute care settings. They were also less likely to agree with the benefits of smartphones and more likely to agree with the drawbacks. In contrast, participants younger than 31 years were more likely to own, carry, or use smartphones in acute care settings. They were also more likely to agree with the benefits and less likely to agree with the drawbacks of smartphones. The implication of these results is the need for additional education and support for more seasoned nurses regarding use and for younger nurses regarding smartphone policy adherence if smartphones become standard equipment in a healthcare facility. A survey of nursing students in the Republic of Korea found that almost half reported using their smartphones during clinical practicum, approximately two-thirds indicated that they had seen other students using smartphones, and one-quarter indicated that they had been distracted by their smartphones during clinical care.25 The need for professional guidelines, education, and support to address smartphone use, addiction, and distraction has been advocated.1,12,21,25,26
Gill et al1 suggested that health organizations complete a strengths, weaknesses, opportunities, and threats analysis related to the development of smartphone policies in acute care settings. They indicated that smartphones must comply with basic security and malware protection policies and that unauthorized, unlawful access to information be prohibited. The suitability of specific smartphone features and appropriate use in different communication and situational contexts must be addressed. While the need to enhance communication among healthcare professionals is advocated, this must be balanced with a need to reduce disruptions in patient care. Other policy considerations include the hygienic use of smartphones in patient care areas and the regulation of ring and alert tones. Gill et al1 also emphasized the need to stay focused on patients when identifying safe use, legal compliance, data security and access control, improved privacy management, effective and efficient communication, and regulation of cell phone use zones, although they did not provide specific recommendations on policy enforcement. In addition, regulatory guidelines must be considered. For example, on December 2016, The Joint Commission issued recommendations that (1) healthcare organizations need policies prohibiting unsecured text messaging from a personal mobile device for protected health information; (2) computerized order entry is the preferred method because it ensures that orders are directly entered into the electronic health record; (3) verbal orders can be used when computerized provider order entry is not available—however, these verbal orders should be used infrequently; and (4) secure text orders are not currently permitted. The Joint Commission and the Centers for Medicare and Medicaid Services plan to continue to monitor advancements in this area as the technology advances.27 This guidance was a reversal of a previous position28 and reflects the need for healthcare facilities to closely monitor regulatory guidance before expending funds for state-of-the-art technology.
Findings from this study cannot be generalized to other healthcare settings because results may differ in other healthcare settings. In addition, this survey was electronically delivered to employee email addresses, and most participants needed to complete the survey at a facility computer because of the challenges of accessing work email off-site. Although the survey did state that participant answers would remain anonymous, requesting participants to take the survey at work may have altered the candor of their responses. In the future, more information should be provided to direct potential participants to the survey through external means.
This online survey of nurses from six hospitals determined that participants carry and use personal smartphones in acute care settings for multiple purposes including communicating with healthcare providers, accessing patient-related information, and using aspects of functionality related to patient care. While smartphones are no longer considered new technology, and their usefulness was clearly documented in this study and other studies, the implementation of policies guiding their use has lagged. There is a critical need for administrators to recognize the reality of smartphone use and to develop, implement, and evaluate realistic policies for smartphone use to enhance patient care and minimize smartphone distractions. There is also a need for administrators to encourage caring and creative people to develop smartphone uses that keep nurses at the bedside providing quality patient care.
The authors would like to thank Jill Berger and Dr Paul Clark for their help with this study.
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