1. Mobile Technology The Patient Experience
Introduce ourselves
Kate Holmes MSN, RN, AGCNS-BC; Cindy Phelan, PhD, RN and Jordan Posie, MS, RN
Aurora Medical Center Kenosha
Wisconsin Association of Clinical Nurse Specialists
CNO/CNS/Shared Governance Breakfast
September 6th , 2019

2. Background and Significance ~To Nursing and Shared Governance~
Aurora Medical Center Kenosha implementing mobile devices
Patient experience is a nurse sensitive indicator
Use of mobile technology becoming increasingly prevalent in healthcare
Dearth of research as it relates to perception of patients we care for
Instead, majority focused on perception of the users of such devices in the healthcare setting – physicians, nurses, other staff
Study focuses on the patient experience which is a nurse sensitive indicator
Link to shared governance (Kate CNS support for NRIC and site lead for mobile devices; Cindy, Research Scientist support for NRIC and Co-Investigator for study; Jordan, ICU RN and NRIC member, Co-Investigator for study
Special mention to Donna Jamieson here as the CNO who has supported this work and shared governance (she will not be present for the presentation)

3. Literature Review
Improved accessibility to staff & more timely communication (Lo, Wu, Morra, Lee & Reeves, 2012).
Reduced interruptions in patient care, improving communication quality and workflow efficiency (Whitlow, Drake, Tullmann, Hoke & Barth, 2016).
Reluctance to switch to mobiles; fear lags or drops in the transmission of messages (Whitlow, Drake, Tullmann, Hoke & Barth, 2016).
Risk of the propagation of technology-induced errors and distraction (Farrell, 2016).
Numerous studies originate from the usability standpoint
Most involves the patient’s use of their personal mobile device to engage in their own health care
Very limited evidence pertaining to patient’s and family’s perceptions of staff use of mobile devices during patient care.
In reviewing the literature we found…..again, not much on how this patient/family perceive the devices

4. Project Description
Mobile device project originated with our site Practice Council
Identified evidence-based quality improvement and potential research opportunities within the project scope
Nursing Research and Innovations Council became involved
Research Scientist guides this team
CNS participant
Supported by CNO
Staff RN led
Magnet implications
EBQI and research opportunities especially came up when looking at deliverable or metrics when operationally planning for the mobile devices

5. Purpose
To investigate how the use of mobile devices at the bedside impacts the patient experience
How patients view the impact of the device on their care
Note any expectations and potential concerns patients may have regarding staff use of mobile devices
We wanted to understand and then use that information to have a successful mobile device implementation at AMCK with particular attention to how this will impact the patient experience

6. The Study

7. Methodology Qualitative Study Focus Groups
Participant mobile device experiences
Concerns, perceived benefits, strategies to address concerns
Recruited adult patients, and family members of patients, receiving care at a large not-for-profit health care system in the Midwest
Patient Advisory Boards
Local Parishes (Parish Nurse)
Recruitment flyers strategically located throughout hospital & clinics
Age-based groups (young adult, middle-aged, older adult)
IRB approval obtained /CNO letter of support (this is key as CNO support identified time commitment for RN involvement)
Qualitative study that utilized focus groups that focused on participant mobile device experiences
Recruitment efforts with a hope to have age-based focus groups knowing that mobile device experiences may be different based on age

8. Focus Groups Focus Groups (six) Audio recordings transcribed
Semi-structured 60-minute focus group sessions
Participants received a Study Information Sheet and completed a demographic questionnaire
Brief video demonstration of staff RN using mobile device
Audio recorded, note-taking and behavioral observation by study team member
Audio recordings transcribed
Transcripts checked for accuracy and coded by two independent reviewers
Dimensional analysis to identify concepts using NVivo 12 (qualitative software)
Qualitative researcher consultation to guide analysis
Six focus groups were held
HUC transcribed data and also scheduled participants into focus groups
Nvivo allows for classification/sorting in order to determine any relationships in the data obtained

9. Demonstration of Mobile Device Use
Jordan created a video to show the study participants an idea of how mobile devices will be used in healthcare…this was showed at the focus groups and created good conversation to begin the sessions

10. Focus Group Key Questions
Video reaction.
Reflect back on own/family member’s experience(s)/hospitalization (any exposure to mobile devices).
How might mobile device use at the bedside be valuable?
What are some potential problems/benefits of using mobile devices at the bedside?
What ideas do you have regarding how we can maximize the value of these devices, while minimizing any problems raised?
Most important consideration/concern.
Probing questions r/t these overarching topics asked of group to get thorough responses/keep participants participating/get wide variety of ideas

11. Sample Characteristics(N=26)
N=26; 3 males, 23 females
All white/non-Hispanic

12. Cellphone Use Among Participants
22 admitted to using a smartphone, while 4 did not
***Unknown/Did not respond obviously would include the 4 participants who did NOT use a smartphone***

13. Concepts Identified Device Use and Functionality
“So many times…(staff) miss the call or you hear them being paged and they will say, oh I’ve got to run and get that page right now. If they had (the device) available right away, that would be very beneficial“
“I think it is really good because it really cuts down on all that waiting, with you know…This way, you do it all at one time, right there when it is on your mind, and I think for charting too it will help because you don’t have to do so much recall.”
“It could probably be more accurate. I have had nurses come in…if they don’t have a piece of paper, they might take all my vitals and try to remember them…so less risk [of forgetting] involved”
“Having this device that you know [staff] can move around…umm I think increases that value of communication and education and relationship with the patient, so I think there is just an operational efficiency but also just a potential to kind of create more of a personal engagement with that patient.”
“Is it supposed to be a tool for helping the patient feel at ease and part of the process?”
I imagine uhm…the apps just not functioning, you know, entering data…not being able to get the data, then having to move to another place to…being stuck with information not saved.”
We themed out the findings into different categories; the first being device use and functionality
What is new here, beyond efficiency, accuracy, and workflow we expect, is that some patients see this as an opportunity to engage them, help them feel at ease and part of their healthcare

14. Concepts Identified Emotional Responses to Staff Device Use
“This is my fear. When [staff] use the technology you just get ignored.”
“I think that it is very important that [staff] don’t go off and use the phone and leave you dangling.”
“I would rather they use it in front [of me…rather] than walk out the door…[worried] that they are saying something they don’t want me to hear. That would make me a bit anxious.”
“To me it seems like the mobile device is a little bit more personal than a laptop cuz you can get closer to the bedside and umm deal with, you know, better eye contact and things like that”
“there are some people who would think, oh my God, there is something awful going on…that just exacerbates any kind of stress that [patients] might be feeling while they are in the hospital”
“I can definitely see that escalate with any patient who already feels frustration with who is giving them care if they feel that somebody was unprofessional in their room. They are going to think everything else they do is not professional.”
“…I think that patients could get frustrated because they have kind of a higher expectation of response time.”
“I know that some people get irritated with rings and pings and things like that, but not something that I even kind of notice anymore.”

15. Concepts Identified
Impact on Communication between Healthcare Team and Patient/Families
“I think that is great because whenever the physician gets a chance to call, the nurse is right there.”
“This could be a big time saver - a big time saver that would increase face-to-face patient time.”
“Even if it is written down in some record or in some file, you really don’t know [a] patient until you have been in the room”
“I think [it] increases that value of communication and education and relationship with the patient, so I think there is just an operational efficiency but also just a potential to kind of create more of a personal engagement with that patient”
“I think the mobile device allows an opportunity to kind of, uhm, share that information but also give the appearance of sharing.”
“[the doctor] came in my room, and he is saying we are going to order tests…[I ask him] what is going to happen to other things are scheduled. He is carrying a phone…he says excuse me…And he never came back…We never finished the conversation.”
“the biggest concern to people would be if there as an interruption, and you know that [patient/family] are going, okay what is going on, where do we go from here, and that phone is going off, you know, and this it is interrupting that conversation and that information”
“the primary concern…[is] for train of thought. It is just unfortunate to be interrupted…interrupting that thought process…losing the next step they were going to take, and perhaps having a situation.”
“The only negative which I don’t think is, you know that bad…but I could see it happening is the nurse is just on the phone too much…what if they keep getting calls?”
“I had two instances where I had questions, I had a list of questions that I wanted answered. [Now patients] could ask the nurse and she can call the doctor right away with your questions. Now then the nurse could right away call, now.”

16. Concepts Identified Privacy/Security: Protecting Personal Information
“My biggest (concern) would be again, the confidentiality. [A nurse] is in my room but is he/she talking about a different patient? I would hope the nurse would exit…or as long as they don’t mention [the patient’s name]…but if the nurse is giving out names…the whole confidentiality (issue)…”
“I could see as a patient being concerned, like who is on the other end, if [someone] calls about me, who is around [the nurse] at that time? Some people will assume that their nurse is going to do the right thing and go to somewhere nobody is going to over hear them, but some people are going to assume that the nurse doesn’t care”
“I think you have to be your own best advocate, you know, I mean if somebody is on the phone in your room, is that about me? You know, just don’t assume that it is or don’t assume that it isn’t. Umm, because we are all human, they were busy, they were running like crazy … you know, they are just, anything can to wrong.”
“the information and what could potentially be confidential, …ensuring patients that (the device) is a reliable entrusted device and that their medical information isn’t going to get out somewhere”
“I would just want to see some kind of confirmation saying…[the nurse] is putting this information [being charted] in the right place”
“And somebody…sets their device down and walks away from it and say, oh where did I leave it

17. Concepts Identified Safety: Concern about Transmitting Infections
“Sanitation. I think it is really important.”
“Well, you are in a hospital and where do a lot of people get their diseases? Sometimes it is in the hospital. You know, there is bacteria everywhere and that is why they clean the floors and take down the beds and so they better sanitize the phones too.”
“Now since the devices are going to go into multiple patient rooms with diseases and illnesses…how are you guys going to clean these devices?”
“The only other negative I could see is if a nurse, uhm, would inadvertently, I know they wouldn’t do it on purpose, forget to…they go into a room and it gets dirty or something and they forget to, when they leave the room, grab one of the wet wipes or whatever is safe to use, and then they go into another patient’s room. [The device] is just another vehicle to transmit a communicable disease of some sort.”
“I think it would be a good reminder for [staff], …they are moving their hands from room to room, keep those hands clean…”

18. Concepts Identified Conditions for Use Introducing the device
“I want to make sure that it is fully explained to me what [was] going on before hand…introduce [the device] to me right away”
“It is really about making sure the patient’s have kind of that introduction to why [staff] have this and what [staff] are doing with it, umm, to lower the risks”
“How it is introduced to patients really needs to be consistent to make sure that all patients know that it is there for…”
General Use
“I think the nurse would step into a private space where nobody who shouldn’t be hearing that conversation is hearing it…not everybody has such a positive outlook on how people will act and be professional”
“There is a set up that needs to happen with patients, you know, we take (your) care very seriously, we take everyone’s care very seriously…you are going to get the same attention that these other patients get, so when [staff] are in the room, [they] are only reacting to an emergency outside this room, otherwise, it is time with you.”
“[Staff] shouldn’t be taking any personal phone calls on that thing…because they are taking that time away from some patient then, so that is a no-no.”
“…if you could turn it on vibrate, if you knew you were going to go into a patient’s room that they are sensitive to sounds…if it could vibrate…nursing working nights, oh yeah, (phone interruptions) would drive me insane. Cuz there is enough waking up going on”

19. Limitations Limited generalizability:
Focus groups predominantly: female, white/non-Hispanic, older adults
One geographic region
Community-based (church) setting
Could not examine possible age-related differences
Wanted to look at age related differences but were unable

20. Conclusions
Patients and families very interested in shaping staff use of mobile devices.
Engaging patients in use of the device was of particular importance.
Not all patients want to be engaged in the same way.
Devices come with advantages and disadvantages, patient and family indicated the perceived value outweighed concerns.
Whether staff successfully engage patients in use of device will determine its perceived value to patients.
We did/are using the results of this study in training our team members for mobile device use. A tip sheet on how to talk with the patient about mobile devices was created
Other sites within the Advocate Aurora system plan to replicate this study

21. Implications for Nursing Practice
Potential to change the way nurses practice
Allow for more time at the bedside
Additional education that needs to be provided
Higher accessibility
Champions of mobile device use across the Advocate Aurora system
Resources for expansion of program
Team members engaged and eager to participate and learn
Guidance of Research Scientist
CNS spheres of influence
CNO support
RN development
Seek feedback to improve

22. References
Farrell, M. (2016). Use of iPhones by Nurses in an Acute Care Setting to Improve Communication and Decision-Making Processes: Qualitative Analysis of Nurses’ Perspectives on iPhone Use. Journal of Medical Information Research, 4(2): ed: 43. doi: /mhealth.5071
Lo, V., Wu, R. C., Morra, D., Lee, L., & Reeves, S. (2012). The use of smartphones in general and internal medicine units: a boon or a bane to the promotion of interprofessional collaboration? Journal of Interprofessional Care, 26, doi: /
Whitlow, M. L., Drake, E., Tullmann, D., Hoke, G., & Barth, D. (2014). Bringing technology to the bedside: Using smartphones to improve interprofessional communication. Computers Informatics Nursing, 32, doi: /CIN

23. Contact Information
Kate Holmes MSN, RN, AGCNS-BC Clinical Nurse Specialist Aurora Health Center - Kenosha th Street Kenosha, WI O:
Cynthia Phelan PhD, RN, Center for Nursing Research and Practice Senior Nurse Scientist Aurora Sinai Hospital 945 N 12th Street Milwaukee, WI O:
Jordan Posie
RN – Interventional Radiology (formerly ICU)