THE USE OF SMARTPHONES IN CLINICAL PRACTICE

Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
THE USE OF SMARTPHONES
IN CLINICAL PRACTICE
Sally Moore and Dharshana Jayewardene look at
the rise in the use of mobile software at work
Abstract
The use of smartphones and applications or ‘apps’ in clinical practice among
nurses and doctors is on the increase. This article discusses the results of a survey
undertaken as part of a service improvement project to develop an ‘app’ for use by
junior doctors. The survey asked nurses and doctors to share information about how
they used their smartphones at work, what they used them for and how and if they
risk assessed the apps they use. Responses from 82 nurses and 334 doctors show a
high level of users of text books, formularies, clinical decision tools and calculators,
with less than one quarter of these users performed any risk assessment before use.
Keywords
Smartphones, apps, survey
Correspondence
[email protected]
Sally Moore is a patient safety
research nurse at Bradford
Institute for Health Research,
Bradford Teaching Hospitals NHS
Foundation Trust
Dharshana Jayewardene is
a researcher at the Institute
of Psychological Sciences,
University of Leeds
Date of submission
April 3 2104
Date of acceptance
May 28 2014
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
nm.rcnpublishing.com
A SERVICE improvement project was set up in
2012 by the patient safety team at the Bradford
Institute of Health Research to develop a ‘junior
doctor’s handbook’ app for use in the trust. It became
clear that there was little in the literature about how
mobile phones and apps are used in clinical practice
(Moore et al 2012).
A service evaluation survey was undertaken by
the team to investigate what informs the choice
and use of smartphone and medical apps by
clinicians in England. The results of the survey were
used by the safety improvement team to develop an
app for hospital doctors called the Ignaz Handbook
(Health Education Yorkshire and the Humber 2014).
It supplies cached information comprising overviews
and guidance for practice in the organisation, for
example guidelines for antibiotic prescription or
prophylaxis, thereby supporting up-to-date and safe
delivery of patient care.
Although the survey was designed as service
evaluation to inform the development of the app,
it provided some interesting data, the main points of
July 2014 | Volume 21 | Number 4
which are discussed in this article. The article focuses
on nurses’ responses, but does make comparisons
between nursing and medicine.
Background
Smartphone apps for use in health care appear to
be developing rapidly and there are now nearly
100,000 medical apps available to download
(Kamerow 2013). In the UK there is still much debate
about the use and regulation of healthcare apps.
The RCN (2012), for example, issued a position
statement about the use of mobile phones by nurses
in their clinical practice. With respect to apps,
the RCN (2011) highlights the ‘trustworthiness of
software’ focusing on the variation in ‘quality of
information’ available from downloadable sources
and advises nurses to ‘judge whether the information
is reliable, valid, accurate, authoritative, timely…’.
The potential use of smartphones as an adjunct
to nursing practice (Moore et al 2012) is exciting,
but the variable quality and lack of regulation also
means there are potential risks; the same risks that
are associated with the internet and the quality
of information that can be easily accessed and
downloaded (Purcell et al 2002).
Little work has been undertaken on the use of
smartphone apps in practice by health professionals
in the UK. In one survey (Devices 4 2010) of the use
of smartphones at work, in which just under half
the sample of 474 respondents were registered
nurses, 80% of the healthcare professionals surveyed
carried a smartphone at work and 18% of these
ran work-related software or apps. A more recent
study (Payne et al 2012) of medical students and
junior doctors in the Midlands demonstrated an
increased use of medical apps by doctors (76%
NURSING MANAGEMENT
Getty
Art & science | healthcare apps
Table 1
The use of smartphones and risk assessment of apps
Use of smartphones
Nurses
(n=82)
Doctors
(n=334)
Nurses and
doctors
(n=416)
Using their smartphone
at work
58% (48/82)
81% (271/334)
77% (319/416)
Accessing textbooks and
formularies (of responses
to the question)
72% (31/43)
83% (217/265)
81% (248/308)
Use as clinical decision
tools and calculators
61% (25/41)
73% (191/261)
72% (216/302)
Risk assessing apps
before use
24% (8/33)
23% (56/248)
23% (64/281)
n=98) and medical students (80% n=203) since the
Devices 4 (2010) survey. Research indicates that
nurses do not always have time to access information
from the internet or journals to support delivery of
evidence-based care (Gerrish et al 2008), but there
has not yet been an investigation into how mobile
technology can be made available at the point of care.
Survey
Method The project was a service evaluation so
ethical approval was not sought (Health Research
Authority 2014). A team of nurses, doctors and
health psychologists developed an electronic
survey, using SurveyMonkey, to ask healthcare
professionals about their use of smartphones and
apps at work. The survey was based on usability
theory (Karsh 2004) and focused on the features
that are important to users, for example, ease of
use, acceptability and safety. Single-item five-point
Likert scales were used to measure the concepts of
interest; although these are not as reliable or valid
as multi-item scales, single-item scales were chosen
to keep the survey at a manageable length while
allowing for breadth of coverage.
The survey was piloted on a group of
50 foundation-year doctors (FY1s), after which some
questions were removed to make it shorter and
easy to complete. A second pilot asked colleagues
in the institute to complete the survey to check
for additional issues with the questions. Once this
second pilot was complete the survey was sent out to
the survey population. Results were analysed using
SPSS software.
Survey sample One hundred and sixty one NHS acute
trusts in England were identified (NHS Choices 2013)
and their chief nurses or directors of nursing, medical
July 2014 | Volume 21 | Number 4
directors and chief executives were contacted and
asked if they would circulate an invitation to staff to
complete the survey. In addition, nurses were invited
to complete the survey through Nursing Management
(Moore et al 2012).
A prize draw of £100 in vouchers was used as
an incentive to participate. Where there were no
responses from named trusts, the invitation to
complete the survey was sent a second time.
All responses were anonymous, and respondents
who wanted to be included in the draw were asked
to supply an email address. Four hundred and
forty eight people completed the survey, of whom
82 were nurses, 334 were doctors and 32 were other
healthcare professionals. Only the nurse and doctor
responses have been analysed for this article. The
mean age in both groups was 40, with no significant
difference in age between the professions or between
users and non-users of smartphones.
Results
Four hundred and sixteen nurses (n=82) and doctors
(n=334) from more than 40 trusts responded to
the survey. It was not possible to identify all of the
employing trusts from the responses, but where
this was possible it was observed that 256 (62%)
respondents came from 26 trusts. Table 1 shows
the sample breakdown. Not all participants will
have used all of the types of apps mentioned,
so may have skipped those sections that they were
less informed about.
Patterns of app use Smartphone users tended to be
younger and the younger the respondent the more
likely they were to use a smartphone; this was the
same for nurses and doctors (Table 1). Of the nurse
respondents, 58% used their smartphones at work,
and this increased to 81% for doctors.
When asked about their perceptions of the use
of smartphone applications at work, there was no
significant difference in the responses from nurses
who used and those who did not use a smartphone
at work. On a rating scale of one to five (1 = strongly
disagree and 5 = strongly agree) the mean scores
were 4.14 for ease of use, 3.68 for safety, 4.25 for
usefulness and 4.17 for time saving.
The most widely used apps were formularies and
textbooks, and 72% of nurses and 83% of doctors had
used these types of apps. Clinical decision tools and
calculators were also widely used and 61% of nurses
and 73% of doctors had used them.
Factors affecting use When asked about factors to
take into consideration when choosing healthcare
apps, the top three considerations for nurses and
NURSING MANAGEMENT
Importance of factor
Figure 1 Factors affecting the choice and use of apps
5.00 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.5 0
Nurses
Price
Official
Colleague
endorsement recommendation
doctors were improved access to information,
improved decision making and improved efficiency
(Figure 1). Barely one quarter of those who used
apps (24% of nurses, 23% of doctors) performed risk
assessment on them. Informal methods were used
most, including: only using apps from credible sources;
running their own tests before use and comparing with
known protocols; checking guidance from professional
bodies; using reviews and recommendations; avoiding
entering patient-sensitive data
Effects on patient care When asked about the effects
on patient care, doctors and nurses indicated similar,
mostly positive, views (Figure 2, page 22): ‘Improved
access to Information’, ‘Improved decision making’,
and ‘Improved efficiency’ were the statements with
most support. Negative effects such as ‘Wastes time’
and ‘Gets in the way of care’ had little support from
either group. There was no difference between the
professional groups when asked in which situations
they would use a healthcare app; respondents were
most willing to use apps in front of peers, followed by
senior colleagues, and were least comfortable using
them in front of patients and their families.
Discussion
The results of this survey offer an insight into the use
of healthcare apps by nurses and doctors in clinical
practice, however the use of directors of nursing
and medicine as a first point of contact means that
most of the sample was from established nursing
and medical staff and not students or trainees.
Respondents were generally positive about the use of
healthcare apps but the self-selecting nature of the
sample means some bias in favour of their use might
be expected. Using a web-based survey technique
and prize draw will have limited respondents to
NURSING MANAGEMENT
Believe will
improve
safety
Evidence of
testing or
validation
Doctors
Reputation/
recognised
brand
internet and email users and possibly people who
are motivated solely by the chance of reward
(Sanchez-Fernandez et al 2012).
The much higher number of doctors (78%) who
responded to the survey might indicate that this
technology has had greater acceptance in clinical
practice among the medical profession; Health
and Social Care Information Centre (HSCIC) (2013)
workforce statistics for August 2013 indicate that
there are about three times as many whole-time
equivalent registered nurses (302,025) as doctors
(104,117) working in the hospital and community
health services. Alternatively it could reflect easier
access to the technology needed to run healthcare
apps and a more relaxed attitude to the use of
mobile phones in the clinical area for doctors.
Further, nurses are generally lower users of the
internet in clinical settings than other professional
groups (Gilmour et al 2008), so they might not
have had the opportunity or inclination to
complete the survey.
All respondents were more comfortable using
a healthcare app in front of peers than in front
of patients, which suggests uncertainty about
the acceptance of the use of smartphones across
the population in general. Nurses appear to want
more ‘official’ evidence of efficacy and official
endorsement to use apps. This finding supports
research that has examined the use of evidence in
practice and internet use by nurses and midwives
(Thompson et al 2004, Gerrish et al 2006, 2011),
and which suggest that nurses tend to prefer to use
experienced colleagues, protocols or guidelines as
information sources rather than online evidence
or published research. Could a well evidenced and
approved app pave the way to improve the use of
research in nursing practice?
July 2014 | Volume 21 | Number 4
Art & science | healthcare apps
Percentage of respondents who agree with statement
Figure 2 Proportion of responses from nurses and doctors choosing statements with which they most agree about using apps in practice
90 Nurses
80 -
Doctors
70 60 50 40 30 20 10 0
Improve
access to
information
Improve
decision
making
Improve
efficiency
Improve
Improve
Improve
care
communication safety
Distract
staff
Get in the
way of care
Introduce
more error
Waste
time
Perceived advantages/disadvantages of apps
Smartphones and healthcare apps are here to
stay and the results of this survey suggest that
their potential benefits are recognised by healthcare
professionals. For healthcare professionals to make
the most of these potential benefits it is important
that they feel confident that the apps they use are
of a suitable quality (Figure 1). They also need to be
more aware of the risks of using apps that have not
been risk assessed. Haffey et al (2013) illustrated these
hazards in a comparison of a number of opioid doseconverting apps that highlighted a wide range of dose
outcomes with a poor evidence base across the apps.
It is therefore important that appropriate apps
that can benefit patient care are officially endorsed
and regulated (RCN 2012) by employing organisations
and government. Until this happens all professionals
must be wary of using healthcare apps that have not
been risk assessed or approved at an organisational
level, at the very least they should undertake a
personal risk assessment on any app they choose to
use as part of their own clinical practice.
Purcell (2002) thinks that regulation is not
the way forward for healthcare information on
the internet, but that education of users of the
information is the answer; could this be true for
healthcare apps? The Yorkshire and Humber
Improvement Academy (part of the Yorkshire
and Humber Academic Health Science Network)
is now working on the introduction of the ‘Ignaz
Handbook’ app; perhaps it is time for nurses to take
up the challenge and work towards making Ignaz a
multidisciplinary tool for safer patient care.
Online archive
For related information, visit
our online archive and search
using the keywords
Acknowledgement
Rebecca Lawton,
John Anderson and
Pierre Laloe for their work
in undertaking the survey
Conflict of interest
None declared
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