- Email: [email protected]
Using Electronic Communication Safely in Health Care Settings
Priority #1: Safety
Using Electronic Communication Safely in Health Care Settings BRENDA S. BROUSSARD, MSN, APRN-CNM, WHNP-BC ANNE B. BROUSSARD, CNM, CNE, DNS, LCCE, FACCE
t
Technology has become an integral part of health care environments. Many nurses carry unit-specific phones to talk directly with patients or with other care providers concerning patient care issues. Some institutions have begun to use smartphones for nurses to text, email or call physicians, or to access the Internet.
In an effort to reduce medication errors, many institutions now use a system of bar-coding and scanning medications before they are administered. Despite the many advantages of technology in the workplace, there are several potential disadvantages, including possible decreased patient safety, de-personalization of care, breach
Abstract Nurses are increasingly using mobile and other devices, such as cell phones, smartphones, tablets, bar-coding scanners, monitoring equipment and bedside computers, to communicate with members of the health care team and with patients. Communication accomplished with such devices includes direct verbal communication, text-messaging, emailing, obtaining patient care information and accessing medical records for order entry and for documenting nursing care. Problems that could occur with such communication methods include distraction, errors, de-personalized care, violation of confidentiality and transmission of nosocomial pathogens. Policies are needed to prevent inappropriate use of technological devices in patient care and to promote patient safety and quality care with their use. DOI: 10.1111/1751-486X.12007 Keywords communication | mobile devices | patient safety | smartphones | technology
http://nwh.awhonn.org
© 2013, AWHONN
59
Priority #1:
Safety
of confidentiality, poor infection control and possible inappropriate behavior. These issues should be examined and policies established to create and maintain high-quality patient care delivery systems.
Dangers of Distracted Caregivers The Agency for Healthcare Research and Quality’s WebM&M highlighted a case that occurred during physician rounds when a resident was asked to discontinue a patient’s warfarin (Halamka, 2011). The resident began to enter the order into her smartphone with access to the hospital’s order entry system, but she was interrupted with a text message from a friend inviting her to a party. She responded to the friend’s text message and forgot to enter the stop order
Patients can perceive a lack of empathy and a sense of aloofness if caregivers focus more on electronic devices than on the patients themselves
Brenda S. Broussard, MSN, APRN-CNM, WHNP-BC, is a staff nurse-midwife at the Family Birthing Center at Ochsner Medical Center in Baton Rouge, LA; she is also a regional clinical faculty member with Frontier Nursing University in Hyden, KY. Anne B. Broussard, CNM, CNE, DNS, LCCE, FACCE, is a retired professor from the University of Louisiana at Lafayette, College of Nursing and Allied Health Professions in Lafayette, LA. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: bsbroussard@ cox.net.
60
for the warfarin. As a result, the patient ended up with an additional 3 more days of warfarin administration, developed a hemopericardium and required emergency open-heart surgery (Halamka). The use of phones by nurses involved in direct patient care activities also has the potential for distraction and errors. Designated unitspecific phones that are assigned to nurses at the beginning of their shifts allow patients and other health care team members to call nurses directly. This can improve the lines of communication among patients, nurses and other members of the health care team, but can also cause numerous interruptions when nurses are involved in tasks requiring concentration and focus. For example, what should a nurse do if the phone rings while a medication is being administered? Answering the phone while continuing the task could potentially cause a distraction and a possible medication error. A policy may need to be in place to allow the call to “rollover” to the nursing desk or for the phone to go to the nurse’s voicemail until he or she is able to respond.
Nursing for Women’s Health
Younger nurses, who have come of age as part of a “digital generation,” are often very accustomed to all forms of electronic communication. Many nursing students have begun using laptops, tablets and smartphones during their nursing education for accessing pharmacology information, evidence-based practices, research and podcasts (Johnson, 2008). However, these newer nurses might underestimate the potential for distraction with such devices. They’ve been more immersed in an electronic culture than older, more experienced nurses who rely upon intuitive understanding and objective assessment skills as well as electronic information.
Decreased Quality of Interpersonal Relationships A Canadian study found that after the introduction of smartphones for medical residents, there was a perceived increase in efficiency of communication between physicians and nurses. However, there was also a perceived decrease in the quality of interprofessional relationships due to the overreliance on electronic communication (Wu et al., 2011). In addition, patients can perceive a lack of empathy and a sense of aloofness if caregivers focus more on electronic devices than on the patients themselves. Nurses are now required to enter patient admission information and routine assessments and administer medications using computers. They often focus on the computer more than making eye contact or using therapeutic touch with patients. Frequently, the computer is placed between the nurse and the patient or off to the side where the nurse’s side or back may be to the patient, creating a perceived barrier or sense of distance. Labor and delivery nurses caring for pregnant women frequently conduct fetal monitoring with electronic devices and chart their findings on a bedside computer. Neonatal intensive care nurses rely on electronic equipment in the care of high-risk infants. The health care environment has become increasingly high-tech instead of high-touch, and it’s important to remember to focus on the patient. Guido (2010) notes that nurses who remain aloof and disconnected from patients and their families display a personality type that is more likely to be perceived as uncaring and possibly
Volume 17
Issue 1
negligent in the caregiving role. Establishing a therapeutic relationship early by displaying empathy, respect and warmth and continuing to maintain this relationship with patients and family members is increasingly important as more technology is introduced into the health care environment.
Health care workers’ and patients’ mobile phones are contaminated with nosocomial pathogens that can be transmitted to patients
Confidentiality Issues During a recent visit to the hospital room of a relative, one of the authors of this article observed a nurse talking on her unit-specific phone about another patient on the same unit while in front of her and the family member. The nurse appeared to be talking to a physician about a specific medical problem this other patient was having. Although the other patient’s name was never mentioned, too many details were discussed about a medical condition and attempted interventions to alleviate this problem. This conversation occurred while the nurse was flushing a central line. In addition to the dangers of making a mistake while
completing a task with one patient, there was also the potential for a violation of patient confidentiality since the nurse was giving a report on a medical condition concerning another patient on the unit in front of people with no
Box 1.
Suggested Policies for Use of Mobile and Other Electronic Device in the Workplace • Personal cell phones should be turned off or in the silent mode when in public areas. • Personal texting or phone calls should take place only at breaks or meal times away from clinical areas. • Employees who are involved in direct patient care should leave their cell phones with their personal items unless cleared by their supervisor. • Employees who drive should under no circumstances text or talk on the phone while driving on company business. • Photos or recordings with personal cell phones are prohibited. • Phones issued by the institution and used in the patient care setting should be cleaned with an approved antimicrobial wipe at the beginning of each shift as well as before and after each patient contact. • Nurses carrying unit-specific phones may choose to allow a call to rollover to the nursing desk if they’re involved in direct patient care activities. • The above policies are enforceable and may result in disciplinary procedures and possible dismissal for violations.
February | March 2013
personal or clinical relationship with this other patient. Another possible violation of patient confidentiality could occur when patient information is forwarded via an e-mail or text message to the wrong address or recipient. Hospitals and other health care systems considering implementing the use of smartphones within their facilities also need to provide secure networks. This would prevent access to confidential information by those who have no clinical relationship with the patient. Halamka (2011) pointed out that portable electronic devices are easy to lose, possibly leading to loss of or inappropriate access to protected health information. Such information could be stored on the device itself, or access to the health care institution’s computer clinical information system could be obtained if passwords are available via the device. Personally owned devices are not likely to possess the security controls that are built in to an organization’s electronic systems, and data found on them might not be encrypted (Halamka, 2011). Lastly, mobile electronic devices left unattended or poorly positioned could be read by
Nursing for Women’s Health
61
individuals who should not have access to the health information displayed on the screen.
Infection Control Issues A study in Turkey found that 94.5 percent of health care workers’ cell phones tested positive for bacteria including the methicillin-resistant strain of Staphylococcus aureus (MRSA) (Ulger et al., 2009). The researchers found that the cleaning rate of mobile phones by health care workers was only 10.5 percent, leaving 89.5 percent of the phones never cleaned. The authors concluded that both health care workers’ and patients’ mobile phones are contaminated with nosocomial pathogens that can be transmitted to patients (Ulger et al., 2009). Health care workers need to be aware of the importance of hand washing before and after patient care and also between patient care and handling of mobile devices, and implement routine cleaning of electronic devices to prevent the spread of nosocomial infections in the workplace. Routine cleaning of all electronic devices should be a component of hospital policy (see Box 1).
Policies to Prevent Inappropriate Behavior Many institutions have implemented policies to outline the appropriate use of technology in the workplace. These policies give guidance and direction to all employees concerning the use of personal cell phones and electronic devices. These policies have been implemented to decrease the incidence of unprofessional behavior such as using personal electronic devices for personal reasons while working. The purpose of these policies is to promote quality patient care and safety. Suggested components of a policy for use of cell phones or personal electronic devices in the workplace are listed in Box 1. With the increased use of social networking, many institutions have more recently found it necessary to
62
Nursing for Women’s Health
Box 2.
Suggested Policies for the Use of Social Networking, Internet and Online Postings • Employees should refrain from sharing any information concerning patients or patient care activities through personal blogs, postings of videos or pictures, or responses made to comments made by other Internet users either publically or via e-mail. • The employer has the right to block access to Internet sites on workplace computers and to monitor Internet and social media activity in the workplace. • Social networking and Internet activities should be limited to breaks and meal times and should occur away from patient care areas. • The employer has the right to ask the employee to remove social media postings that may reflect negatively on the institution. • The above policies are enforceable and may result in disciplinary procedures and possible dismissal for violations.
create a policy on the use of social networking, public Internet and digital online postings. The goal of these policies is to protect patient health information and privacy as well as the employer’s proprietary interests and reputation. Possible components of this policy are listed in Box 2.
Conclusion Every health care institution should have guidelines or policies in place to avoid the potential problems associated with the use of technology in the workplace. Components of such policies should address issues of patient privacy, infection control, prevention of errors from distraction and maintenance of therapeutic relationships with patients despite the use of technology. Policies preventing inappropriate behavior and sharing of confidential information on social media sites should also be implemented. Technology is an integral part of the daily life of bedside nurses and has greatly enhanced patient safety and efficiency of communication in the workplace. The dangers and pitfalls of the use of technology in the workplace have been highlighted and it’s every nurse’s daily challenge to implement
safe and effective behaviors in relation to the use of electronic devices in the work place. NWH
References Guido, G. W. (2010). Legal and ethical issues in nursing (5th ed.). Upper Saddle River, NJ: Prentice Hall. Halamka, J. (2011). Order interrupted by text: Multitasking mishap. WebM&M: Morbidity & Mortality Rounds on the Web. Retrieved from www.webmm. ahrq.gov/home.aspx Johnson, C. (2008). Nurses and the use of personal digital assistants (PDAs) at the point of care. Design of Electronic Text, 1(1), 1–7. Retrieved from fdt.library. utoronto.ca/index.php/fdt/index Ulger, F., Esen, S., Dilek, A., Yanik, K., Gunaydin, M., & Leblebicioglu, H. (2009). Are we aware how contaminated our mobile phones [are] with nosocomial pathogens? Annals of Clinical Microbiology and Antimicrobials, 8(7), 31. doi: 10.1186/1476-0711-8-7 Wu, R., Rossos, P., Quan, S., Reeves, S., Lo, V., Wong, B., & Morra. D. (2011). An evaluation of the use of smartphones to communicate between clinicians: A mixed-methods study. Journal of Medical Internet Research, 13(3), e59. doi: 10.2196/jmir.1655
Volume 17
Issue 1
Using Electronic Communication Safely in Health Care Settings BRENDA S. BROUSSARD, MSN, APRN-CNM, WHNP-BC ANNE B. BROUSSARD, CNM, CNE, DNS, LCCE, FACCE
t
Technology has become an integral part of health care environments. Many nurses carry unit-specific phones to talk directly with patients or with other care providers concerning patient care issues. Some institutions have begun to use smartphones for nurses to text, email or call physicians, or to access the Internet.
In an effort to reduce medication errors, many institutions now use a system of bar-coding and scanning medications before they are administered. Despite the many advantages of technology in the workplace, there are several potential disadvantages, including possible decreased patient safety, de-personalization of care, breach
Abstract Nurses are increasingly using mobile and other devices, such as cell phones, smartphones, tablets, bar-coding scanners, monitoring equipment and bedside computers, to communicate with members of the health care team and with patients. Communication accomplished with such devices includes direct verbal communication, text-messaging, emailing, obtaining patient care information and accessing medical records for order entry and for documenting nursing care. Problems that could occur with such communication methods include distraction, errors, de-personalized care, violation of confidentiality and transmission of nosocomial pathogens. Policies are needed to prevent inappropriate use of technological devices in patient care and to promote patient safety and quality care with their use. DOI: 10.1111/1751-486X.12007 Keywords communication | mobile devices | patient safety | smartphones | technology
http://nwh.awhonn.org
© 2013, AWHONN
59
Priority #1:
Safety
of confidentiality, poor infection control and possible inappropriate behavior. These issues should be examined and policies established to create and maintain high-quality patient care delivery systems.
Dangers of Distracted Caregivers The Agency for Healthcare Research and Quality’s WebM&M highlighted a case that occurred during physician rounds when a resident was asked to discontinue a patient’s warfarin (Halamka, 2011). The resident began to enter the order into her smartphone with access to the hospital’s order entry system, but she was interrupted with a text message from a friend inviting her to a party. She responded to the friend’s text message and forgot to enter the stop order
Patients can perceive a lack of empathy and a sense of aloofness if caregivers focus more on electronic devices than on the patients themselves
Brenda S. Broussard, MSN, APRN-CNM, WHNP-BC, is a staff nurse-midwife at the Family Birthing Center at Ochsner Medical Center in Baton Rouge, LA; she is also a regional clinical faculty member with Frontier Nursing University in Hyden, KY. Anne B. Broussard, CNM, CNE, DNS, LCCE, FACCE, is a retired professor from the University of Louisiana at Lafayette, College of Nursing and Allied Health Professions in Lafayette, LA. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: bsbroussard@ cox.net.
60
for the warfarin. As a result, the patient ended up with an additional 3 more days of warfarin administration, developed a hemopericardium and required emergency open-heart surgery (Halamka). The use of phones by nurses involved in direct patient care activities also has the potential for distraction and errors. Designated unitspecific phones that are assigned to nurses at the beginning of their shifts allow patients and other health care team members to call nurses directly. This can improve the lines of communication among patients, nurses and other members of the health care team, but can also cause numerous interruptions when nurses are involved in tasks requiring concentration and focus. For example, what should a nurse do if the phone rings while a medication is being administered? Answering the phone while continuing the task could potentially cause a distraction and a possible medication error. A policy may need to be in place to allow the call to “rollover” to the nursing desk or for the phone to go to the nurse’s voicemail until he or she is able to respond.
Nursing for Women’s Health
Younger nurses, who have come of age as part of a “digital generation,” are often very accustomed to all forms of electronic communication. Many nursing students have begun using laptops, tablets and smartphones during their nursing education for accessing pharmacology information, evidence-based practices, research and podcasts (Johnson, 2008). However, these newer nurses might underestimate the potential for distraction with such devices. They’ve been more immersed in an electronic culture than older, more experienced nurses who rely upon intuitive understanding and objective assessment skills as well as electronic information.
Decreased Quality of Interpersonal Relationships A Canadian study found that after the introduction of smartphones for medical residents, there was a perceived increase in efficiency of communication between physicians and nurses. However, there was also a perceived decrease in the quality of interprofessional relationships due to the overreliance on electronic communication (Wu et al., 2011). In addition, patients can perceive a lack of empathy and a sense of aloofness if caregivers focus more on electronic devices than on the patients themselves. Nurses are now required to enter patient admission information and routine assessments and administer medications using computers. They often focus on the computer more than making eye contact or using therapeutic touch with patients. Frequently, the computer is placed between the nurse and the patient or off to the side where the nurse’s side or back may be to the patient, creating a perceived barrier or sense of distance. Labor and delivery nurses caring for pregnant women frequently conduct fetal monitoring with electronic devices and chart their findings on a bedside computer. Neonatal intensive care nurses rely on electronic equipment in the care of high-risk infants. The health care environment has become increasingly high-tech instead of high-touch, and it’s important to remember to focus on the patient. Guido (2010) notes that nurses who remain aloof and disconnected from patients and their families display a personality type that is more likely to be perceived as uncaring and possibly
Volume 17
Issue 1
negligent in the caregiving role. Establishing a therapeutic relationship early by displaying empathy, respect and warmth and continuing to maintain this relationship with patients and family members is increasingly important as more technology is introduced into the health care environment.
Health care workers’ and patients’ mobile phones are contaminated with nosocomial pathogens that can be transmitted to patients
Confidentiality Issues During a recent visit to the hospital room of a relative, one of the authors of this article observed a nurse talking on her unit-specific phone about another patient on the same unit while in front of her and the family member. The nurse appeared to be talking to a physician about a specific medical problem this other patient was having. Although the other patient’s name was never mentioned, too many details were discussed about a medical condition and attempted interventions to alleviate this problem. This conversation occurred while the nurse was flushing a central line. In addition to the dangers of making a mistake while
completing a task with one patient, there was also the potential for a violation of patient confidentiality since the nurse was giving a report on a medical condition concerning another patient on the unit in front of people with no
Box 1.
Suggested Policies for Use of Mobile and Other Electronic Device in the Workplace • Personal cell phones should be turned off or in the silent mode when in public areas. • Personal texting or phone calls should take place only at breaks or meal times away from clinical areas. • Employees who are involved in direct patient care should leave their cell phones with their personal items unless cleared by their supervisor. • Employees who drive should under no circumstances text or talk on the phone while driving on company business. • Photos or recordings with personal cell phones are prohibited. • Phones issued by the institution and used in the patient care setting should be cleaned with an approved antimicrobial wipe at the beginning of each shift as well as before and after each patient contact. • Nurses carrying unit-specific phones may choose to allow a call to rollover to the nursing desk if they’re involved in direct patient care activities. • The above policies are enforceable and may result in disciplinary procedures and possible dismissal for violations.
February | March 2013
personal or clinical relationship with this other patient. Another possible violation of patient confidentiality could occur when patient information is forwarded via an e-mail or text message to the wrong address or recipient. Hospitals and other health care systems considering implementing the use of smartphones within their facilities also need to provide secure networks. This would prevent access to confidential information by those who have no clinical relationship with the patient. Halamka (2011) pointed out that portable electronic devices are easy to lose, possibly leading to loss of or inappropriate access to protected health information. Such information could be stored on the device itself, or access to the health care institution’s computer clinical information system could be obtained if passwords are available via the device. Personally owned devices are not likely to possess the security controls that are built in to an organization’s electronic systems, and data found on them might not be encrypted (Halamka, 2011). Lastly, mobile electronic devices left unattended or poorly positioned could be read by
Nursing for Women’s Health
61
individuals who should not have access to the health information displayed on the screen.
Infection Control Issues A study in Turkey found that 94.5 percent of health care workers’ cell phones tested positive for bacteria including the methicillin-resistant strain of Staphylococcus aureus (MRSA) (Ulger et al., 2009). The researchers found that the cleaning rate of mobile phones by health care workers was only 10.5 percent, leaving 89.5 percent of the phones never cleaned. The authors concluded that both health care workers’ and patients’ mobile phones are contaminated with nosocomial pathogens that can be transmitted to patients (Ulger et al., 2009). Health care workers need to be aware of the importance of hand washing before and after patient care and also between patient care and handling of mobile devices, and implement routine cleaning of electronic devices to prevent the spread of nosocomial infections in the workplace. Routine cleaning of all electronic devices should be a component of hospital policy (see Box 1).
Policies to Prevent Inappropriate Behavior Many institutions have implemented policies to outline the appropriate use of technology in the workplace. These policies give guidance and direction to all employees concerning the use of personal cell phones and electronic devices. These policies have been implemented to decrease the incidence of unprofessional behavior such as using personal electronic devices for personal reasons while working. The purpose of these policies is to promote quality patient care and safety. Suggested components of a policy for use of cell phones or personal electronic devices in the workplace are listed in Box 1. With the increased use of social networking, many institutions have more recently found it necessary to
62
Nursing for Women’s Health
Box 2.
Suggested Policies for the Use of Social Networking, Internet and Online Postings • Employees should refrain from sharing any information concerning patients or patient care activities through personal blogs, postings of videos or pictures, or responses made to comments made by other Internet users either publically or via e-mail. • The employer has the right to block access to Internet sites on workplace computers and to monitor Internet and social media activity in the workplace. • Social networking and Internet activities should be limited to breaks and meal times and should occur away from patient care areas. • The employer has the right to ask the employee to remove social media postings that may reflect negatively on the institution. • The above policies are enforceable and may result in disciplinary procedures and possible dismissal for violations.
create a policy on the use of social networking, public Internet and digital online postings. The goal of these policies is to protect patient health information and privacy as well as the employer’s proprietary interests and reputation. Possible components of this policy are listed in Box 2.
Conclusion Every health care institution should have guidelines or policies in place to avoid the potential problems associated with the use of technology in the workplace. Components of such policies should address issues of patient privacy, infection control, prevention of errors from distraction and maintenance of therapeutic relationships with patients despite the use of technology. Policies preventing inappropriate behavior and sharing of confidential information on social media sites should also be implemented. Technology is an integral part of the daily life of bedside nurses and has greatly enhanced patient safety and efficiency of communication in the workplace. The dangers and pitfalls of the use of technology in the workplace have been highlighted and it’s every nurse’s daily challenge to implement
safe and effective behaviors in relation to the use of electronic devices in the work place. NWH
References Guido, G. W. (2010). Legal and ethical issues in nursing (5th ed.). Upper Saddle River, NJ: Prentice Hall. Halamka, J. (2011). Order interrupted by text: Multitasking mishap. WebM&M: Morbidity & Mortality Rounds on the Web. Retrieved from www.webmm. ahrq.gov/home.aspx Johnson, C. (2008). Nurses and the use of personal digital assistants (PDAs) at the point of care. Design of Electronic Text, 1(1), 1–7. Retrieved from fdt.library. utoronto.ca/index.php/fdt/index Ulger, F., Esen, S., Dilek, A., Yanik, K., Gunaydin, M., & Leblebicioglu, H. (2009). Are we aware how contaminated our mobile phones [are] with nosocomial pathogens? Annals of Clinical Microbiology and Antimicrobials, 8(7), 31. doi: 10.1186/1476-0711-8-7 Wu, R., Rossos, P., Quan, S., Reeves, S., Lo, V., Wong, B., & Morra. D. (2011). An evaluation of the use of smartphones to communicate between clinicians: A mixed-methods study. Journal of Medical Internet Research, 13(3), e59. doi: 10.2196/jmir.1655
Volume 17
Issue 1