Authors

  1. Brandt, John MA, MILS
  2. Katsma, Diane DNP, MN, RN, FNP
  3. Crayton, Diane DNP, MSN, RN-BC, FNP
  4. Pingenot, Alleene PhD, MA, MS, RN

Article Content

The use of cell phones and other personal wireless devices is prevalent in today's society. Mobile devices have expanded beyond being used as simple communication tools to become multifunctional, accessing, capturing, processing, and sharing a vast range of personal and professional information. Since the Institute of Medicine report forecasted a growing use of technology to increase work productivity in nursing, the incorporation of personal wireless devices within the healthcare setting has grown rapidly.1 Mobile devices now often replace the use of written instructions and fixed computer workstations for clinical tasks, and physicians use a variety of clinical apps on their personal devices.2-6

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Cell phones have been shown to enhance communication between healthcare providers and patients. At the same time, the general population-especially the younger generation-has become more willing and accustomed to exchanging health information via mobile devices.7-11 Facility-owned wireless devices are being used to streamline nursing tasks, and nurses may use their own cell phones in clinical settings for professional and personal reasons.2,12-16 The utility of cell phone use for communicating within hospital departments, as well as with personnel outside of the care facility, has been noted.17,18 Research literature has also touted the benefits of new technology that addresses the communication needs of nurses.12

 

However, there are documented concerns regarding cell phone technology, including possible electromagnetic interference with medical equipment, as well as the potential to violate patients' privacy.19-23 The possible distraction and discomfort caused by cell phone use has been studied in the public sphere, including medicine and nursing.22,24-28 Because many younger nurses are avid cell phones users, institutions are struggling to implement appropriate policies.13,29-31 At some facilities, cell phone use while at work can lead to termination of nurses.32,33

 

Although the need for cell phone/mobile device policies and regulations has been noted, only brief studies of facility cell phone policies exist and there's currently no documentation of cell phone policies for nurses.19,34,35 We surveyed nurse leaders with the aim to document current policy governing cell phone use in the inpatient setting and issues surrounding such use. Feedback received by nurses attending a poster presentation of our survey reflected frustration about how nurses were using cell phones; acknowledgment that policy enforcement was difficult; and uncertainty about best practice policies, including whether nurses should be able to have their own cell phones while working.36

 

Methodology

In 2011, a 12-item online survey asking about nursing cell phone use in California acute care settings was distributed via e-mail to 963 members of the Association of California Nurse Leaders through the North Central chapter. (View the survey on the Nursing Management iPad app.) Because the target population was nurse leaders in acute care, the 17 respondents who identified themselves as nurse educators outside of acute care were eliminated from the analysis.

 

Questions included multiple choice and open-ended responses, providing the opportunity for participants to share any comments they wished to provide. Demographic and multiple choice question results were analyzed using percentages for categories. Qualitative data were analyzed using a content analysis approach.37 These idea categories were then combined into themes. Some adjustments in data analysis were made during the coding process. Item 11 "other concerns" and item 12 "other views" had so much overlap in response content that they were coded together. County locations were classified as rural or urban.

 

Results

A total of 217 participants were included in the study, yielding a response rate of 23%. Participant demographics reflected the population of nurse leaders in the Association of California Nurse Leaders. A majority of the respondents were from California (67%), female (89%), and age 45 or older (90%).

 

Almost two-thirds of the respondents (65%) were midlevel nurse managers, such as department and patient care directors, supervisors, and other nurse administrators. Most of the remainder (29%) were senior nurse directors, including CNOs, assistant CNOs, and vice presidents/assistant vice presidents. Only a small number (6%) were clinical nurses.

 

Of those who reported their location (n = 149), about three-quarters were from California urban areas (76%), just under a quarter were from California rural areas (21%), and a small number reported being outside of the state (3%). A wide range of institution size was represented, from facilities with 6 to 24 beds to those with more than 500 beds. Large institutions (with more than 400 beds) accounted for somewhat under half (41%) of the survey population, whereas midlevel facilities (between 100 and 399 beds) accounted for just over half (56%). Only a few respondents (3%) indicated a small institution size of between 6 and 99 beds. Only 17% (n = 34) of respondents reported using cell phones provided by their institution.

 

Of the respondents who reported whether their facility had a cell phone policy (n = 212), a large majority (75%) indicated that their institution had a policy applicable to nursing staff. Reported descriptions of policies (n = 159) varied greatly, from complete prohibition of cell phone use while working (23%) to allowing use with limitations, such as texting only or use outside of critical care areas. (See Table 1.) Many of the policies restricted use by location, some allowing cell phones in break and lunch rooms only (36%) and others specifically forbidding use in all patient care areas (42%). Several policies explicitly prohibited use in specific critical care areas, such as EDs and ICUs (5%), or in proximity to sensitive equipment (3%). Some policies permitted work-related calls on hospital-provided phones (17%) or even on personal phones (3%). Other policies mentioned allowing cell phone use for personal emergencies (5%) or restricting various aspects of use, including setting phones on vibrate only (5%) or not allowing nurses to carry phones while working (3%).

  
Table 1: Policy char... - Click to enlarge in new windowTable 1: Policy characteristics (n = 159)

Of those nurse leaders working at institutions with a policy (n = 163), a sizable minority (40%) reported that their institution's policy wasn't enforced. At institutions where policies were enforced, the most frequently mentioned enforcement practices included progressive discipline (from verbal warnings to written notations for subsequent infractions), disciplinary action, and general guidance by nurse managers (such as coaching, education, and verbal warnings). A few specifically described measures that were potentially more stringent, including informing institutional security, confiscation of cell phones, and possible termination. (See Table 2.)

  
Table 2: Enforcement... - Click to enlarge in new windowTable 2: Enforcement methods of nursing cell phone policies (n = 83)

When asked about specific concerns, 96% of the respondents chose at least one of the three options listed on the questionnaire: nurses taking personal calls in patient rooms (73%), nurses being distracted while working (88%), and unauthorized picture taking (46%). For those expressing no concern (4%), some cited the utility of cell phones for nurse communication with physicians and patients while also mentioning trust in their facility's wireless communication system (secure, hospital-supplied phones) and the professional etiquette of staff.

 

From the qualitative responses (questions 11 "other concerns" and 12 "other views") regarding cell phone use (n = 123), seven themes emerged. Six of these areas depicted concerns about the negative impact of cell phone use in nursing environments and one theme identified the benefits of cell phone use.

 

Theme 1: Professionalism concerns

Cell phone use by nurses wasn't seen as professional behavior. Figure 1 depicts the perceived breaches in professionalism, with the predominant issue being portrayal of an unprofessional image. Several respondents wrote about the relationship of professionalism and cell phone use:

  
Figure 1:. Professio... - Click to enlarge in new windowFigure 1:. Professionalism concerns

* "Nurses won't portray a professional image-providing care for patients that promotes optimal outcomes. Patients feel as if they aren't nurses' first priority."

 

* "[It's] unprofessional behavior when [cell phones are] used while doing bedside care."

 

* "The look of a nurse 'texting' on her phone just drives me crazy."

 

 

Generational differences do affect the perception of cell phone use and professionalism, as one respondent pointed out:

 

* "Younger nurses feel that cell phones should be utilized for the applications that are available on the new smart phones. They also voice that taking a picture of an anomaly may be used as a learning tool. The more experienced nurses comply with the existing policy. They voice concerns about the lack of professionalism."

 

 

There was an inability to self-regulate cell phone use, as one respondent noted:

 

* "Most don't have the discipline not to check who's calling when they receive notice of a new call or text."

 

 

Theme 2: Distraction concerns

Cell phone use was perceived as interfering with nurses' work; the central work of nurses was seen as providing patient care. One respondent wrote:

 

* "If I go to a nice restaurant, I don't expect the waiters/staff to be on their cellphones instead of providing the service that the customers need/expect. So why is it that our patients shouldn't have our devoted attention in various areas of the acute clinical setting?"

 

 

Another respondent saw the distraction as a violation of altruistic service:

 

* "Nurses and other healthcare staff seem to place their own personal needs before the patient when they use cellphones during patient care."

 

 

Cell phone use was also seen as a commonplace disturbance:

 

* "It's a very distracting phenomena and one that has become almost the rule rather than the exception. It's rude and distracting."

 

 

Theme 3: Usage concerns

Respondents identified specific cell phone activities that were considered inappropriate. (See Figure 2.) Taking pictures, texting, and using social media were at the top of the list. In addition, physicians communicating and texting orders to nurses, surfing the Internet, and playing games or watching movies were considered problematic.

  
Figure 2:. Usage con... - Click to enlarge in new windowFigure 2:. Usage concerns

Theme 4: Patient privacy concerns

The confidentiality of patient information on unsecured networks, especially the posting of images, and potential Health Insurance Portability and Accountability Act violations were listed among privacy concerns:

 

* "[I] have always been concerned with the use of personal cell phones at work and have seen privacy breeches with photos taken and even put on Facebook accounts."

 

* "We have had multiple issues with pictures inappropriately being taken. This is better now after much work and counseling staff."

 

 

Theme 5: Safety concerns

Cell phone use at work was thought to contribute to unsafe work environments. (See Figure 3.) Many respondents made a reference to patient safety as a general concern without additional explanation:

  
Figure 3:. Safety co... - Click to enlarge in new windowFigure 3:. Safety concerns

* "There are numerous safety concerns on a variety of levels."Cell phones were also considered to be a vehicle for infection transmission and a source of equipment interference. The quality and, hence, safety of medical apps for use on cell phones was questioned. Nursing errors were also attributed to cell phone use.

 

* "Physicians have informed me that nurses have been seen preparing medications while taking personal phone calls."

 

* "It's poor professional conduct, and if texting and driving is a safety concern due to distraction, how about texting when calculating meds, titrating medications, or observing for critical changes in patient status, etc?"

 

 

Theme 6: Policy enforcement concerns

Respondents had an array of concerns related to cell phone policies that focused primarily on either what the policy should be (for example, use limited to breaks) or the challenges of enforcement. When asked to share additional comments, many respondents expanded on the challenges of enforcement they had reported in a previous question on how policies were enforced at their institution. There was a resignation that policy or not, nurses won't relinquish their cell phones.

 

* "While the policy is 'enforced' to a point, most nurses still have their cell phones in their pockets."

 

 

One respondent wrote bluntly when asked about views on cell phone use at work:

 

* "I wish it would go away."

 

 

Theme 7: Benefits

The study's questionnaire specifically asked about concerns regarding nurses' cell phone use, but a number of respondents (18%) voluntarily described benefits when prompted for additional comments. Positive aspects of cell phone use by nurses included easier communication with physicians, managers, and patients; the ability to quickly double-check medical information; and the ability of the nurses' family members to reach them in an emergency.

 

* "I think cell phone use should be okay. Especially when looking up medications and diagnosis. I have a drug book and I.V. calculator application on my phone that come in handy at times. It's just so much quicker and easier."

 

* "They have calendars with alarms that remind them to attend patients, meetings, etc. The nurses feel more comfortable when their children call and say they are home safe and sound. New mothers can view live video of their child's first words, steps, etc. One of my nurses was able to view and communicate with her son who was having chemotherapy on the days that her husband was with their son. I can go on and on about the advantages. This is a way of life for certain ages and as long as the phone doesn't distract from patient care, I feel the advantages outweigh...I say let it be with the understanding by all that the phone never distracts from patient care."

 

 

Discussion

Most of the acute care agencies did have some type of cell phone policy in place for nurses. Although there was no uniformity among the policies, the vast majority restricted cell phone use by not allowing the devices in patient care areas or while working. A few policies went as far as to not allow nurses to carry cell phones at all. This restrictive approach contrasts with how other healthcare professionals integrate cell phones into their practice. According to one author, "virtually all physicians carry a personal cellular device for work purposes" and it's considered as important to their work as a stethoscope.38 Policies for nursing staff, however, assume that the only use a nurse has for a cell phone or other mobile device at work is for personal and social purposes.

 

Given the complexity of implementing cell phone policies, it isn't surprising to find that many agencies don't enforce their cell phone use guidelines. Those agencies that did attempt to enforce policies used a variety of strategies, many of which were informal. Talking to the offender, along with coaching and education, were common tactics; however, there were also severe consequences, such as ultimately being terminated. Enforcement of a blanket prohibition on carrying a cell phone may not only be impossible, but also likely counter to best practice in today's technology-enriched work environment. Young nurses may have owned a personal cell phone since grade school. They may use apps for increasing effectiveness at work, similarly to other professionals. Policies that prohibit all cell phone use may reflect a disconnect between generations. Indeed, one study reported that nurses who carried their personal cell phones felt more at ease while at work.16

 

Some of the comments reflected the difficulty of enforcing policies. For example, several respondents indicated that nurses used their cell phones to communicate with physicians and patients or access medical applications, making it difficult to monitor personal use. Others reflected on the inconsistency of enforcement or the disconnect between official policy and actual practice. One respondent stated, "Cell phones are to be in the employee locker while clocked in, but in practice everyone carries their personal cell phone." Interestingly, although our study found restrictive policies common, another study found that a large majority of nurses use personal cell phones while working, reporting diverse activities from texting to shopping and playing games.15

 

Implications

Because this study focused on nurse leaders, the results are the views of nursing management. The nurse leaders voiced more concerns regarding cell phone use than benefits from tapping into technology. However, clinical nurses working at the bedside may have very different perspectives about personal cell phone use at work. There are a plethora of apps relevant to nursing practice, and clinical nurses at the point of care may desire the autonomy to determine which databases, books, and online sources are pertinent to their work. Clinical nurses may also appreciate the ready retrieval of information that their cell phone affords them.

 

Even though a majority of respondents had cell phone use policies in place, one quarter didn't. It seems advisable for agencies to have an official policy so that nurses are clear about what's considered acceptable personal technology use, but just what that policy should consist of is another matter. The study results revealed 16 different approaches, with a majority severely restricting cell phone use by nurses. One wonders how realistic these restrictive policies are, given the ease and ubiquity of nurses carrying cell phones and the connection that younger generations have with their personal devices. Indeed, 40% of respondents who had cell phone policies admitted that the policies weren't enforceable.

 

The challenge highlighted in this study is to devise policies that allow professional and intelligent use of technology while protecting nursing's professional image and the rights of patients to confidentiality. Further, policies need to address the use of personal cell phones differently than agency-provided phones and specifically address professional versus personal use by nursing staff.

 

This study describing the state of cell phone policies should be followed by a focus on how to devise policies that encourage the appropriate use of technology while protecting patient information from inappropriate release. Appropriate use may include bedside communication between professionals; documentation, including pictures of the current status of a wound; and bedside information access, including medication, lab, and disease information for clinical applications. Inappropriate use includes any release of protected patient information.

 

This study has several limitations. The survey was sent to a select group of nurse leaders who had membership in a specific nursing organization and, therefore, represents only a small subsection of the profession. The results represent middle- and high-level nurse managers who are generally from a generation that didn't grow up with widespread use of technology. Their perception of technology, including cell phone use at work, may not be representative of all nurses. The participants in this study were predominately middle-aged female acute care nurse mangers and nurse directors in California. Future research should query younger clinical nurses to see how they're using cell phones at work and what they perceive as the benefits and challenges of cell phone use.

 

Studying cell phone use in agencies and populations throughout the United States is important to get a national picture of what's happening. Studies that validate or challenge some of the concerns raised by nurse managers are a possible direction for future research. For example, do patients and their families view nurses' personal technology use as unprofessional? Do units with no cell phone policies in place have an increase in nurse errors? The questionnaire used in this study had a focus on cell phone policies and the concerns of nurse managers. Subsequent studies may highlight the positive aspects of cell phone use by nurses. Finally, it would be interesting to see how nursing schools are encouraging appropriate cell phone use with students in the classroom, labs, and clinical rotations.

 

Our exploratory study is a beginning step in thinking about how nurses can best use personal technology in work settings. It's up to nurses as professionals to use available technology to advance and transform nursing practice.

 

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