ONeill, K., Robb, M., Kennedy, R.Bhattacharya, A., Dominici, N. & Murphy, A. ( July, 2018).Mobile technology, just-in-time learning and gamification: Innovative strategies for a CAUTI education program. Online Journal of Nursing Informatics (OJNI), 22(2), Available at http://www.himss.org/ojni
Mobile technology deployment at the point of care (POC) is rapidly being embraced in healthcare as a means to address hospital-acquired infections and improve patient outcomes. Implementing technology-driven tools and best practices can be a challenge due to limited accessibility to clinically relevant resources, and reduced workforce engagement. To address this issue, an evidence-based practice change project was implemented in a community hospital located in New Jersey.
The aims of this project were twofold: 1) increase nurses’ knowledge with respect to best practices for catheter-associated urinary tract infections (CAUTI); and 2) enhance frontline staff engagement in best practices using a technology-driven platform infused with game-based learning.
The project followed a multi-modal, time-series interventional design in which mobile tools were incorporated at the POC to provide targeted CAUTI education, and best practice strategies for registered nurses (n = 37) working in the intensive care and medical/surgical units. Presentations, videos, quizzes, case studies, and discussion boards were uploaded weekly onto a mobile technology platform (MTP) for eight weeks. This socio-technical frontline strategy allowed for just-in-time training (JIT) that promoted action-oriented learning. To incentivize ongoing user engagement, nurses accrued gamification reward points for completing structured online learning activities.
Results demonstrated an 18.2% increase in sustained nursing knowledge retention scores (p = .02). In addition, staff rated technology uptake as very favorable at 87%-100%. Findings revealed the project increased nurses’ knowledge of CAUTI best practices guidelines, promoted active staff engagement, encouraged technology use, and supported a positive change in POC practices overall.
Mobile technology is rapidly being adopted by healthcare leaders and hospital clinicians worldwide (Jones et al., 2015). Although health information technology and evidence-based practices are readily available, challenges remain in translating best practices to the frontline care team in a consumable, accessible format. A breach in best practice guidelines often leads to hospital acquired conditions (HACs), such as catheter-associated urinary tract infections (CAUTIs), which are a substantial financial burden to healthcare organizations (Agency for Healthcare Quality Research [AHRQ], 2012, 2013; Association for Professionals in Infection Control [APIC], 2014). This article describes an innovative evidence-based CAUTI education project that was implemented as part of an annual quality improvement initiative at a community hospital in New Jersey. Findings from this project are applicable across other healthcare initiatives and can guide the development of game-based practice change initiatives to support action-oriented learning and provider workforce engagement.
The National Quality Strategy serves as a federal roadmap to reduce patient harm and improve provider engagement while promoting technology to support best practices (U.S. Department of Health and Human Services [HHS], 2015). The failure to implement best practices in a sustainable, cost-effective manner contributes to medical errors, hospital waste and patient harm (Berwick & Hackbarth, 2012). In the United States, over 400,000 preventable deaths occur each year from hospital-acquired infections (HAIs) (James, 2013). Even with increased public awareness campaigns, CAUTIs continue to be one of the most common forms of HAIs, occurring in 450,000 patients per year resulting in 13,000 deaths (Centers for Disease Control[CDC], 2017) annually. CAUTIs are preventable and negatively impact both the patient and organizational financial performance, resulting in lower hospital reimbursement. CAUTI events and associated expenditures are a financial burden to the health care system, costing $565 million dollars per year in lost revenue (AHRQ, 2014). Since 2015, underperforming hospitals are financially penalized up to 3% from Centers for Medicare and Medicaid Services (CMS) as part of the HAC Reduction Program. This program is an effort to reduce HAIs and adverse events while improving care quality and patient safety (CMS, 2016).
Incorporating just-in-time training (JIT) initiatives at the point of care (POC) is the gold standard for many high-reliability organizations to provide clinical excellence, address HAIs, and reduce costs. According to surveys by Press Ganey Associates (2013), workforce engagement levels significantly impact hospital quality and safety scores and are critical towards effectively improving healthcare delivery services. Regrettably, national studies on provider-related performance data reveals nursing ranks lowest on workforce engagement scores at 32.6%, when compared to other frontline care providers (Advisory Board Company [ABC], 2014). Likewise, Melnyk & Fineout-Overholt (2015) reported that only 34% of nurses implement best practices when working in the clinical care environment. In a large scale study, Cimiotti, Aiken, Sloane, and Wu (2012) surveyed over 7,000 registered nurses working in 161 hospitals in Pennsylvania. The researchers linked nursing burnout to higher rates of HAIs, such as CAUTIs (r = 0.82; p = .03). Because nurse engagement in best practices correlates with hospital safety, quality, and patient outcomes, understanding the current state of worker engagement, associated infections, and related costs is a national healthcare imperative.
Clinical decision support (CDS) systems are a powerful functionality of health information technology that can be leveraged to address HAIs when intelligently built and integrated seamlessly within provider workflow. According to the Office of the National Coordinator for Health Information Technology (2013), CDS encompasses a wide variety of readily available tools to enhance decision-making in healthcare settings; these tools include computerized alerts, clinical guidelines, bundled order sets, patient data reports, diagnostic support, contextually relevant reference information, and others. As demonstrated by Lee (2013), when applied effectively, CDS can produce positive benefits such as improved patient status, enhanced nurses’ work environment, and increased staff knowledge. Piscotty and Kalisch (2014) had similar findings showing real-time CDS tools improved overall patient care and unit safety. Conclusions offered by Lee (2013), Piscotty and Kalisch (2014) and ONC (2013) recommended integrating CDS tools into providers’ daily clinical workflow for optimal support and user benefit.
Behavior modification, such as gamification, is yet another evidence-based strategy that has been successfully used in the education domain to sustain active and ongoing learner engagement (Huang & Soman, 2013). According to Meister from Harvard Business Review (2013), gamification takes the essence of “games” (attributes of fun, play, transparency, design), infused with human’s innate drive for “competition,” and applies these principles to a range of real-world processes inside an organization, including learning and development. By applying these key principles to healthcare, early research offers positive results with game-based competition as a behavioral incentive to motivate staff in reducing hospital infection control rates (McKeown, 2014; Yegge, Gase, Hopkins-Broyles, Leone, Trovillion, & Babcock, 2014). Gamification was also used as an innovative learning method in a pediatric intensive care unit as a frontline strategy to improve nursing workforce engagement. Through the use of an online social media gaming platform, this healthcare system demonstrated a two-fold increase in frontline nursing workforce engagement levels (Roy-Burman et al., 2013).
Equally important is how and where providers access essential information in the clinical practice setting. According to leading experts, today’s complex patient care environment requires the use of agile technology-driven solutions that are portable, convenient and available in various delivery care settings (Lumsden, Byrne-Davis, Mooney, & Sanders, 2015). A recent study by Dykes and Collins (2013) demonstrated improved nursing knowledge and evidence-based skills when mobile technology was used to access clinical information, education, and JIT practice-related resources. Furthermore, Mosa, Yoo, and Sheets (2012) reviewed smart phone applications for health professionals and concluded that wide-spread adoption of mobile tools is a necessary vehicle to help integrate scientific evidence into bedside clinical daily practice.
The aim of the evidence-based CAUTI education project was to help build workforce capacity and life-long learning for effective knowledge transfer that improves care quality – a national imperative by the National Academies of Sciences, Engineering, and Medicine ([NASEM], 2016a, 2016b). Based on the complexity of care and patient harms data at the project site, the project objectives were threefold: (1) increase nurses’ knowledge on the 2015 American Nurses Association (ANA) CAUTI Prevention Guidelines; (2) enhance frontline staff engagement of best practices through the use of an MTP; and (3) improve uptake of mobile technology for JIT learning and CDS at the POC.
The evidence-based CAUTI change project was conducted over eight weeks, and included registered nurses (RNs) who worked in the intensive care unit (ICU) and medical/surgical (med/surg) units. Data collection for the project followed a pre-post test design to allow for evaluation of changes in the mean scores of frontline nurses with respect to CAUTI knowledge, staff engagement in use of best practices, and technology uptake. Three discrete surveys were used: a 10-item quiz created for the purposes of this project using the ANA CAUTI Prevention Guidelines (2015), the Utrecht Work Engagement Scale (UWES-17) (Schaufeli & Bakker, 2003) that measured workforce engagement (Cronbach’s alpha coefficient of 0.91-96); and the User Acceptance Survey (UAS) by Georgia Tech (n.d). The UAS is a standardize survey tool for computer software development, and was used as summative evaluation for consistency of a technology interface, platform usability, and user acceptance. Data analysis was completed through use of SPSS Version 22 (IBM Corporation, 2013). Both descriptive statistics and the Wilcoxon Signed-Rank test were conducted to analyze findings. The level of significance was set at α = 0.05.
Mobile Technology Platform (MTP)
For this project, the MTP was an interactive engagement tool that resided outside of the electronic health record (EHR). This tool was provided for use in this project as an in-kind prototype that was developed through the collaboration of innovation experts and systems engineers. The MTP platform was installed behind the hospital firewall on a secure server. Standard data management governance rules were followed for patient protection and confidentially using secure passcode rules and encryption. The MTP was built specifically to support frontline workflow using integrated mobile tools and gamification design. Nurses logged into the MTP portal with a unique user ID and passcode via a secure link on the hospital’s internet home page. Nurses accessed JIT resource tools using computer desktops, secure wireless workstations on wheels, or tablets during frontline clinical care.
The project design included a two-phased approach conducted over eight weeks using a socio-technical intervention plan. Time-series measures were obtained for CAUTI knowledge at three discrete intervals: weeks 0-1 (T0) for a staff baseline assessment regarding CAUTI best practices; again at week 2 (T1) immediately following a targeted CAUTI education program; and finally at week 8 (T2) to assess ongoing staff knowledge and retention of CAUTI prevention activities. Phase I commenced in weeks 0-2 after baseline CAUTI data were obtained. ICU and medical/surgical nurses completed Phase I, which was annual mandatory training on ANA Practice Guidelines (2015) and CAUTI prevention using the MTP as a static platform.
Phase II of the project was voluntary and commenced weeks 2-8 using micro-learning and gamification principles. Each week CAUTI educational modules were uploaded to the MTP that provided ongoing learning and supported staff engagement in best practices. At change of shift, ICU and med/surg nurses logged onto the MTP portal and completed a structured handover for patients who had indwelling Foley catheters. Throughout the clinical day, nurses logged into the MTP to complete interactive modules, access real-time CDS, engage in shift-shift handoff, participate in discussion boards, review CAUTI resources (presentations, video vignettes, algorithms, case studies, policies, procedures), and take a quiz. The MTP was built to allow staff to re-take online quizzes to improve their passing scores until they achieved 100%. Even with multiple quiz attempts, staff continued to receive activity points to drive motivation and self-improvement. The MTP also provided real-time learner feedback where staff could view daily dashboards and compare their progress with peers. Dashboards included peer rankings based on the number of accumulated engagement points. Thus, the MTP offered access to game-based learning in a non-punitive clinical environment. Staff used these reward points towards gift cards to purchase food items.
Phase I (weeks 0-2) included 50 registered nurses who completed the annual mandatory CAUTI training sessions by accessing mobile tools at the POC; 20 RNs were from the ICU, and 30 RNs were from the med/surg unit respectively. Thirty-seven nurses from Phase I voluntarily agreed to continue in Phase II (weeks 2-8) with ongoing use of the MTP and real-time access to online CDS tools, JIT education, CAUTI best practice resources, and game-based learning.
During the pre-implementation, baseline nurse knowledge (T0) responses were collected and reported as a group mean. This aggregate data were not included in the statistical analysis, but served as baseline data for trending the difference between pre-implementation (T0) and post-implementation (T2) staff knowledge scores. The Wilcoxon Signed-Rank test was used to compare differences in nursing knowledge scores immediately following the intervention of the MTP at week 2 (T1), and repeat measure week 8 (T2). As seen in Table 1, results showed a statistically significant (p = 0.02) increase in staff knowledge from week 2 (T1) to week 8 (T2) following the intervention of mobile technology tools at the POC. Mean knowledge scores of nurses continued to rise from 73.85% to 86.15% (T2) respectively for an additional six weeks when using MTP support that was clinically integrated into staff frontline workflow. Overall, nursing knowledge scores increased by 18.2 % from a baseline of 67.87% at pre-implementation (T0) to 86.15% (T2) after eight weeks.
Work engagement is defined by Schaufeli and Bakker (2003) as a positive affective motivational state of fulfillment, manifested as vigor, dedication, and absorption, and the opposite of nurse burnout. In this project, staff engagement was measured by a self-reported survey, and electronically using the interactive MTP platform in weeks 2-8. Engagement points were accumulated daily and awarded to staff after completing targeted action-oriented learning activities, such as CAUTI peer-to-peer handoff, education quizzes, staff discussion boards, and JIT learning tools for clinical decision support. A total of 3487 activity points were accumulated by ICU and med/surg nurses and displayed in Figure 1 as a time series graph. Overall, the graph demonstrates a positive user trend and noticeable workforce engagement in best practices by nurses who accessed online resources for CDS at the POC.
Although staff were engaged in the project, as evidenced by the number of activity points, enhanced nurse engagement was not reflected in the self-reported UWES-17 (Schaufeli & Bakker 2003) workforce survey. The UWES-17 survey remained essentially unchanged from pre-implementation (T0) to post-implementation (T2) with the mean scores of 4.55 to 4.37 respectively. These findings may suggest that staff were engaged due to an external reward and self-driven competitiveness; whereas the components of workforce engagement, such as vigor, dedication, and absorption (items measured by the UWES-17) were not directly influenced using this self-survey tool.
The User Acceptance Survey (Georgia Tech, n.d) measured ICU and med/surg nurses’ uptake and adoption of mobile tools for CDS at the completion of the project in week 8 (T2). The data showed that 100% of nurses (n = 37) rated the MTP as highly acceptable with scores ranging from 85-100% for technology uptake with respect to consistency of interface; platform usability/design; information helpfulness; and ease of use. These favorable ratings regarding the MTP demonstrated a high degree of staff acceptance when using clinically relevant mobile tools and JIT resources in their daily workflow.
The outcomes of this project offer several implications for key stakeholders in healthcare such as policy leaders, nurse executives, staff educators, informatics specialists, and quality improvement analysts. When considering practice change initiatives to address HAIs, key decision makers should consider gamification design and JIT methods used in this evidence-based CAUTI project. As demonstrated in the project’s outcomes, JIT training was successfully implemented using the MTP as a pragmatic tool to deploy action-oriented learning and real-time staff engagement in best practices. Providing meaningful mobile applications for frontline nurses was achieved by incorporating relevant resources and tools into daily clinical workflow. The JIT training format made essential CDS resources readily accessible, consumable, and actionable at the POC when and where staff needed them the most, thus creating a supportive social culture for enhanced clinical performance and life-long learning. This socio-technical approach aligns precisely with the American Nurses Credentialing Center’s new vision to implement outcome-based learning to help translate knowledge into satisfactory clinical performance for continuous learning and development (Dickerson, Shinners, & Chappell, 2017).
Likewise, the key decision makers should consider how technology can be leveraged to support a sustainable change transitioning front-line nurses from rote memorization to higher-level thinking regarding evidence-based practice. As demonstrated in the project’s outcomes, nursing knowledge and levels of workforce engagement continued to increase throughout Phase II of the CAUTI project. During this phase, mobile technology offered real-time learner feedback, encouraged shared practice accountability, and revealed a unit level of transparency that supported a positive non-punitive, social work environment.
In addition, key decision makers should consider the role of gamification principles in creating an experience that supports professional development through discovery and self-regulated learning. As reflected in the project’s outcomes, the MTP provided staff with online rewards that served as a successful improvement strategy that reinforced ongoing learning for sustained frontline workforce engagement in best practices. Adding an extrinsic motivating reward encouraged staff to remain engaged with interactive CAUTI content, increasing staff knowledge of EBP and hardwiring them in clinical practice settings.
Lastly, key decision makers should also consider the role of staff buy-in when incorporating mobile tools and applications at the POC. As suggested in the project’s outcomes, staff rated the MTP as highly acceptable. More specifically, bedside nurses provided high ratings for items pertaining to “ease of use” and meaningful frontline functionality. This suggests that staff buy-in is augmented when technology solutions are complementary toclinical tasks at hand and, when integrated seamlessly, can be viewed as a “value add” to deliver safe care.
Nurses play an essential role in improving patient care and population health. Emerging care delivery science demonstrates a strong relationship between evidence-based practice and better patient outcomes. With a growing emphasis on quality indicators and value-based care models, nurses require timely access to relevant practice resources at the POC. The clinically integrated MTP served as a workforce engagement lever that improved learning and workforce engagement by incorporating CAUTI best practices, social rewards, gamification, and JIT tools for real-time interaction by frontline staff. This innovative change project proved to be an action-oriented strategy to help drive effective and efficient nursing care while supporting clinical practice excellence. Project outcomes demonstrated enhanced nursing knowledge, staff engagement, and mobile tool adoption among frontline nurses in a community hospital.
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Kate ONeill, DNP, RN, is VP of research and clinical excellence at eConnectiveCare; and serves as an adjunct assistant professor at the Frances Payne Bolton School of Nursing, Case Western University.
Megan Robb, PhD, RN, is an assistant professor of nursing at Chatham University. She has taught a variety of professional role development courses at the master and doctoral levels. As a nurse educator, Dr. Robb focuses on exploring innovative methods for engaging learners in reflective practice through the use of technology.
Rosemary Kennedy, PhD, RN, MBA, FAAN, is CNO of Sotera Wireless and formerly associate professor and associate dean of strategic initiatives at Thomas Jefferson University School of Nursing in Philadelphia. Most recently, Dr. Kennedy was vice president of health information of technology at the National Quality Forum in Washington, D.C. In addition to being an informatics domain expert, she holds many leadership roles through her work with the American Medical Informatics Association (AMIA) and Technology Informatics Guiding Educational Reform Board (TIGER). Dr. Kennedy is widely presented and published in the field of nursing informatics, clinical documentation and terminology standards. She is a fellow in the American Academy of Nursing and received the HIMSS 2009 Nursing Informatics Award as well as the top 25 women in healthcare award for 2009. She is currently on the TIGER board and sits on the safety council for the American Association of Medical Instrumentation. For many years, she was the chief nursing informatics officer for Siemens Healthcare Solutions.
Andy Bhattacharya, MHS, serves as university faculty and statistical consultant to Villanova University, College of Nursing, and the University of Pennsylvania, College of Nursing.
Nicholas R. Dominici, MSN, RN, graduated with a master’s degree in nursing informatics at Chamberlain University, and serves as the program director for wound care, Restorix Health.
Andrew Murphy, BS, graduated summa cum laude from Ursinus College in the pre-med track. Formerly, he served as a research extern at iCareQuality.us with a focus on quality, safety, and healthcare informatics.