Collins, R. (Winter 2019). Nurses’ Perceived Usefulness of Secure Texting Applications for the Purpose of Patient Care. Online Journal of Nursing Informatics (OJNI), 23(1). Available at http://www.himss.org/ojni
Mandates for secure digital patient-care communications were recently established, but due to the rapid growth of cell phone technology, little research has been done on the impact of these technologies on patient privacy and healthcare team communication. This research used a cross-sectional survey to explore nurse willingness to adopt secure texting applications and their perception of the ease of use of these applications. Six constructs related to the technology acceptance model were evaluated, and while trust in the secure technology appeared high, relative ambivalence towards use of the technologies was noted, and full adoption of these technologies was not indicated without further research.
The use of smartphones for patient care by nurses and other healthcare workers is becoming a common practice in U.S. hospitals (Landis, 2016). Many benefits exist to having critical information readily available to the nurse at the point of care from data repositories such as electronic health records, various services, and professionals within the hospital. The ability to foster seamless communication or send critical alerts and information to busy, non-stationary nurses has the potential to dramatically improve communications among the healthcare team and facilitate increased safety in the care environment (Landis, 2016).
Because of the recent mandates from The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) on security standards, hospital personnel are now required to work within a secured technology environment, and thus the use of secure texting applications is becoming more common in US hospitals. This common use of messaging or texting between and among care providers necessitates the need for applications that can facilitate the adherence to security of digital messages.
A secure app requires users to open the app, sign in with a designated password, and send or receive information inside the secure, enterprise-grade software. While the term enterprise-grade has no formal or universal definition, the information technology industry says “[e]nterprise-grade describes products that integrate into an infrastructure with a minimum of complexity and offer transparent proxy support” (Partridge, 2017, para 3). A true enterprise-grade application considers the importance of security from the outset of development, and along with the highest level of security, addresses the issues of productivity, compliance, integration, support, and scalability for large numbers of users.
Keeping protected health information (PHI) private is facilitated by security provided in software built for the purpose of secure texting. Criteria for security standards for the purpose of texting have been set forth by TJC and the CMS. These standards specify both the technical security standards and what information is allowed to be communicated via a digital message (CMS, 2017; TJC, 2016).
Accessing purpose-built software applications may add more steps to the nurse’s workflow. Depending on the secure software used, access can be more difficult to navigate due to the complexity of application or device issues, such as battery drain, reliability, or network. Because of the extra steps, nurses and physicians frequently choose to text clinical information, PHI, and even photos of wounds or burns using the common, unsecured, cellular networked texting feature on their personal cell phones. While many healthcare disciplines are using purpose-built, secure applications for secure messaging/texting, this study is focused exclusively on nurses’ responses to mandated use of secure texting applications.
Further, the potential to violate the Health Insurance Portability and Accountability Act (HIPAA) laws by using unsecured data transmissions puts patients’ privacy and safety at risk. The frequency of nurses exchanging critical clinical information with no ability to record the exchanged information is extensive and occurs every day in U.S. hospitals. No scholarly literature was cited in three major search engines to document the high usage of unsecured messaging between and among healthcare providers. Nurses clearly understand the importance of privacy of patient information because of the extensive education and focus on HIPAA laws over the past decades. However, a lack of understanding of what constitutes security of information in an open-text message application threatens security. As an example, Spyglass Consulting Group surveyed a select group of nurses and determined that 67% admitted to texting unsecured PHI to co-workers or physicians (Malkary, 2014). Even though all of these nurses stated that their hospitals had a policy against such a practice, because they were contacted via text by physicians, they responded in the same manner. The same study showed that 92% of the physicians’ responses indicated they texted unsecured PHI on their personal cell phones.
Thus, being able to validate a tool and identify nurses’ willingness to adopt and their perception of ease of use of secure applications formed the basic purpose of this study. The adoption of secure texting applications has not yet been documented in the professional nursing literature, so this research study forms the seminal work on this topic.
CINAHL, Ovid, and Pub-Med data bases were searched for articles from 2012 to 2017 and included requirements for English language, data-based, and peer reviewed.
Although many literature searches span longer time frames, the rapid pace of change in mobile technology made a briefer timespan more relevant. Search terms used were: nurse use of smartphones, nurse acceptance of handheld technology, benefits of hands-free communication or smartphones, risks and limitations of smartphones in the clinical environment, rates of adoption of smartphones among all clinicians, common practice environments for use of smartphones, human error factors related to technology adoption, and healthcare disciplines using smartphones for clinical practice. This search produced 15 articles. Two additional articles were added because they provided a definition of technical terms and market-user information (Malkary, 2014; Partridge, 2017), resulting in a total of 17 scholarly articles. Additionally, numerous online and printed articles on various topics related to the use of smartphones in health care and the need for secure texting/messaging between and among caregivers/providers were found. However, since the bulk of these publications were thought leader or opinion articles, they were not utilized for this literature synthesis.
Three articles focused on physician use of mobile phones for patient care and were included as a reference for how nurses communicate with physicians (Attri, Khetarpal, Chatrath, & Kaur, 2016; Bastawrous & Armstrong, 2013; Webb, Spina, & Young, 2016). Their conclusions about the wide variation in use and the need for mobile communication determined that further study and policy development should be considered. Bastawrous and Armstrong (2013) determined that the use of mobile phones in low-income countries had the potential to increase access to medical treatment through apps if the infrastructure and regulatory guidelines were in place. The need for security and guidelines was the primary conclusion of their study.
Because the use of mobile smartphones for the purpose of communication with the patient care team is a rapidly changing practice, only seven of the articles directly addressed the appropriate use of mobile phones in the patient care setting. These studies observed that the use of phones for personal activities, such as accessing social media, taking pictures, and using unsecured applications, put the end user at risk of inadvertent violation of patient privacy. The conclusion is consistent across all literature that appropriate policies and guidelines for use must be developed to support the use of smartphones for the purpose of patient care (Bautista & Lin, 2017; Bohot, Hammond & Stanbrook, 2017; Flynn, Polivka, & Behr, 2017; Free et al., 2013; Mather, Cummings, & Allen, 2014; McBride & LeVasseur, 2017; Snoots & Wands, 2016; Wyatt & Biller Krauskopf, 2012).
The obvious benefit of time savings that mobile technology provides for everyone was a critical component of the integration of smartphones into the patient care setting. Mobile phones used in both inpatient and outpatient settings were shown to increase accuracy of, and save time for, communication between and among nurses, care teams, nurses and physicians, and extended-care teams (Bastawrous & Armstrong, 2013; Bautista & Lin, 2017; Mather et al., 2014). Other high-value tasks for mobile phone use were reference support (able to look up drugs, disease, and treatments), being connected when working from remote locations, and time savings of actual walking time between tasks and patients (Pemmasani, Paget, van Woerden, Minamareddy, & Siri, 2013; Sedgwick, Awosoga, & Grigg, 2017).
The study was approved by both the hospital’s and university’s institutional review boards (IRBs). The participants’ privacy was safeguarded through use of an anonymous survey. Because the hospital used a purpose-built software application for secure texting, this study did not ask any nurse to violate any standards or regulatory requirements related to secure texting.
The Technology Acceptance Model (TAM) (Holden & Karsh, 2010) provides the theoretical framework for this study (Figure 1). The TAM was developed in the 1980s as information technologies (IT) were being introduced into clinical practice, and at that time the low acceptance of IT was identified as a problem to be solved for future success. The TAM evaluates the end users’ perceived usefulness and perceived ease of use of technologies, and together, these two human behaviors form the attitude of the end user. According to Holden and Karsh (2010), these variables then predicted the individual user’s intention to use, or their acceptance of, technology, followed by full adoption of the technology. Using the TAM as a foundation, Gao, Krogstie, and Siau (2011) developed an instrument to measure the adoption of mobile services.
Methods and Design
A quantitative, cross-sectional design with an online survey was used to examine nurses’ perceived usefulness of secured texting applications for patient care. Survey responses were collected and collated to obtain respondent demographic frequency distributions, and mean response values from the six survey constructs were analyzed to evaluate the nurses’ willingness to adopt this secure technology, as well as their perceptions of the ease of use of the applications. Additionally, a multiple regression analysis was conducted to determine whether any of the TAM – Mobile Information Systems survey subscale domains significantly contributed to the percent change in R2 variance accounted for in the predictive effective of the mean intention to use scores of registered nurses using secure texting applications in clinical settings.
This study utilized the abbreviated version of a 33-item survey developed by Gao et al. (2011), which was based on the theoretical foundation of the TAM. These items were grouped into six constructs: (a) perceived usefulness, (b) perceived ease of use, trust, (d) personal initiatives and characteristics, (e) context, and (f) intention to use.
Using a pilot study to evaluate the Intention to Use survey instrument, Gao et al. (2011) distilled the original 33 items to 20 with a resulting reliability of all six constructs maintaining a value greater than a 0.70 level, a reliability threshold targeted for this study. Although the reliability of the scale for perceived ease of use decreased from 0.829 to 0.811, it was still above the 0.80 level, which demonstrated high reliability of the scale. The post hoc analysis of my participant submission yielded an overall Cronbach Alpha of .913, which illustrated high instrument reliability within this study’s participants.
The instrument was converted to an electronic format, which consisted of threeparts:
- A cover letter explaining the purpose of the survey, that the survey was voluntary and that the survey was anonymous,
- The online survey, which also included demographic questions about age, level of education, and years in practice.
- A final question that asked if the user had to perform any workarounds with the secure texting application. An open text box allowed for a description of the workaround.
Specific product pros and cons were not identified in this study, and neither were any function issues such as battery usage or type of phone used.
A convenience sample of 60 licensed nurses was obtained from an intermediate medical surgical patient care unit in a large acute care hospital in the Southwest United States. An anonymous, voluntary, online survey was emailed via an online access link through Survey Monkey to employees who self-identified as registered nurses or advanced practice registered nurses. The link was distributed by the unit director, and the survey was accompanied by a cover letter explaining the study.
The survey link was sent to 60 nurses, which resulted in a 40% (n = 24) response rate. From these 24 respondents, one survey was excluded based on respondent non- use of secure texting formats, leaving 23 valid cases for the cross-sectional analysis.
Fourteen people responded in whole or in part to the demographic questions. The average age of these respondents was 35. More than half of these (n = 8) held a Bachelor of Science degree, and 43% (n = 6) had between 5-10 years of nursing experience.
All of the questions were evaluated on a 7-point Likert Scale with 0 reflecting Strongly Disagree and 7 reflecting Strongly Agree. Figure 2 illustrates the mean values of each of the six constructs. The mean of perceived usefulness of the secure texting feature was 4.30, and ease of use scored 4.88. The construct of trust was rated highest at 5.70, personal initiatives and characteristics scored lowest at 3.60, and context was scored at 4.32. The final construct of intention to use had a mean score of 4.89.
I then evaluated the predictive effect of the variables, using a multiple regression analysis. Since my sample size was considerably below the conventional power requirement, I conducted two additional tests to enhance the validity of the results. A linear regression on the underpowered group was performed (Table 1), followed by a bootstrap model of 1,000 respondent samples using statistical modeling based on the actual participants in my study (Table 2). Both models reported that the only statistically significant (p = 0.02) predictor was the construct of context.
Discussion of Findings
Although the construct of context was shown to be a statistically significant predictor, the percent change in R2 variance was not high (R2 = 3.73). This may mean that nearly two-thirds of the change in variance was due to unmeasured variables that further influenced the nurses’ intentions to use mobile technology.
When examining the means of the responses (Figure 2), it appeared that the nurses in this study were somewhat ambivalent about the use of secured texting applications to ease the burden of patient care by facilitating communication from the bedside. These nurses were somewhat comfortable with the texting features of the secure technology and fundamentally trusted that it would work as expected. However, some of the free-text response comments regarding workarounds to the secure technology revealed that accessing and programming a phone while in the act of patient care was awkward and not possible when both hands were engaged. These comments might help explain the range of scores in the perceived ease of use construct (Figure 3), specifically the lower rating for Question 3.
Figure 3. Comparison of mean values of the questions for the perceived ease of use construct.
The ratings on the construct of perceived usefulness may indicate a positive impression of the nurses’ intent to use the secure technology. However, the nurses noted that the usefulness of the technology was limited by how many users were active in the system.
The higher mean score in the construct of trust (5.70) appears to indicate an above-average trust of the technology and its use. Conversely, the lower motivation scores (3.60 in the personal initiative and characteristics construct) may reflect an uncertainty about using the specific technology in this study, or it could signify a lower level of technology acceptance overall.
The construct of intention to use indicates the commitment of the nurse to use, or adopt, the technology for the foreseeable future. While the respondents indicated they may favor an intention to use, only a trend toward full adoption can be asserted.
Assumptions and Limitations
A cross-sectional study design carries inherent limitations, such as the inability to rule out rival explanations, the reliability of the survey process, and an overarching assumption for respondents’ truthfulness. Additionally, the generalizability of the results of this study was constrained by the small, non-probability sample size.
Another limitation involved the concept of context in the environment of hospitals. Nurses are often not part of the selection committee for new technology, but rather they are given a product and expected to use it. This may undermine the validity of the construct of context in this study because this hospital provided no selection choice from nurses. Also, there was no way to ensure that everyone responsible for patient care was fully and concurrently engaged in using the same software product during this research.
Recommendations and Conclusion
The data from this study offer an important first look at the perceptions of nurses on the usefulness of secure text messaging applications, and their willingness to adopt these applications to enhance communications within the healthcare team. Given the apparent ambivalence exhibited by this sample population, this study should be repeated in a variety of different hospitals and populations and expanded to settings other than hospitals. Further research should be conducted to understand the actual burden of managing the functions of a smartphone while the nurse is engaged in direct patient care, and the features and functions of such devices should be examined for proper use in the patient care environment. Mobile technology can be a critical part of the health care team’s patient care technology when deployed properly to all workers with consideration to the complexity of bedside care.
Secure texting features for the purpose of healthcare team communication are still in the early stages of use and acceptance in the patient-care environment. We have much to learn to ensure that technology enhances and supports the burden of care, rather than adding to the complex environment nurses work in every day. Given the mandates on security standards, this research is an important first step in our understanding of this technology’s impact on patient care.
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Rhonda Collins, DNP, RN
Chief Nursing Officer
Vocera Communications, Inc.
Rhonda Collins, DNP, RN began her nursing career 28 years ago in Labor and Delivery, caring for high-risk mothers and their babies. After 10 years in direct care for patients, she assumed leadership positions in several hospitals across Texas. She was Vice President for Women and Children’s Services at Baylor University Medical Center in Dallas, Texas when she made the decision to enter the healthcare business industry as a clinical subject matter expert.
In 2003, Ms. Collins joined Cardinal Health/ALARIS Medical Systems in San Diego, California, where she held several executive positions. For nearly 10 years, she managed and supported business development and client relations focused on medication safety for the Clinical Technology and Services business unit, known as CareFusion.
After her tenure at CareFusion, Ms. Collins became the Vice President of Nursing at Masimo Corporation in Irvine California, and then Vice President and Business Manager for Fresenius Kabi, USA, LLC in Schaumburg, Illinois, where she managed a medical device through FDA clearance and launched it in the U.S. market.
In 2012, Ms. Collins co-founded The American Nurse Project dedicated to telling the stories of nurses all across the country. Today, Ms. Collins is Vice President and Chief Nursing Officer for Vocera Communications, Inc., the leading communication company in healthcare focused on providing innovative solutions that improve care team collaboration, and the patient, family and staff experience. In 2017, she was named a “Woman in MedTech to Know” by Becker’s Hospital Review.
Ms. Collins earned her bachelor’s degree and doctorate of nursing practice from Texas Tech University Health Sciences Center, and a master’s degree in nursing administration from the University of Texas. She is a frequent speaker on the evolving role of nurses, the importance of communication, and how to use technology to improve care team collaboration.