Keywords
messaging - qualitative research - care teams - communication
Background and Significance
Background and Significance
Pager use is declining by 11% each year in U.S. hospitals. Pagers are increasingly
being replaced by smartphones with functionalities for team communication via clinical
text messages while maintaining compliance with policies and requirements for privacy
and security.[1]
[2]
[3] With this change comes shifting norms regarding communication about clinical care,
because phones and pagers require different processes and considerations for sending
and receiving messages. Many clinical texting platforms also include more functions
than traditional pagers, such as the ability to include pictures. Despite the increased
prevalence of these clinical texting systems (CTS), professional guidelines and etiquette
for team communication by CTS are still evolving.
Communication is an integral part of the workflow of inpatient teams. Effective communication
practices and teamwork are positively associated with markers of care, including fewer
communication errors, a positive safety culture, shorter lengths of stay, and lower
mortality rates.[4]
[5]
[6]
[7]
[8] Changes to communication practices have the potential to alter the quality of care
delivered. Yet, little attention has been paid to the effects of the implementation
of CTS on team communication. A recent review by Martin et al, for example, found
a lack of high-quality evidence about associations between mobile technology and team-based
relationships and work.[9]
As more institutions adopt text-based team communication,[10]
[11]
[12] the need to understand the impact of such transitions becomes ever more significant.
The nuanced, detailed experiences of clinical teams are especially important for understanding
how to replicate best practices, address problems, and deliver high-quality care to
patients. In this study, we aim to address this and describe the experience of hospital
medicine clinicians (“hospitalists”) and nurses with text-based communication. We
use the Donabedian framework to consider the use of CTS by hospitalists and nurses.[13]
[14] The Donabedian model considers health care quality through three domains: structure,
process, and outcomes; and posits a causal linkage between the domains. [Table 1] illustrates the three domains as applied to the current study. We focus our analysis
on the outcome of hospitalist–nurse communication, with considerations of the structural
and procedural factors that affect the communication.
Table 1
Donabedian model of care quality, as applied to CTS
|
Structure
|
Process
|
Outcome
|
|
• CTS platform
• Institutional policies
|
Paging, clinical texting, calling, or having in-person conversations
|
• Hospitalist–nursing communication
• Satisfaction
• Clinical outcomes (patients)
|
Abbreviation: CTS, clinical texting systems.
Methods
Setting
Our study was conducted at a large, Midwestern academic medical center. Diagnotes
is a CTS that includes a smartphone app and a desktop software application. Clinical
texting was introduced to hospitalists at the institution in July 2018, and to the
nursing staff nearly a year later, in June 2019. Their different scope of work accounted
for the different implementation timelines. We conducted our study in autumn of 2019.
At the time of data collection, the former paging system was also still in place,
with a plan to be phased out in the near future. This meant that care team members
could still call operators to send short text pages to clinicians—text pages that
the hospitalists received on their phone via the CTS. Beyond the nurses and the hospitalists
in our study, adoption of clinical texting varied among other specialties and service
lines within the hospital.
Participants
Participants were registered nurses of one inpatient unit, and hospitalists (physicians
and advanced practice providers) of the academic medical center. These two groups
were chosen for their frequent interactions with each other, and presumed ability
to reflect meaningfully on their experiences in hospitalist–nurse communication before
and after CTS implementation. We used a maximum variation strategy to sample participants
across a range of age groups, race, and experience on the unit. Maximum variation
sampling is used to elicit a broad range of perspectives and allows for wide applicability
of findings.[15]
Recruitment and Sample Size
The nurses were recruited as a part of a related study in which their communication
workflow was observed. They were recruited by a team member (A.K.) in person during
morning huddles. Hospitalists were recruited by email to participate in focus groups
about their experiences with the CTS. Recruitment and data collection for both the
interviews and focus groups occurred until each method reached saturation—a point
when the study team heard similar responses from the respondents, and no new themes
or codes were uncovered.[16]
Interviews
We conducted semistructured, one-on-one interviews with the nursing staff of the pulmonary
care unit. Each interview was about 30 minutes long and focused on how the participants
communicated with hospitalists, their perspectives on different modes of clinical
communication available (e.g., paging, texting, or in-person conversations), as well
as their understanding and experiences with clinical texting.
Focus Groups
We held two focus groups for hospitalists, each an hour long and facilitated by one
member of the research team while two others served as note takers. There were 14
participants in the first focus group, which was held for day-shift hospitalists,
and 7 in the second group, for night-shift hospitalists. The focus groups were semistructured,
with the facilitator using a discussion guide to begin each session. The guide focused
on user rationales for texting and paging, experiences with texting, as well as barriers
and facilitators to team communication with texting. The moderator invited contributions
from all participants about their experiences. The semistructured guides (see [Supplementary Appendix A], available in the online version) for nurses and hospitalists differed because focus
groups and interviews require different considerations and approaches; additionally,
the workflow demands and experiences with CTS of the two groups also differed.
Data Analysis
All interviews and focus groups were audiorecorded, transcribed, and deidentified
for analysis. All transcripts and notes were independently read by two members of
the research team and coded for themes. The transcripts were coded using an immersion
and crystallization approach to thematic analysis.[15] Through this iterative process, analysts organized the data in the transcripts into
meaningful units, inductively developing categories for use in representing a coherent
account of participants' experiences and perspectives with CTS.[17]
[18]
[19] Each analyst first noted their overall impression of the interview and focus group
session, then identified and coded each meaning unit; the units were then organized
into groups as themes emerged. The interview guide was compared with the notes and
transcript to support and refine the analysis. The pair then combined their notes
and organized findings into major themes. Procedures to ensure rigor and validity
included practicing reflexivity (e.g., questioning interpretations, becoming aware
of one's own expectations), depth of description (i.e., seeking out rich, particular
details of participants' experiences), and actively seeking alternative interpretations
of the data that might challenge study findings.[17]
[18]
[19]
Results
A total of 21 hospitalists, a group that included physicians, nurse practitioners,
and physician assistants, participated in the focus groups. Eight nurses participated
in interviews. Although we collected data after the texting platform was introduced
to clinicians (for 14 months) and nurses (for 3 months), we observed that both groups
were still adjusting to communicating by text. While participants found texting to
be useful, their experiences with, and knowledge of, the CTS platform varied. A list
of key benefits and dissatisfactions with CTS identified by the participants is summarized
in [Table 2].
Table 2
Key benefits and dissatisfactions with CTS, as reported by participants
|
Theme
|
Exemplary quote
|
|
Benefits of CTS
|
|
|
Ease of access
|
“The people that you need to communicate with are more easily accessible”
|
|
Ability to send pictures
|
Being able to take and send pictures for dermatology consults has been ““a huge life
saver”
|
|
Ability to have record of conversation
|
“It's easier for people to understand me when I text, when I write it down”
|
|
Dissatisfaction with CTS
|
|
|
Implementation challenges
|
“I have no idea how to [use this]. We've gotten no in-service on it”
|
|
High volume of texts
|
“It's not that the quantity is annoying. It's that we have too many things during
a night [shift]—too many critical patients that we're dealing with. I don't safely
have the time to respond to this many”
|
|
Lack of shared understanding about texting
|
“[Emojis are] just so unnecessary. Why should we have emojis?”
versus
“The emoji allows there to be another layer of personal interaction”
|
Abbreviation: CTS, clinical texting systems.
Perceived Benefits of CTS
Overall, nurses and hospitalists had positive impressions of texting, describing it
as “easier” than the paging system and noting several key benefits. A hospitalist
noted that “the people that you need to communicate with are more easily accessible
[by texts than by pager].” In addition to easy access, being able to take pictures
and send them securely by text was cited as “a huge life saver” by hospitalists. This
was especially true for their communication with dermatologists. Prior to the availability
of texting, hospitalists would sometimes have to wait days to receive a dermatology
consult. “Dermatology is very unavailable because they're only here Mondays and Tuesdays,”
one participant explained. “Calling on a Wednesday usually means you'll wait five
days.” But by texting photos, hospitalists could receive feedback from the consultants
and meet the patients' needs sooner.
Another noted benefit of texting was having a record of communication between team
members, either by text or photo, that was previously unavailable. Some nurses believed
that this simplified communication. “It's easier for people to understand me when
I text, when I write it down,” said one nurse who spoke with an accent [Nurse respondent
8]. Another nurse said having a written record helped preserve information, saying,
“For documenting the note later, right now if I communicate with the doctor I have
to write it down” [Nurse respondent 6]. But with texting, the nurse reasoned, there
would be a record of the communication to refer to for documenting in the chart later.
Dissatisfaction with CTS
Despite the benefits of texting the participants described, we also observed great
dissatisfaction with clinical texting. Notably, focus group participants spent much
more time discussing their negative perceptions of texting than positives. Some of
the frustrations were specific to the uneven implementation and a lack of education
about texting from the hospital. Although we did not explicitly ask participants about
CTS implementation, issues related to implementation emerged as a theme in the discussions.
Nurses and hospitalists had questions and commented on how little they knew of various
aspects of the texting rollout, policy, and platform. One nurse attributed her hesitation
to adopt texting with not knowing how to use the platform, explaining, “I have no
idea how to [use this]. We've gotten no in-service on it” [Nurse respondent 6]. During
the focus groups, discussion was disrupted several times when participants paused
to teach each other about different features and shortcuts.
Another source of frustration had to do with disagreements with how texting is perceived
and used by different users. Specifically, nurses described decision rules they used
for determining whether and when to text the hospitalists. Many described a deliberate
decision-making process. “I pick and choose when and what I bother the physician with
at that moment because I know that person,” one nurse said, “Each one operates differently”
[Nurse respondent 7]. Another spoke of being cognizant of not contacting hospitalists
too often. “I try to be judicious about when I page and when I don't page,” the nurse
said. “I don't want to bomb the doctor with pages [and texts]” [Nurse respondent 6].
Although the nurses in the sample spoke of not wanting to send too many texts to the
hospitalists, hospitalists nevertheless spoke of texting interactions with the nursing
staff with frustration.
“[Texting] is great for communicating with other providers,” one clinician said in
the focus group, but “I don't think it's useful [for] communicating with nursing staff.”
“The big problem [is] getting more messages from nurses,” another hospitalist said.
“They're just sending FYI messages because it's easy.”
Another hospitalist expressed that receiving too many messages from nurses affected
patient safety and their ability to deliver care, saying, “it's not that the quantity
is annoying. It's that we have too many things during a night [shift]—too many critical
patients that we're dealing with. I don't safely have the time to respond to this
many.”
While these sentiments were common, they were not universal. One hospitalist challenged
the notion of receiving too many messages. “I think that's our projection. I haven't
personally seen that I've had too many nurses paging me yet.” She qualified that the
volume of messages was an existing issue, and may be related to nursing experience.
“[It's] experienced nurses versus non-experienced nurses. The new nurses are like,
‘there's a slight issue I need to call the team no matter what.’”
In addition to the volume of messages, hospitalists also stated that nurses were not
texting appropriately and that messages from nurses often lacked key pieces of information.
One questioned what training about texting the nursing staff had received and noted
that messages from nurses “should include the patient name, [medical record number]
or call back number and that's it.” Another repeated the need for training later,
saying, “no matter what tool we use, nurses have to be instructed on the right use.”
These instructions would include necessary information to include in a message, like
“make sure I know the patient… and a callback number at minimum. Maybe toss the urgency
in there.”
Lack of Shared Understanding about Appropriateness
The study participants had differing perspectives about the types of interactions
that were appropriate over texting. While there was consensus among the participants
that texts were replacing traditional pagers, there was a lack of consensus whether
it was appropriate to use texting for information that most would not have chosen
to transmit via pagers previously. One example of this disagreement centered around
the use of text messages to convey nonurgent updates.
One nurse expressed finding the option a helpful alternative to interrupting clinicians,
and said texting was useful for conveying information that the hospitalists “probably
already know because it's been a recurring issue or something that's pretty easy fix,”
they said. “They can come to [the messages] at a specific time when they're not in
the middle of something” [Nurse respondent 4].
Some hospitalists agreed with the utility of nonurgent notification texts. One cited
an example of when such notifications are helpful, saying “If [a patient has] blood
sugar that's out of range or a critical result, I've had [nurses text me] and tell
me what they've done about it.”
Some hospitalists even send such notification messages themselves. “Where I really
find [secure texting] helpful is when there can be that communication replaces the
[unsecure] text messaging that I would otherwise do rather than wait for someone to
call me back for.” Rather than expecting a response back, they explained, those texts
simply serve to notify specialists. “I'm just letting the specialist know that I need
them to see the patient before they go.”
Yet, many hospitalists were wary of receiving nonurgent notifications from nurses,
who found notifications to be disruptive and unnecessary. “[Notifications] aren't
necessary and don't require a response back,” one hospitalist said of them, “There's
just a lot more interruptions during the day.”
The discussion around notifications was just one of several examples where some focus
group participants deemed a particular practice “unnecessary” and expressed annoyance
with how nurses texted, while other hospitalists defended the practice. Other disagreements
included the function and appropriateness of “polite chatter” and “thank you texts,”
and whether and how text messages should be used to convey urgent patient issues like
chest pains. Another example centered around the use of emojis.
“I have had nurses messaging me, they're sending me OK thanks emojis [in response
to my messages],” one hospitalist commented. “It's so unnecessary. Why should we have
emojis?”
In response, another hospitalist defended the use of emojis, noting their use as an
efficient way of conveying acknowledgment and context. “The emoji allows there to
be another layer of personal interaction and I find it much faster to write a thumbs
up when traffic gives me a message. Then I know that they know I've received that.
[Instead of typing] ‘yes, I have received your message, send.’”
These disagreements illustrate the lack of shared understanding between users of clinical
texting. While hospitalists and nurses alike shared consensus on some aspects of texting:
that it should be professional, focused on important issues, and replace traditional
pagers, there were many interpretations of how that was to be operationalized. Frustrations
arose when senders and recipients disagreed. While most of the hospitalists' frustrations
were directed at the nurses, the diversity of opinions and experiences with texting
that arose in the focus group discussions suggested that there were nuances of clinical
texting for which there was a lack of consensus on appropriateness even among hospitalists.
Discussion
This study is one of the first in-depth, qualitative analyses of team communication
after the implementation of a CTS platform in a hospital. Although the study participants
spoke favorably of texting, they identified more dissatisfactions with texting than
benefits, and spent more time discussing the negatives. The perceived benefits of
texting appeared to be limited by shortcomings of the implementation process as well
as a lack of shared understanding among the health care team. There were disagreements
regarding appropriate texting practices both within and between the hospitalists and
nurses. These findings suggest that despite the benefits of texting, there is room
for improving team communication and understanding in the realm of clinical texting.
The challenges of health care team communication, particularly between physicians
and nurses, are well documented. Physicians and nurses have been found to have differing
perceptions of communication with one another, with physicians reporting higher levels
of interdisciplinary open communication than nurses,[20] and more physicians reporting that communication with nurses is well coordinated.[21] Physician responsiveness to communication from nurses depends on clinical and nonclinical
factors, including message medium (e.g., by text or not), clarity, and urgency, as
well as interpersonal relationships and personal preferences.[22] Our study contributes to this literature by noting the experiences and approaches
of hospitalists and nurses communicating via clinical texting; we uncovered the ways
clinical texting exposed or exacerbated existing communication challenges. Different
expectations about when and how text messages should be sent led to frustrations for
many in our study. In particular, hospitalists described some nurses as sending too
many texts and not knowing how to use texting, although the nurses in our sample described
a deliberate judiciousness in their sending of these messages. Our findings are in
line with the limited and emerging research to date on the effects of texting implementation
in clinical settings, as well as the greater body of work on face-to-face communication
between physicians and nurses.[9]
[11]
[23]
[24] The benefits we reported also support the findings of Patel et al that secure texting
was less disruptive to workflow compared with one-way text paging by both nursing
and physician survey respondents.[24] Yet, we also uncovered tension and dissatisfaction. Similarly, in a 2012 study,
Lo et al interviewed nurses and physicians about the use of smartphones in team communication,
and observed that while smartphone use could facilitate team communication, it could
also lead to conflicts. Both the nurses and physicians in the study identified a lack
of clarity and discrepancies on the level of perceived urgency and the appropriate
medium of communication.[25] In the absence of clear guidelines, stated preferences, and shared understanding,
nurses and physicians are left to navigate the discrepancies on the individual level.
Given the importance of effective communication and teamwork in maintaining patient
safety and preventing medical errors, such an absence could have negative consequences
for team performance and patient outcomes.
In our study, only hospitalists, not nurses, spoke negatively of the volume of messages
they received via text. In some ways, the experience of receiving a disproportionate
number of team messages echoes physician experiences with electronic health record
(EHR) systems. Much has been written about the negative impacts of “alert fatigue”
and of the high burden of EHR documentation.[26] The toll for both is often heaviest for physicians. A recent survey found that 50%
of physicians reported frequent EHR use on workday evenings compared with 41% of nurses.
The probability of physicians' reporting frequent EHR use on days off was 20 percentage
points higher than nurses (average marginal effect = 0.20, p < 0.001).[27] In 2015, recognizing the serious consequences associated with documentation burden
and alert fatigue for clinicians, the Joint Commission released a sentinel event calling
for health care organizations to pay close attention to information technology (IT)
as a safety issue. The Commission noted the importance of paying careful attention
to safe IT implementation, and recommended engaging leadership to provide oversight
of health IT planning, implementation, and evaluation.[28]
The findings of this study have important implications for health care administrators
and health care team members, as well as researchers. We offer a checklist of planning
considerations pre- and post-CTS implementation based on our findings in [Table 3]. Although we did not report on implementation challenges in depth, that they were
raised by participants without prompting suggests the need for thoughtful education
and implementation. While the circumstances of each institution may be different,
implementation challenges related to new health IT are not unique and demonstrates
the need for frequent and continuous attention by administrators.[12]
[24] Our study focused on the different shared experiences and understandings of texting
by users, and the frustrations that arose when senders and recipients were not aligned
in experiences and understanding. These findings contribute to the literature by highlighting
user frustrations with CTS related to interprofessional communication and workflow
issues that may have predated CTS implementation.
Table 3
Checklist of CTS implementation considerations
|
Consideration
|
Activities
|
|
Maximizing the benefits of CTS
|
Remind users of
1. their dual role as sender and recipient of messages, and
2. that a benefit for one party (e.g., ease of use), may be associated with dissatisfaction
with another
|
|
Minimizing dissatisfaction with CTS
|
Given that CTS will be used differently by users of different clinical roles:
• Recruit diverse stakeholders are needed in the implementation so not one group will
be favored or inconvenienced
• Conduct education sessions in different formats and for different audiences
|
|
Building shared understanding about CTS appropriateness
|
Conduct group discussions about CTS with specific cases contributed by users to generate
team buy-in and develop user consensus about different aspects of appropriateness
|
Abbreviation: CTS, clinical texting systems.
Several implications can be drawn from these results. First, our findings point to
the need for health care leaders—including institutions, administrators, and even
professional societies—to provide explicit guidance and shared expectations on how
and when clinical texting should be used to overcome mismatched expectations and understanding.
Second, for health team members, the experiences described in our study suggest that
establishing a common understanding needs to happen on both institutional and individual
levels. Team members may need periodic, brief trainings on how to establish a shared
understanding in communication preferences. Lastly, for researchers, our findings
point to the need for more understanding about improving team dynamics as well as
different aspects of clinical texting (e.g., the use of texting for specific clinical
processes) as the practice becomes more prevalent in health care. This includes understanding
the relationship between successful team texting and quality of care outcomes.
Limitations
This study focused on the experiences of one clinician specialty group (hospitalist)
and the nurses from one unit in one academic medical center. Because institutional
settings and policies may greatly affect user perceptions of texting as well as their
patterns of use, our findings might not be generalizable to other settings. We were
constrained by the availability of the participants, and so had to use two different
data collection methods—focus groups for hospitalists, and interviews for nurses.
However, we were able to draw from a range of experiences of both groups, and reach
thematic saturation. Another limitation of this study was that not all the nurses
who participated in the interviews had used the texting platform. Because of this,
our data may have been limited in understanding the depth of texting experiences for
nurses. However, the inclusion of nurses who do not use texting contributed to our
understanding of implementation challenges related to texting.
Conclusion
This study is one of the first to describe the experiences of hospitalists and nurses
with clinical texting, and to consider the effect of texting on inpatient team communication.
There is a dearth of literature considering the long-term effects of clinical texting.
And while some studies have evaluated the impact of CTS on clinical processes (e.g.,
time-to-procedure, number of interruptions), few have examined their effects on clinical
outcomes, such as patient safety or readmission rates.[9]
[23]
[24] The issue of how to communicate effectively over text is an evolving one that affects
many institutions, and clinical texting is likely to only increase in the U.S. health
care landscape in the coming years as more institutions decommission their pager systems.
A lack of shared understanding regarding when and how to use texting may require long-term
solutions that address teamwork and appropriateness. Future research should address
current gaps in the literature by considering the effects of team texting on patient
safety as well as long-term user satisfaction.
Clinical Relevance Statement
Clinical Relevance Statement
As more and more institutions decommission their pager systems, the issue of how to
communicate effectively over text will be increasingly important. This study found
a lack of shared understanding among the team regarding when and how to use. Long-term
solutions will need to address teamwork and appropriateness to improve teamwork via
clinical texting.
Multiple Choice Questions
Multiple Choice Questions
-
How has clinical texting system adoption trended in the U.S. in the last decade?
-
Increased among hospitals.
-
Decreased among hospitals.
-
About the same among hospitals.
-
Increased among hospitals then decreased then increased again.
Correct Answer: The correct answer is option a. The use of clinical texting systems has increased
in the U.S.
-
What clinical system is the clinical texting systems replacing?
Correct Answer: The correct answer is option b. Clinical texting systems are meant to replace pagers.
