Jan 01, 2012
By Lloyd Tapper, RN, MN, NP, ACCN , Holly Quinn, RN, BScn, MHS , June Kerry, RN, MN , Katherine Grant Brown, RN
Introducing Handheld Computers into Home Care
In the fall of 2009, Bayshore Home Health (BHH) provided tablet computers to 75 home care nurses working in Barrie, Ont. The devices were equipped with an embedded evidence-based documentation system and loaded with decision-making supports such as drug reference databases. The technology was designed to facilitate client assessment, care planning and evaluation at the point of care. This article documents the experience of implementing handheld computers in a home care setting and presents the lessons learned from the perspectives of the BHH executive team and front-line nurses. These groups were asked to complete online surveys, developed by the BHH research and evaluation steering committee, to assess the impact of the implementation on the organization, its nurses and its clients. An analysis of the feedback indicated support for the implementation. However, both groups had concerns about the capability of the hardware and software to meet the needs of decentralized home care nurses working in both urban and rural areas. Front-line nurses also identified the impact of handheld computers on the time required for charting and on the nurse-client relationship as areas of concern.
Bayshore Home Health (BHH) is a national health-care organization that provides both nursing and home support services to more than 75,000 Canadians. In late 2009, the organization distributed tablet computers to 75 home care nurses working in Barrie, Ont. The devices contained nursing documents with one-touch access to embedded evidence-based clinical practice guidelines. Wireless access to the Internet allowed nurses to access decision-making supports, such as websites and drug reference databases, at the point of care. The technology was implemented to help nurses complete client assessments, plan care and evaluate client outcomes. This article documents BHH’s experience with introducing handheld computers into the work of its front-line nurses in home care and presents the lessons learned from the perspectives of the BHH executive team and the nurses themselves.
TECHNOLOGY SELECTION PROCESS
During the summer of 2009, BHH established a device review committee. The committee was composed of representatives from the information systems (IS) department, the nursing administration, the front-line nursing staff and the infection prevention and control committee. Its mandate was to develop criteria for selecting a handheld device (see box [JPG, 318.9 KB]), consult with vendors and identify the most suitable technology. The committee assessed multiple devices and ultimately selected a PC tablet computer.
Once the hardware was selected, it needed to be equipped with a software package. A number of packages were reviewed, and several vendors were shortlisted. They were invited to demonstrate their products, and the long-term financial viability of their companies was assessed.
During the vendors’ presentations, nursing administrators and IS representatives on the committee identified the following additional concerns:
- All of the software products were relatively new.
- BHH would need to make ongoing investments in developing the functionality of any of the products.
- BHH might not be able to validate assertions made by vendors that their software could communicate with existing technology and allow for data extraction and reporting. This issue presented a significant risk to the success of the implementation process and meant that ongoing collaboration with the software vendor would be required.
Physical environment factors. Powell-Cope, Nelson and Patterson (2008) created a conceptual framework that places the use of technology in the context of nursing practice. They suggest that physical environment factors such as lighting, noise and architectural features can have an impact on the implementation of technology. Although these specific factors were not relevant in this case, the committee identified two environmental factors that would affect the usability of the device: the cold outdoor temperatures and lack of Internet connectivity in rural areas. The committee members believed that the first factor would be mitigated by using car chargers to charge the device’s batteries between client visits and switching the device to hibernation mode when not in use, and that the second factor could be addressed through the use of store and forward technology. This allows nurses to collect and store client data in their device while it is disconnected from the Internet, and the information is automatically uploaded to the database when the device is reconnected.
Organizational factors. In the months leading up to the distribution of the devices, nursing administrators and the IS team recognized the need to develop a comprehensive training program for front-line nurses, to develop strategies to empower nurses and to revisit organizational policies governing the use of handheld technology. Subsequently, the IS team, the clinical support team and the clinical nurse manager in Barrie developed three educational modules. The modules, which took 12 hours for nurses to complete, included basic instruction on the use of tablet computers and the process for completing electronic documents, along with a review of operational processes and policies governing the use of handheld technology. Given that wound care represents a substantial component of the work of BHH’s home care nurses, a separate four-hour module devoted to reviewing best practice guidelines in this area was offered. In addition, the clinical nurse manager facilitated the development of interactive activities designed to provide nurses with practical experience in the use of handheld technology. Nurses were invited to participate in these activities, which were scheduled over an additional five days, once they had completed the four modules. While they were working on the modules, nurses interested in becoming expert users were asked to identify themselves. These individuals, who were provided with ongoing education and support by the IS staff and the clinical nurse management, functioned as mentors for front-line staff and became champions for the implementation of the technology.
Social factors. According to Powell-Cope et al. (2008), nurses’ age, experience, attitude, knowledge, perception and intention to use the technology can affect the implementation process, as can the impact of the technology on their clients. The committee took many of these factors into consideration when selecting a handheld device, developing the content of the educational modules and developing strategies to support and empower the nursing staff. One strategy that proved particularly effective in getting buy-in from front-line nurses and reducing their level of anxiety was to distribute the devices before the nurses were expected to start using them on the job, so that they had time to explore the functionality of the device.
To evaluate the implementation process, members of BHH’s research and evaluation steering committee developed questions for two online surveys, drawing on the work of Powell-Cope et al. (2008).
Perspective of the executive team: Thirteen months after the implementation, the first survey, consisting of 11 open-ended questions, was distributed to members of the BHH executive team: the chief nursing officer, executives from the business administration, finance and IS departments at Bayshore’s National Service Centre in Mississauga, Ont., and nursing executives located in the Barrie branch.
Early in the implementation process, difficulty opening, closing and saving files, problems with synchronizing information with the central database,short battery life and limited access to the Internet presented significant challenges for front-line nurses. Information collected from the survey completed by the executive team indicated that ongoing concerns about the functionality of the software and the handheld device had to be addressed to optimize buy-in from front-line nursing staff.
The respondents were also concerned about an inability to achieve a return on investment. It was noted that it can take longer than expected to integrate a new IS technology and that efficiencies gained through the implementation of handheld computers are often offset by the cost of data transfer and additional IS staff.
The respondents identified important lessons the organization had learned:
- The cost of implementing handheld computers can be prohibitive.
- Improvements in handheld devices and software must be made to address the needs of a decentralized home care team working in both urban and rural areas.
- A highly collaborative relationship between the IS team and nursing staff is a key ingredient in the implementation of handheld technology.
- An experienced project manager, an informatics specialist and ongoing feedback from front-line nurses are required to successfully implement handheld computers in home care.
- When selecting a handheld device and a software program, health-care organizations should make every attempt to validate assertions made by vendors about the ability of their software to communicate with the existing IS infrastructure.
Perspective of front-line nurses: Eighteen months after implementation, the home care nurses were invited to participate in a 15-question online survey. They were asked to rate their responses to the first 12 questions using a five-point Likert scale. Possible responses ranged from “strongly agree” to “strongly disagree” and from “extremely satisfied” to “extremely dissatisfied.” Space was also provided for respondents to elaborate on their responses. Questions 13-15 required a narrative response and reflections on the lessons nurses had learned from their involvement in the project. They were asked to consider the impact of the technology on their practice and to offer advice to others who may become involved in implementing handheld computers. Nurses were given assurances of anonymity, and informed consent was obtained.
Twenty-six (35%) of the nurses responded. Sixty-three per cent of respondents agreed that handheld computers had improved their work environment, 12 per cent were neutral and 23 per cent disagreed. Sixty-five per cent of respondents agreed that handheld computers had improved their use of evidence-based practice, 27 per cent were neutral and eight per cent disagreed. Twenty per cent agreed that handheld computers had not affected nurse recruitment and retention, 42 per cent had no opinion on this subject and 38 per cent disagreed.
Feedback on the quality of the educational program and access to IS support was also collected. Sixty-six per cent of respondents agreed that the educational support they received before handheld computers were implemented was sufficient to meet their learning needs, while 34 per cent disagreed. Fifty-eight per cent of respondents agreed that access to IS support during the implementation process was sufficient, 12 per cent were neutral and 31 per cent disagreed.
Nurses were also asked to respond to the statement “Documenting using a handheld computer while conducting a client interview has positively impacted my relationship with clients.” Nineteen per cent of respondents agreed with this statement, 31 per cent were neutral and 51 per cent disagreed. Thirty per cent of respondents agreed with the statement “The use of handheld computers has improved client outcomes in home care,” 46 per cent were neutral and 23 per cent disagreed. Fifty-four per cent of respondents agreed that home care clients are supportive of nurses who use handheld computers, 23 per cent had no opinion and 23 per cent disagreed.
Nurses’ opinions on the impact of handheld computers on the time required to chart and the cost of care were also assessed. Fifteen per cent of respondents agreed with the statement “Handheld computers have decreased the time that I spend charting,” 15 per cent were neutral and 70 per cent disagreed. Twelve per cent of respondents agreed that handheld technology had reduced the cost of care, 50 per cent were neutral and 38 per cent disagreed.
Thirty-five per cent of respondents agreed that any initial concerns they had with the hardware and the software had been resolved, 15 per cent neither agreed nor disagreed and 50 per cent disagreed. Sixty-two per cent of respondents were satisfied with the process of implementation and integration, 19 per cent were neither satisfied nor dissatisfied and 20 per cent were dissatisfied.
The following themes emerged from the narrative feedback provided by the survey respondents:
- Integrating handheld technology in home care is challenging and complex.
- Handheld technology can improve access to clients’ information, the use of evidence-based practice, communication between staff members and the quality of documentation.
- Nurses must have a mechanism for providing ongoing feedback to the administrative staff responsible for the implementation regarding the impact of technology on their practice and the changes necessary to improve the implementation process.
- When handheld devices and software are implemented, the needs of front-line nurses must be met to optimize their productivity, preserve the nurse-client relationship, prevent a decrease in nurse satisfaction and minimize any negative impact of the technology on nurse recruitment and retention.
- Nurses can assist in the transition process by actively participating in all training opportunities, asking for assistance when necessary and maintaining a positive attitude.
The executive team and the front-line nurses agreed that improvements in handheld devices and software programs are needed before the true benefits of this technology can be realized in home care. To that end, BHH is currently conducting a review of handheld computers and is piloting multiple devices as part of its ongoing commitment to successfully implement handheld technology in home care. The organization also has plans to introduce new software that should improve the stability of the system and the experience of front-line nurses.
Given that the marketplace is highly competitive, it is expected that the functionality and capability of handheld computers will improve rapidly, which will in turn improve the experience of end-users. Improved access to high-speed Internet in rural areas should occur with time.
The content of BHH’s educational program and its approach to educating front-line nurses will also be reviewed and evaluated, and recommendations made by Wright (2004) and Hockenjos and Wharton (2001) concerning the components that should be included in such programs will be considered. In addition to 24-hour telephone access to the IS team, nurses will be able to consult with an IS specialist who is now located in the Barrie branch.
Our experience at BHH indicates that when handheld technology is implemented in home care, nurses benefit from improved access to client data and evidence-based decision-making supports at the point of care. However, improvements in handheld devices, software programs and high-speed Internet access will be necessary before the full potential of handheld computers in home care can be realized.
Hockenjos, G. J., & Wharton, A. (2001). Point of care training: Strategies for success. Home Healthcare Nurse, 19(12), 766-773.
Powell-Cope, G., Nelson, A. L., & Patterson, E. S. (2008). Patient care technology and safety. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2686
Wright, C. S. (2004). Orienting the clinician to point of service systems. Home Healthcare Nurse, 22(10), 687-694.