Journal Assignment Week 10

Improving nurse–patient communication with patients with communication impairments: hospital nurses' views on the feasibility of using mobile communication technologies Bridget Sharpe, BSp Path (Class I Hons), Bronwyn Hemsley, PhD ⁎ The University of Newcastle, Callaghan, NSW, Australia abstract article info Article history:

Received 30 July 2015 Revised 13 November 2015 Accepted 18 November 2015 Keywords:

Communication impairment Mobile technology Communication aids Hospital communication Nurse-patient communication Nursing Background:Nurses communicating with patients who are unable to speak often lack access to tools and technol- ogies to support communication. Although mobile communication technologies are ubiquitous, it is not known whether their use to support communication is feasible on a busy hospital ward.

Purpose:The aim of this study was to determine the views of hospital nurses on the feasibility of using mobile communication technologies to support nurse–patient communication with individuals who have communica- tion impairments.

Method:This study involved an online survey followed by a focus group, withﬁndings analyzed across the two data sources.

Findings:Nurses expected that mobile communication devices could beneﬁt patient care but lacked access to these devices, encountered policies against use, and held concerns over privacy and conﬁdentiality.

Conclusion:The use of mobile communication technologies with patients who have communication difﬁculties is feasible and may lead to improvements in communication and care, provided environmental barriers are removed and facilitators enhanced.

© 2015 Elsevier Inc. All rights reserved. 1. Introduction Communication in hospital is a fundamental human right (UNCRPD, 2006) and is essential to safe hospital care (Bartlett, Blais, Tamblyn, Clermont, & MacGibbon, 2008). Recent reviews have revealed that com- munication in hospital is problematic for patients with communication impairments (e.g. seeHemsley & Balandin, 2014; Hemsley et al., 2015) and that research evaluating strategies to improve communication and safety for these patients is lacking. Effective communication with patients who have communication impairments in hospital relies on many factors in the patient, including skilled nurses who take time to communicate (Hemsley, Balandin, & Worrall, 2012), prepared patients (Costello, Patak, & Pritchard, 2010), the availability of communication aids (e.g.,Hemsley & Balandin, 2004), and the support of familycaregivers and paid carers in hospital (Hemsley, Balandin, & Togher, 2008; Hemsley et al., 2012). Not only does effective communication in hospital allow individuals with communication disabilities to assert control over their environment (Hemsley, Balandin, & Worrall, 2011), it also helps them to communicate and manage pain, exchange informa- tion, reﬂect on emotions, demonstrate politeness, and develop relation- ships for social closeness (Happ, Tuite, Dobbin, DiVirgilio-Thomas, & Kitutu, 2004; Hemsley et al., 2011).

A wide range of conditions may impede a patient's ability to commu- nicate basic care needs and exchange information about their health.

People with lifelong disabilities (e.g. cerebral palsy, intellectual disabil- ity, autism), acquired disabilities (e.g. stroke, traumatic brain injury, cancer, neurodegenerative disease), physical trauma, or mechanical ventilation (Beukelman & Mirenda, 2013) might require communica- tion supports to convey their message to unfamiliar nursing staff. Difﬁ- culty communicating in hospital is associated with an increased risk of patient safety incidents (Bartlett et al., 2008; Hemsley et al., 2015; Wassenaar, Schouten, & Schoonhoven, 2014). Also, patients report experiencing negative emotional consequences when unable to speak in hospital, including fear, anger, worry, depersonalisation, frustration, and loss of control (Happ et al., 2004; Hemsley et al., 2008). In light of this evidence, the development and use of Augmentative and Alterna- tive Communication (AAC) solutions (e.g. communication boards, books, electronic devices with speech output such as speech generating devices, mobile communication technologies) are vital for these Applied Nursing Research 30 (2016) 228–236 Conﬂict of Interest: The authors declare no conﬂicts of interest.

Funding statement: This research was supported in part by a grant to theﬁrst au- thor from the National Health and Medical Research Council, on investigating patient safety incidents involving people with communication disabilities.

⁎Corresponding author at: Level 2 McMullin Building, The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. Tel.: + 61 2 4921 7352.

E-mail address:[email protected](B. Hemsley).URL:

http://twitter.com/bronwynhemsley(B. Hemsley). http://dx.doi.org/10.1016/j.apnr.2015.11.012 0897-1897/© 2015 Elsevier Inc. All rights reserved. Contents lists available atScienceDirect Applied Nursing Research journal homepage:www.elsevier.com/locate/apnr patients with communication impairments and are widely recommend- ed (Costello et al., 2010; Hemsley & Balandin, 2014).

Despite the known beneﬁts of using AAC in hospital, the literature is replete with barriers to using communication aids in hospital. Patients rarely have access to their communication aids in hospital, due to this being discouraged and fears that systems will be lost, damaged, or stolen (Hemsley et al., 2008). Also, nurses report lacking time and access to professionals with appropriate expertise to support their use of complex speech generating devices (Balandin, Hemsley, Sigafoos, & Green, 2007; Finke, Light, & Kitko, 2008; Hemsley et al., 2008). Unfortu- nately, human factors also affect the implementation of AAC in hospital, with many reports of negative staff attitudes towards patients with communication disabilities (e.g. presuming patients who cannot talk have an intellectual disability) (Balandin et al., 2007; Hemsley et al., 2008; Hemsley et al., 2011), and patients' reduced physical and cognitive status while ill in hospital (Costello et al., 2010). These barriers empha- size the need for readily available, cost-effective communication solu- tions that can be easily used by nurses, and by patients who are unwell, to improve nurse–patient communication.

Mobile communication technologies, which include portable elec- tronic devices that have software installed for communication (e.g.

mobile phones, tablets, portable laptops, gaming consoles), are accessi- ble, engaging communication options for individuals with severe com- munication impairments (McNaughton & Light, 2013; Van der meer et al., 2011). Mobile communication AAC applications (‘apps’), such as ‘Proloquo2go’(Assistive Ware, 2013), and‘Predictable’(Therapy Box, 2013), provide text-to-speech and/or symbol or picture-to-speech options that can be personalized to suit the individual's communication needs. Such software is relatively easy to use, enabling words and pictures to be inserted into a‘grid’pattern for selection by pointing or scanning with a switch, or typing for speech output. Unlike traditional high technology AAC systems, mobile technologies are ubiquitous (Shane et al., 2011), and are therefore likely to be owned by both nurse and patient populations. Mobile technologies are also compact and relatively inexpensive, potentially increasing motivation for pa- tients to keep their devices with them by less costs being incurred if the device is lost, stolen, or damaged. In addition, mobile technologies have many universal features (e.g. camera, photo gallery, zoom func- tion, Internet access), which may facilitate multi-modal communication (Shane et al., 2011) and social networking.

It is not known whether the attitude and knowledge barriers outlined in previous research on using AAC systems in hospital also apply to the new generation of readily accessible mobile communica- tion technologies with AAC apps. Examining the feasibility of using mobile technologies for communication in hospital could inform both the design of ecologically appropriate hospital communication apps, and hospital policies and procedures regarding the use of mobile technologies for nurse–patient communication. Nurses, who are primary communication partners of all hospital patients, may provide unique insight into potential use of mobile communication technologies in hospitals, and any barriers to or facilitators for successful use to improve patient communication. The aim of this study was to deter- mine the feasibility of nurses using mobile communication technologies to support patients who have communication impairments in hospital, by investigating nurses' views and experiences on barriers and facilita- tors to using these technologies on the hospital ward to support patient communication in hospital.

2. Method This mixed method research involved two connected stages: an on- line survey and a focus group. The online survey was used initially to capture a broad range of views ( Leeuw, Hox, & Dillman, 2008), and the focus group expanded upon and clariﬁed theﬁndings of the survey (Krueger & Casey, 2003). This design was selected to strengthen the re- sults of each data source in line with the principles of triangulation,convergence and corroboration of results, complementarity, and the elaboration and expansion ofﬁndings across studies.

2.1. Participants From May to July, 2014, nurses who had worked in a hospital setting in the past 12 months were recruited through a global network of nurses in Twitter (e.g., @WeNurses, #WeNurses) to take part in an online survey. Online recruitment and data collection were used to obtain a large convenience sample of respondents (Leeuw et al., 2008). In total, 43 nurses attempted the survey. Of these, 31 responded to all survey questions, and 11 answered only some of the questions.

Two respondents were excluded from the survey: one accessed the survey, but did not answer any questions, and another respondent only provided responses that both authors deemed to be non-genuine ‘troll’or mischevious acts. Nurses were aged between 23 and 65 years (average 42 years), most were in Australia (n = 37) and had worked on children's and adults' wards (n= 29), and were female (n= 34).

Focus group participants were recruited purposively and through snowballing sampling technique through community advertising to locate nurses who had worked with patients with communication impairments. This method of recruitment yielded four nurses who had had broad experiences in a range of hospital settings, and who were therefore more likely to represent the range of viewpoints. Details on the survey and focus group participants are presented inTables 1 and 2.

2.2. Data collection 2.2.1. Survey An online survey, based on literature on the use of communication technologies in hospital, was developed by theﬁrst two authors to determine the barriers and facilitators to mobile technology use by nurses working with people with communication impairments. The survey was piloted with a colleague of the second author, and following feedback and subsequent revision, was published online in Survey Monkey™. Survey items included multiple choice, free-response ques- tions, and Likert rating scales (Leeuw et al., 2008). The survey questions Table 1 Demographic information of survey respondents.

Survey question Categories in responses Number of responses in that category Nursing role Registered nurses 24 Nursing administrators 5 Clinical nurse specialists 5 Enrolled nurses 4 Nurse educators 3 Hospital setting Metropolitan setting 30 Rural 10 Country of residence Australia 37 United States of America 2 United Kingdom 2 Frequency caring for patients with severe communication impairmentsDaily 10 Weekly 14 Monthly 13 Experience with types of health conditions in patients with communication impairmentsStroke 33 Anaesthesia 33 Cancer 30 Developmental disability 29 Lack of consciousness 25 Intellectual disability 24 Traumatic brain injury 23 Ventilation/intubation 20 Oral/laryngeal structures 17 Cerebral palsy 14 Motor neuron disease 14 Autism 12 Locked-in syndrome 7 Other 4229 B. Sharpe, B. Hemsley / Applied Nursing Research 30 (2016) 228–236 were divided into three sections, which sought information about respondents' views on their: (a) experiences and training related to communicating with patients who cannot speak, (b) access to commu- nication aids and support, and (c) experiences and perspectives regard- ing the use of mobile technology for patient communication, including conﬁdence. A copy of the survey is available from the second author.

2.2.2. Focus group The face-to-face focus group was moderated by theﬁrst author according to methodology described byKrueger and Casey (2009).Six key questions derived from themes identiﬁed in the survey responses, were used to allow for the generation of diverse perspectives.

(1)“What is your understanding of communication aids and mobile technologies that could be used to help with patient communication?” (2)“What experiences have you had communicating with patients who were unable to speak?”(3)“Is mobile communication technology something that you see often in your setting for any purpose?”(4)“The survey respondents raised a number of barriers to using mobile technol- ogy for patient communication (showﬁgures). Do you agree? Why do you think this might be the case? Are there any other barriers that you can think of?”(5)“The survey respondents also listed a number of features that could make it easier to use mobile technology for patient communication. (Showﬁgures). Do you agree? Are there any other facilitators that you can think of?”(6)“Would you be willing to use mobile technology as a tool for patient communication in your hospital setting? At the focus group, two printed communication boards were shown as examples of communication aids designed for use in hospital settings (Widgit Health Bedside Messages™,2010) to support common communication needs (Hemsley et al., 2011). The focus group was audio recorded and transcribed by theﬁrst author with all identifying information removed prior to analysis.

2.3. Ethical considerations The survey was anonymous and participants were not approached directly to take part in the study. Participation was voluntary and conﬁdential, and the study was ethically approved at the University of Newcastle, Australia. Focus group participants received a summary of the results of the study, and survey respondents were given access to a report on theﬁndings of the study on a public Website, and details of the Website were provided in the landing page of the survey at the point of data collection.

2.4. Data analysis Survey questions yielded both quantitative data for descriptive anal- ysis (e.g. frequencies, percentages) and qualitative results in written comments. Quantitative data were represented graphically and analyzed using descriptive, univariate statistics (e.g. frequency distribu- tion, median) (Berg & Lune, 2011). Qualitative data (i.e. respondents' comments) were analyzed for content themes. The focus group tran- script was read and re-read by both authors, who identiﬁed and discussed the content categories emerging from the discussion using the same steps as for the online survey. Key concepts were identiﬁedtoﬁ rst form categories of meaning, and then these were grouped to form the content themes.

2.5. Rigor Findings from theﬁrst stage of the research were discussed with focus group participants. Theﬁrst author's coding was reviewed and veriﬁed by the second author to ensure the trustworthiness, credibility and reliability ofﬁndings (Patton, 2002). After theﬁrst two authors an- alyzed the key focus group content themes, a written summary encap- sulating these themes was emailed to all focus group participants to check whether the researcher's interpretations of the data adequately reﬂected their views and the discussion. Two of the participants con- ﬁrmed by email that the summary of content themes represented the focus group discussion, and none of the participants requested any changes to the summary.

3. Findings Forty-one participants commenced the online survey. As all survey questions were optional, and not all survey respondents answered all questions, the number of responses for the questions are provided when reporting the results. Experiences and views on the feasibility of using mobile communication technologies are reportedﬁrst for the survey and then the focus group to provide contextual factors potential- ly affecting the use of mobile communication technologies in hospital.

To reduce repetition across the paper, and to reﬂect the analysis across studies, barriers and facilitators to the use of mobile communication technologies for communication in hospital across both studies are reported together (Patton, 2002). Participant comments are labelled to show study group as R1 (e.g., survey respondent 1) or as P1 (e.g., focus group participant 1).

3.1. Surveyﬁndings related to experiences and expectations 3.1.1. Use of communication aids with patients who have communication impairments Thirty-six survey respondents reported lacking access to communi- cation technologies of all types, including mobile devices. The frequen- cies for respondent reports of experience with different communication aid types in hospital are presented inFig. 1.

AsFig. 1shows, the most common communication aid accessed at all times by almost two thirds (n= 21) of the 36 survey respondents was the ubiquitous‘notepad and paper’. Most respondents indicated that they never had access to speech generating devices (n= 29). However, despite being ubiquitous in general society, few survey respondents always had access to laptops (n=3)ortablets,suchasiPads(n=2).

The most common use of mobile communication technologies by respondents was for Internet searches (n= 11). Nonetheless, a majority (two thirds) listed multiple potential uses for tablet or smart phone technologies at the bedside that they would be likely to access in the future, including use of nursing, health and education apps, as a music player, for communication, and for social media use. One third of survey respondents (n= 9) reported that they would not be likely to use Table 2 Demographic information on focus group participants.

Participant Number Age Qualiﬁcation Clinical responsibilities 1 58 Registered nurse Critical care, recovery 2 48 Registered nurse Medical, surgical, palliative care 3 51 Registered nurse General medical, surgical, palliative care, pre-admission clinic, management 4 34 Registered nurse General surgical, oncology, palliative care, orthopaedic 230B. Sharpe, B. Hemsley / Applied Nursing Research 30 (2016) 228–236 mobile technologies at all to aid patients' communication, now or in the future.

3.1.2. Support for using communication aids of any type Despite having had clinical experience caring for patients with communication impairments (n= 30, or 73%), and with communica- tion aids or technologies (n= 21, or 51%), few survey respondents had received any training related to caring for or communicating with patients with communication impairments (n=6,or15%)orusing communication technologies (n= 8, or 20%). Where nurses had received any training, it had been completed over 2 years ago, and for many, prior to the introduction of the iPad in 2010. A reported lack of support from speech language pathologists and occupational therapists for using aids for communicating with patients who have little or no speech was common. Just over half reported having access at least sometimes to a speech language pathologist (n= 23, or 56%) or an occupational therapist (n= 21, or 51%) for communication support, but a considerable number of nurses never or rarely had access to speech language pathologists (n= 13, or 32%) or occupational thera- pists (n= 15, or 37%) for communication support on the ward. Overall, survey respondents received little support in the use of mobile technol- ogies. The most frequent sources of support for nurses were speech language pathologists (n= 13, or 32%), other staff members who knew about the technology (n= 10, or 24%), and patients' family/ caregivers (n= 9, or 22%). Few nurses had completed relevant work- shops (n= 5, or 12%), in-services (n= 4, or 10%), or certiﬁcates/degrees (n= 4, or 10%), while two thirds of respondents (n= 22, or 54%) had received no support related to the use of mobile communication tech- nologies in hospital.

3.1.3. Conﬁdence in using communication aids Survey results reﬂected a lack of conﬁdence in using all types of com- munication aids and technologies. On average across the group, nurses ranked their conﬁdence on a Likert scale at 2.7, where a score of 1 rep- resented not conﬁdent at all, and a score of 5 represented extremely conﬁdent. Only 1 of 31 survey respondents rating their conﬁdence on the survey felt extremely conﬁdent in her ability to use communication technologies. In contrast, 5 of the 31 respondents did not feel conﬁdent at all in their ability to use communication aids with patients.3.2. Focus groupﬁndings related to experiences and expectations Like survey respondents, focus group participants had some famil- iarity with a small range of low technology communication aids (e.g.

pen and paper, alphabet boards), but limited experience with or access to any type of high technology communication aids in the hospital setting. When shown the AAC systems in the group, one nurse (P1) said that while such picture boards were a standard option in the ICU, there were not enough of these on the ward. Three nurses had previous- ly used a patient's own communication aid (P1-3) and one had cared for a patient who used a speech-generating device (P2). As with survey results, the focus group results reﬂ ected that‘pen and paper’was the most commonly used and preferred method for aided patient commu- nication. Even so, focus group participants acknowledged several barriers to using a pen and paper, including patient fatigue, poorﬁne motor skills, expressive language impairment, and poor literacy skills.

Focus group participants reported they did not have ready access to mobile communication technologies owned by the hospital. This suggests that, like speech generating devices, low cost and relatively common communication technologies might still be guarded—and secured—as highly valued items on a hospital ward. No focus group participants reported using technologies of any type for communicating with patients. Indeed, they agreed that they had learned how to“get by” using unaided communication strategies (e.g. lip-reading, facial expres- sion) and striving to understand the patient.

Focus group participants had little access to their own personal mobile communication technologies, due to hospital policies banning or limiting staff use of mobile phones, with only one participant having access to her personal phone at all times. Despite this, nurses described instances in which they felt obliged to work outside the policy and use their own mo- bile devices to aid patient care. P4 illustrated this in the following account:

If someone comes in and they're supposed to be photographed, I don't have access to the camera, doctors have asked me before to take a photo on my iPhone, with the patient's verbal permission.

They didn't say that, but obviously I had to gain it. So, I take a photo on my iPhone and then send it to them (the doctor) and then go back to the patient and say,“I'm deleting that photo from my phone.” In relation to access to the Internet on the ward, patients used their own mobile phones and wireless connection was not available for staff: 0 5 10 15 20 25 30 35 40 Numnber of nurses (N =36) Type of communication aid used (ascending in chart) Never Rarely Sometimes Most of the time Always Note: Tablets = mobile technology devices without phone capability Fig. 1.Frequency for types of communication aids used by the survey respondents. Note: 'Never' is at the bottom of each column, working upwards for other categories in increasing fre- quency of use.231 B. Sharpe, B. Hemsley / Applied Nursing Research 30 (2016) 228–236 “We don't have wireless at the bedside anyway. We do for our computer at the desk, and it's just so slow”(P2).

3.2.1. Perceived advantages of communication technologies As they had limited personal experiences using communication technologies, focus group participants hypothesized on potential ad- vantages of using traditional and mobile communication technologies in their settings. All considered that low-technology communication boards—particularly if laminated and kept at the patient's bedside—would be useful for communicating with patients about basic needs, increasing patients' independence, and decreasing patients' feelings of frustration. The group viewed that low technology communi- cation options may be useful for basic needs communication more than other communication purposes (e.g. social communication) and that in contrast mobile communication technology might facilitate more social communication with patients and enhance the provision of personal- ized care. Focus group participants suggested that the multi-functional nature of mobile technologies would be advantageous for improving communication, as the devices serve multiple purposes, including com- munication, leisure, distraction, education, and social participation (e.g.

via social media). Finally, participants viewed mobile communication technologies as having the potential to save time by enhancing the ‘ﬂow’of patient care. The focus group discussion reﬂected nurses' ex- pectations of a future where mobile communication technologies were both necessary and useful for communication in hospital. As stated by P1:

When you see how simple it is out there, and everybody's got some sort of device with apps and they use it every day, all day…you would have to think that it…shouldn't be that hard to, sort of, imple- ment. (P1) However, the group members agreed that using mobile technologies might be more difﬁcult with patients with severe behavioral, cognitive or physical impairments. The group considered that the need for com- munication support might be greater for patients with more severe dis- abilities, due to the long-term nature of their communication impairments, than for that patients with short-term communication impairments, who might need to“wing it”(P2) without access to com- munication aids in hospital.

3.2.2. Training and professional support for using communication technologies Aligning with the results of the survey, the focus group participants explained that nurses did not currently receive training in how to use communication aids with patients. P4 said she had been shown how to use a communication board 10 years previously at university and reﬂected that“since then I have never really had to use it, and I've never really thought about it until this study”. All but one of the focus group members were readily able to call upon a speech language pa- thologist during ofﬁce hours. However, the nurses rarely sought the speech language pathologist's support regarding communication for pa- tients with little or no speech. Rather, speech language pathologists were consulted primarily for dysphagia referrals:

On our ward, [communication's] not our, not a focus, is it?…It, it could be, it should be…probably more, more so…But we, we tend to use our speech pathologists to assess swallowing problems… rather than communication. (P3) 3.3. Both studies'ﬁndings related to barriers and facilitators to mobile tech- nologies for communication All 31 of the survey participants who responded on the questions re- lating to barriers and facilitators, and the focus group membersidentiﬁed barriers (seeFig. 2 ) and facilitators (seeFig. 3) to the use of mobile communication technologies in hospitals.

Content themes relating to barriers and facilitators for nurses' use of mobile technology were identiﬁed in the survey respondents' com- ments and focus group discussion. These are presented inTable 3, with example quotes for each theme.

3.3.1. Access to mobile technologies for communication Results across both the survey and the focus group reﬂected nurses being inhibited from accessing mobile devices for patient communica- tion at the bedside for a range of reasons which will be outlined in this section. The limited availability of mobile communication aids on hospital wards was considered a signiﬁcant barrier to their use, with 75% of 36 survey respondents never having access to hospital-owned mobile communication technologies.

3.3.2. Policies affecting access to mobile technologies Policies preventing nurses from using their own mobile technologies were noted as barriers to use for just under a third (n= 10) of survey respondents, and the focus group discussion reﬂected that personal use of mobile technologies could be considered a potential distraction from attention to patient care. However, one focus group member (P4) who did have personal access to mobile technologies on her ward disputed this, noting that use of her own mobile phone facilitated patient care by allowing her to conduct Internet searches more readily.

Almost three quarters of survey respondents (n= 23) considered that simply having more mobile technologies available on hospital wards might facilitate use for patient communication. The focus group further emphasized the need for more ward-owned devices to be made avail- able for the sole purpose of supporting communication.

While only one survey respondent cited patient conﬁdentiality is- sues as a potential barrier to the use of mobile communication technol- ogies in hospital, the focus group reﬂected that there might be potential threats posed to patient conﬁdentiality by patients or nurses using the multi-purpose devices to take or share photos inappropriately. Thus, while access to technologies might be helpful, participant's held some concerns about patient conﬁdentiality and privacy.

3.3.3. Security Concerns regarding the theft, damage, and loss of mobile communi- cation devices were expressed across both studies. The focus group nurses reported that concerns associated with the high personal value and subsequent scarcity of these devices in hospital led to restrictions on their use on the ward.

3.3.4. Time using mobile technology Almost half (n= 13) of the 31 survey respondents noted lack of time for using communication technologies as a barrier to their use in supporting patient communication. Focus group discussion veriﬁed thisﬁnding, with participants agreeing that they were“time poor” (P2) in completing basic care tasks on the ward. Participants agreed that the relative priority of basic care tasks over communication would further limit the use of mobile communication technologies at the bedside. However, more than a third (n=12)ofthesurveyrespon- dents, and all focus group members, considered that having more time to use mobile communication technologies would facilitate communi- cation at the bedside and improve workﬂow.

3.3.5. Attitudes towards communication technologies A small number of survey respondents considered that negative staff attitudes (n= 2) and reluctance to use the technologies (n= 3) were potential barriers to the future use of mobile technologies to support pa- tient communication. Focus group members concurred, and considered that mobile communication technologies may be perceived as unneces- sary, (e.g. “I don't have a need in my area of work”, R22), unwanted (e.g.

“People are resistive to change”, P3), or unrecognized (e.g.“It sort of 232B. Sharpe, B. Hemsley / Applied Nursing Research 30 (2016) 228–236 slips through the cracks”, P2). They agreed that a lack of conﬁdence might contribute to nurses' unwillingness to use mobile communication technologies with patients. Indeed, survey results revealed that positive staff attitudes (n= 15) and increased conﬁdence in nurses' ability to use the devices (n= 13) were seen as facilitators for using mobile com- munication technologies. Some survey respondents identiﬁed a need for attitudes towards technology to change, for example:“Their use (mobile devices) would require a cultural shift”(R39). Focus group par- ticipants agreed that a shift in culture to a positive attitude towards using communication technologies would enhance the feasibility of using these aids in hospital settings.

3.3.6. Training and support regarding use of mobile technology All focus group participants and almost half (n= 14) of the survey respondents viewed insufﬁcient training as forming a considerable bar- rier to the use of mobile technologies for communication. Focus group participants also suggested that a lack of training or experience wasassociated with decreased conﬁdence and therefore reduced willing- ness to use the technologies among nurses. However, results also sug- gested a link between‘training’and the potential for this to inﬂuence nurse attitudes towards the use of mobile technologies. Approximately two thirds of the survey respondents reported that an increase in pro- fessional support (n=18),staffknowledge(n= 18), and staff compe- tence (n= 17) would be necessary for successful implementation of mobile devices in their settings.

The focus group participants agreed that nurses having training in the use of mobile communication technologies might facilitate their use in hospitals, but only if certain conditions were met in the training.

They suggested that relevant training must incorporate not only educa- tion (i.e. information provision, including a written information pack for the ward), but also hands-on demonstration (i.e. showing nurses how to use the technology), and repeated practice or coaching (i.e. nurses being supported to gain increased experience with implementing the technology in real-life situations). The focus group members viewed 0 5 10 15 20 25 30 35 Number of nurses who identified barrier (N =31) Barrier Fig. 2.Barriers to the use of mobile communication technologies (survey respondents).

0 5 10 15 20 25 Number of nurses who identified facilitator (N = 31) Facilitator Fig. 3.Facilitators to the use of mobile communication technologies (survey respondents).233 B. Sharpe, B. Hemsley / Applied Nursing Research 30 (2016) 228–236 that the ideal mode of training would be hands-on and‘workshop’in style, however, they also agreed that online learning modules may be useful, particularly for the education component, and for demonstration videos.

3.3.7. Logistical or technical issues While 10 out of 31 survey respondents noted that a lack of storage space would reduce the feasibility of mobile technologies in hospitals, the focus group did not share this concern. Other logistical and technical barriers to the use of mobile communication technologies, identiﬁed byless than a third of survey respondents, included threats to hygiene (n= 7) or occupational health and safety (n=7),insufﬁcient wireless Internet connection for online functions (n= 1), and any known or po- tential interference with medical equipment (n= 1). Conversely, tech- nical issues identiﬁed as facilitators by many survey respondents included: the messages or images on the devices being helpful (n= 10), social marketing for promotion and increased popularity of the technologies (n= 3), relative affordability of personal mobile commu- nication technologies (n= 2), and having adequate wireless Internet connection for full use of all functions (n= 2). Focus group members agreed that the items identiﬁed as facilitators in the survey would be important for enhancing the feasibility of mobile communication tech- nologies in hospital. They also noted that (a) additional technological features, such as larger screens and secure mounting systems, might further enhance ease of use of mobile communication technologies in hospital; and (b) consistent introduction of mobile technologies across hospital wards might facilitate their use for supporting nurse–patient communication.

3.3.8. Patient factors affecting use of communication technologies Although patient-related factors were not identiﬁed in the survey as being barriers to the use of mobile communication technologies, the focus group perceived that the skills or capacity of the patient (e.g. de- gree of illness, cognitive ability, behaviors of aggression) would affect implementation on some hospital wards.

4. Discussion and recommendations The present research identiﬁed a number of barriers and facilitators to nurses' use of mobile communication technologies for communicat- ing with patients with communication impairments in hospital. Even though some nurses might optimistically view the use of mobile com- munication technologies as being feasible, nurses' perception of the barriers listed above could considerably reduce feasibility of the devices for supporting patient communication. These barriers are also similar to those noted in the use of speech generating devices in hospital (e.g.

Balandin et al., 2007; Finke et al., 2008; Hemsley et al., 2008).

Nurses in this study viewed that the most common barriers to the implementation of mobile communication technologies in hospital were the limited availability of devices on the ward, security concerns (of theft, damage, or loss), a lack of staff training/support, and a lack of time to use the devices. The results suggest that—like speech generating devices—low cost and relatively common communication technologies might still be‘locked away’as highly valued items on a hospital ward (Hemsley & Balandin, 2004). The results of this study support theﬁnd- ings of previous research that nurses are not well supported and are insufﬁciently trained in communicating with patients who have com- munication impairments (Balandin et al., 2007; Hemsley & Balandin, 2014; Radtke, Tate, & Happ, 2012). Therefore, speech language patholo- gists may need to play a more active role in advocating for communica- tion support in the hospital setting and providing education and coaching in hospital if mobile technologies are to be used at the bedside to improve nurse–patient communication. The increased availability of devices, role clariﬁcation, and increased staff knowledge were most fre- quently perceived by nurses as facilitators to the use of mobile commu- nication technologies. Therefore, increasing nursing staff access to mobile technologies needs to be matched by providing safe storage for these devices and education to staff on ways to use the equipment.

Theﬁnding that nurses might be concerned about conﬁdentiality and privacy issues with patients with communication impairments using mobile technologies to communicate has not been reported previ- ously. The concerns raised in this study related to the mobile technology camera and Internet functions. Nurses having access to patients' own mobile devices, or using the nurse's own personal mobile device to cap- ture patient health data to send by email or short message to medical staff, also reﬂects some‘looseness’in implementation of hospital Table 3 Content themes with quotes illustrating barriers and/or facilitators in the content theme.

Content theme Example quote illustrating the barrierExample quote illustrating the facilitator Access There are no devices available in my workplace. (R39) The lack of these…and you know, nurses having to be that empathetic and just spend their time trying to do things like drawing pictures to communicate better with the patient. (P4)Just to have one available for assistance would be beneﬁcial to any ward.

(R35) If you had the availability of iPads and that speciﬁc for your working area and not your own personal ones that would be a better idea.

(P1) Policies affecting access to mobile technologiesNo carrying mobile phones.

(R9) Restrictive and ill-informed smart phone use policies in NSW health. (R23) Infection control may be an issue if the ward had some available as it’s harder to clean an electronic device. (R17)Policy/guideline encouraging use would be useful. (R30) I believe keeping them clean would be relatively easy. (R22) Security Management would be concerned regarding theft of such devices.(R37) If they go missing, who is responsible? (R22) It's (the ward iPad) under lock and key so you can’t get access to it. (P2)(Not raised as a facilitator) Time We are so time poor to get through the basic stuff. (P2)If…they'veﬁnally explained what they were trying to tell us…it'd deﬁnitely save time. (P4) Attitudes towards communication technologiesPeople are resistive to change.

(P3) I don't have a need in my area of work. (R22) On our ward, it's not our, not a focus, is it? (P3) It might be out of fear of not being able to do it. (P4)Their use would require a cultural shift.(R39) Those that are willing and can do it willﬁnd it really, really helpful. (P1) Training More training, more awareness throughout staff.(R6) General information pack on objectives of using the device with patients. (R38) If people are shown how easy it is to use, people are happy to try it. (P3) The more you use it, the more used to it you will get.

(P2) Technical issues We don't have wireless at the bedside. (P2) The thing with the laptop is that you…don't have to hang onto it.

(P1) Patient factors Degree of illness has got a lot to do with it too. (P1) Sometimes people can't even, you know, open their eyes to read. (P4) 234B. Sharpe, B. Hemsley / Applied Nursing Research 30 (2016) 228–236 policies on the use of mobile phone technologies on hospital wards.

However, the camera, Internet, and social media functions of mobile technologies may be used to enhance communication, by visually supporting written or spoken information and facilitating the mainte- nance of social relationships (McNaughton & Light, 2013). Furthermore, such devices can also be used without the Internet function, as commu- nication aids. Theseﬁndings highlight the need for further research into the protocols associated with the use of mobile technologies on hospital wards, and development of policies and guidelines for both patients and hospital staff on the risks and beneﬁts, along with rights and responsi- bilities associated with the use of mobile communication technologies in hospital.

The results of this study further support the notion that time can be both a facilitator and a barrier to the use of communication technologies in hospital (seeHemsley et al., 2012). Therefore, the speed and ease of use of mobile communication technologies may be critical in determin- ing whether nurses will use these technologies to communicate with patients with communication impairments in hospital. As with using other technologies, nurses may need to invest time—putting efforts to- wards the use of unfamiliar mobile communication technologies for which they receive little training or support—inordertocreatetimeef- ﬁciencies through improved communication with patients who struggle to communicate their care needs.

4.1. Limitations This study was an initial investigation of the views of nurses on use of mobile communication technologies in hospital. It involved a small, convenience sample of nurses recruited through Twitter to an online survey, where it was not possible to verify identities of respondents, and only one face-to-face focus group of four participants. The research was time limited by the student's research training enrolment and it is possible that further data could have been captured through a longer re- cruitment period. Therefore, theﬁndings of this research may not reﬂect the views of other nurses and caution is needed in interpreting its re- sults. However, there was a close alignment of results across the data sources, increasing conﬁdence in the results. An additional limitation of this study was the participants' limited experience with traditional and mobile communication technologies in hospital settings. As such, their suggestions of barriers and facilitators to the use of these devices were largely hypothetical. Nonetheless, their views closely align with previous research relating to barriers to the use of more complex speech generating devices in hospital.

Theﬁnding in this study that nurses perceived mobile communica- tion technologies to be feasible for supporting nurse–patient communi- cation in hospital is important given the gap between the substantial evidence highlighting the need for AAC strategies to support communi- cation in hospital (e.g.Balandin et al., 2001; Happ et al., 2004; Hemsley & Balandin, 2004; Hemsley et al., 2008), and the growing body of evi- dence that nurses lack access to communication technologies of any type on hospital wards (Hemsley & Balandin, 2014). Implementation research is needed to determine the outcomes of using a range of com- munication aids, including mobile communication technologies, on hospital care and safety for patients with communication impairments (Hemsley & Balandin, 2014; Hemsley et al., 2015). Future research could include observational studies to inform the development of a valid and reliable tool to measure the communication-related self- efﬁcacy and mastery of hospital staff in using these technologies. In ad- dition, the ethical concerns raised by nurses in this study regarding pri- vacy and patient conﬁdentiality using mobile communication technologies in hospital warrants further attention in the literature. Fur- ther research is needed to fully understand the nature and extent of these concerns of nurses, and to identify not only potential beneﬁts, but also any potential harms associated with enabling use of mobile communication technologies in hospital.5. Conclusions Nurses in this study, from a wide range of different hospital wards, identiﬁed many potential bene ﬁts to the use of mobile communication technologies to communicate with patients who have communication impairments, including that such use might (a) enhance a patient's sense of independence, while being used for a range of purposes (e.g.

leisure, distraction, education, social participation), and (b) create efﬁ- ciencies in communication that improve workﬂow and save time in care. However, these expected beneﬁts were largely hypothetical and based on very limited experiences of using communication technologies on the ward. Nurses identiﬁed several barriers and facilitators to the use of mobile communication technologies on hospital wards, and these are similar to reported barriers and facilitators encountered in the use of speech generating devices in hospital settings. This suggests that envi- ronmental barriers will have to be addressed in order to enable use of any communication technology at the bedside. As nurses expressed positive attitudes towards mobile communication technologies, in- creased access to these—accompanied by training, demonstration, and policies guiding use—might increase the feasibility of adopting mobile communication technologies in the care of patients with communica- tion impairments. Implementation research is now needed to deter- mine the impact of providing access to and training for nurses to use mobile communication technologies on hospital wards and optimal and safe use of the multiple functions of mobile technologies including the use of multimedia and social media functions.

Acknowledgment This research was undertaken as part of the Honours Research of the ﬁrst author under the supervision of the second author. The authors would like to thank and acknowledge Mr John Costello of Boston Children's Hospital, Boston USA for his advice to theﬁrst author on the survey design and comments on the results of the study. The authors would also like to acknowledge the generous contributions of Paul Mc- Namara (@Meta4RN) in assisting to disseminating information about the study, and all of the nurses who took part and gave generously of their views and experiences in this research. Also, thank you to Dr Joanne Steel of The University of Newcastle for her assistance inﬁnal production edits on this manuscript.

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