The influence of technology use on patient care has been a focus of the health care industry in the United States for more than a decade. Millions of dollars have been disbursed to the health care community to increase the use of technology with the hope of building a more efficient infrastructure for care delivery models. Within this frenzy of activity, health professionals often forget to check in with the very core of clinical practice—the patient.
In addition to these changes occurring in the health care system, there is a heightened concern in the nursing profession about maintaining a balance between high-touch care and high-technology (high-touch versus “high-tech”) in the delivery of patient care. Since the early 1960s, the advent of “machine technology” created a perceived “departure from the largely craft technology” (Sandelowski, 1997a, p. 169) that described American nursing practice. In the Middle Ages, a craft or trade was a pastime or a profession that required skills and knowledge to do a specific job. The use of machines and equipment may be perceived as detractions from the human skills of a caring profession.
Almost all the information discovered to date concerns the role of the nurse and the effects of technology on nursing practice. However, the importance of caring in nursing practice is at the foundation of patient care that extends back to Florence Nightingale. This foundation cannot be cracked by the impact of technology but must be strengthened by nurses' ability to blend technology into the core of a caring practice.
An understanding of the evolution of technology in health care delivery systems, specifically its influence on patient care delivery, and the patient's perspective of this evolution is of paramount importance in determining the fine line between high-touch versus high-tech nursing care in a patient-centered environment. This study investigates the hospitalized patient's perspective of the nurse's use of technology (defined as equipment and electronic devices) in care delivery.
The debate of high-touch versus high-tech care has continued throughout the evolution of the nurse's role with patients. The recognized founder of nursing practice, Florence Nightingale, alluded to caring and touch in her many writings about nursing practice in the 1800s and 1900s. Nightingale (1914) made the following observation, “Nurses' work means downright work, in a cheery, happy, hopeful, friendly spirit” (p. 108). Although many of her writings focused on the environmental needs of the patients, she clearly embraced the concept of caring as part of the nurse's role.
The concept of human caring is also the foundation of a more contemporary theory that has evolved from Nightingale's work and writings and is appropriate to mention when looking at the impact of technology and patient care. Jean Watson's theory of human caring provides a tenet of professional practice that examines the act of caring in nursing (Sitzman & Watson, 2013). Watson's theory for nursing practice is based on a foundation of transpersonal caring relationships. According to Watson, there are competencies that nurses need to develop in order to be in the “here and now” with their patients when delivering care.
In addition, there is significant research that supports the improving attitude of nurses and their use of technology in patient care (Barnard, 2002; Huryk, 2010; Sandelowski, 1997a, 1997b). Each of these authors suggest that nurses are becoming more comfortable in their use of technology and that there has been a positive impact on evidence-based practice for the nursing profession. However, an equal number of researchers and authors have suggested, within the past 10 years, there is an emerging concern about whether there is actual caring in the delivery of patient care (Buckner & Gregory, 2011; Johnson, 2015; Locsin, 2001; Nash, 2014). One question that should be asked is whether the nurse is now caring for machines instead of caring for the patient.
Recognizing the impact of technology on nursing practice and how this affects the nurse's engagement with patients is a significant challenge for the future of nursing education and professional development. This study looks at the patient's perspective of the nurse's use of technology and provides data that can be used to improve nursing continuing education, professional development, and, it is hoped, patient outcomes.
The methodology used in this qualitative study is a combination of phenomenology and narrative analysis. This approach acknowledges the researcher's role as a nurse, which cannot be fully eliminated from the patient stories and analysis of their experiences. The combined methodology also focuses on a phenomenological approach that uses a semistructured interview (Table 1) as a mechanism to gather data specific to questions about the patients' perspective of the impact of technology on patient care.
Semistructured Interview Script and Questions
It is important to note that the design of this study focuses on interviewing patients while hospitalized, in an environment surrounded by the high use of technology in care delivery. Although postdischarge patient interviews have been proven to be effective (Richards, Agger-Gupta, & Agger-Gupta, 2012), it was preferable to design a study that engaged the patient while surrounded by the high-tech environment and aware of the possible implications to the patient's nursing care. The study was approved by three institutional review boards: the author's academic place of employment, the doctoral program school, and the hospital where the study was implemented. With stringent eligibility requirements in place, the institutional review boards recognized that the potential patient concerns related to retribution or discrimination in nursing care was minimalized or eliminated.
A semistructured interview format was used to interview eight hospitalized patients (ages 60 to 80 years) in a high-tech environment. Although the limited age range may be seen as a limitation of this study, the sample was selected based on data that indicate that by 2029, more than 71 million older adults will be accessing health care and these adults will have an increase in chronic conditions (Barr, 2014). This suggests that these older adults will be affected most by the rapid evolution of technology and its use in care delivery and will be the patients for whom nurses will be caring in the next 2 decades.
All the participants were inpatients on one of three medical–surgical units of the hospital. Other than age, eligibility for participation in the study included that they be within 24 to 48 hours of discharge; not experiencing pain >5 on a 10-point pain scale; English-speaking; oriented to name, place, and time; and had been admitted with a medical diagnosis. The researcher checked in with the unit charge nurse(s) to determine those patients who were eligible to participate. From that list, the researcher checked in with the primary nurse to consider the care delivery plan and current condition of the patient. If the primary nurse agreed to the potential interruption, the researcher approached the patient, explained the study, and asked for verbal consent to conduct the interview.
The setting for this study was a 126-bed hospital located in the Pacific Northwest region of the United States. The hospital was specifically chosen because it is one of the newest hospitals built in this area (opened in 2013) and is considered to be a modern design with a high-tech patient care environment. This environment includes an innovative eCareBoard® ( http://www.aceso.com) on the wall at the foot of the patient's bed that provides information for the patient, family, and providers about the individualized needs of the patient (i.e., diet, allergies, activity, daily goals, fall prevention). It also has an area similar to a white board where the physician and others can draw pictures to highlight patient education and understanding. Most of the study participants had not seen this level of high-tech design in previous hospitals and had many comments about its use, including:
- Well it helps, because I wouldn't have known the estimated discharge date.… I'm a terrible reader and I don't read everything.
- I love that [pointing to the eCareBoard], because you know when somebody comes in you can relate to a name and then you look at a tag and you can relate to who's who…. And then my goals, they put up there, I had a bad night last night so they put up there for today, “Sleep better.”
However, two of the patients' comments give cause to the continuation of the high-touch versus high-tech debate and the importance of individualized patient assessment:
- I was reading the board and I realized a name comes up and a name drops off. I really would have liked to get a name imprinted in my mind [before it changes].
- There's nothing up there—the doctor's names and nurse's names—other than that there really isn't much up there.
Other aspects of technology in the study hospital are the use of Voceras™ (also called hands-free communication devices). A Vocera is a cross between a cell phone and a walkie-talkie and is often clipped to the nurse's uniform collar or hung around the neck to increase clarity of verbal communication between providers. As with most new technology, patients and their families recognize both the pros and cons:
- I'm sitting here as they're examining me and that thing goes off, and I kind of like it. It's good for them, but I think for the patient it could get annoying.
- I don't like that. Because they are definitely switching over to that phone call, that response, etc…. They interrupted your patient care.
The high-tech environment of this hospital also includes a concierge meal distribution system, bed alarms for fall prevention, and bedside electronic health record-charting nooks, in addition to the now common use of intravenous alarms, bedside monitoring equipment, and call lights.
All the participants were interviewed while they were in bed or sitting at the bedside. They were all in private rooms and the noise levels and interruptions were not controlled. Due to time limitations, there was very little opportunity for follow-up questions or clarification. The interviews were audiorecorded, and the recordings were electronically sent to the transcriptionist as secured files. The typed transcripts were returned electronically to the researcher as secured files.
Semistructured interviewing provides a guided, focused, and open-ended communication between the researcher and study participant. This allows for flexibility and unanticipated prompts for gathering data specific to the context of the topic.
An editing strategy described from Marshall and Rossman (2016) was used to provide increased subjectivity and interpretation of the data. They identify seven stages of an analytic process: (a) organizing the data, (b) immersion in the data, (c) generating categories and themes, (d) coding the data, (e) offering interpretations, (f) searching for alternative understanding, and (g) writing the report. The researcher used these steps in the analysis phases of this study.
In addition to the editing strategy, the transcribed text was analyzed in two phases using a technique described by Koskenniemi, Leino-Kilpi, and Suhonen (2015). The first phase was an inductive content analysis. The researcher used the highlighting function in Microsoft® Word® software to identify key comments from the transcripts. These comments were color coded and then electronically cut and pasted following the steps of editing analysis. These steps made it more feasible to begin the grouping process based on common themes and concepts.
The second phase of the process consisted of the construction of a typology to determine common and recurring themes of the patients' responses related to their perceptions of the effect of technology on the care they receive by the nurses.
Results and Discussion
The study participants (n = 9, one woman dropped out due to fatigue) were diverse: five women, with a self-reported age range of 64 to 73 years, and four men, with a self-reported age range of 61 to 75 years. All the study participants had acute or chronic medical diagnoses and had been hospitalized several times in the past 5 to 10 years. The medical diagnoses for the final eight participants included pneumonia, diabetes, bacteremia, chronic obstructive lung disease, stroke, and a combination of several other chronic diseases common in an aging patient population.
Five themes evolved related to the patient's perspectives of the nurses' use of technology in care delivery: Noise/Lack of Sleep, Emotional/Patient Engagement, Individualized Care, Patient and Nurse Knowledge Levels (related to technology), and the Benefits/Challenges of Care (related to technology). These five themes reflect the common themes found in nursing literature related to this topic (Buckner & Gregory, 2011; Sandolwski, 2000).
The research findings from this study validate the importance of several concepts that are considered foundations of nursing practice. First, treating the patient and family with integrity and maintaining their dignity is a key component of patient care and integrates concepts from a social justice perspective into nursing practice. Second, patient engagement embodies nursing behaviors such as communication, patient education and involvement in decision making, and assessment of potential fears and concerns related to care delivery. Third, a caring environment, as perceived by the patient, is a significant factor in achieving high patient satisfaction, positive health outcomes, and individualized health status sustainability postdischarge. All these concepts have been affected by the impact of technology on nursing practice in the hospital environment.
Based on these findings, which were validated by the study participants' comments, several areas of nursing education and professional development can be improved. Although nurses must learn pathophysiology, anatomy and physiology, pharmacology, and other knowledge related to human science, it is interesting to note that a basic skill, such as listening, is the thread that weaves throughout all aspects of patient care and nursing practice. It is a skill that cannot be lost as technology and machines replace the tasks previously done by human caregivers. According to one patient:
One day they sent me down for a heart MRI [magnetic resonance imaging] I think it was called. And I was asking the [medical] technician about [it] because I didn't know what was going on. And I didn't get many answers I was hoping for….
In fact, this patient was sent for an echocardiogram and it was obvious that none of the nurses or the technician were listening to her questions and providing the patient education that she desired and needed to better understand her medical condition.
Two other skills that are basic to nursing practice are human touch and eye contact. These two behaviors help the nurse quickly establish a trusting relationship with the patient and family so information can be shared and treatment plans can be developed. Comments from study participants reinforced the need for human interaction and engagement:
- They offer earplugs at night. These guys are [a] perfect example of teamwork and knowing what you need, and they're just very kind and patient-oriented.
- They go out of their way to make sure you're comfortable, if you need anything…. I never had a bad experience.
- I feel like when I ask a question I get a correct answer, I get a thoughtful answer.
This is an admittedly small study with a narrow, but significant, focus. The limitations include potential bias of the nurse researcher, concern that the patients may fear retaliation, and awareness that the patient may want to say what the nurse researcher wants to hear. Although these are recognized limitations, the unique role of a nurse researcher is beneficial to developing a quick and open relationship with the study participants. In addition, the patients welcomed the opportunity to tell their stories to someone who understood the hospital environment and, because participation was voluntary, there was no apparent fear of retaliation.
Other limitations are the narrow focus on the Baby Boomer population (ages 60 to 80 years) and the unusual environment of a new hospital with unique design features. In addition, there was a lack of ability to control the hospital environment. It was important to interview the patients while they were surrounded by technology and equipment so that they were present in the environment being addressed in the study. However, it is difficult to have access to patients during what has become a very short hospital stay. There is little or no opportunity to conduct follow-up visits to confirm the interview content or clarify aspects of the stories that were told. Although it has its challenges, more research is needed while patients are in the hospital in order to facilitate a more factual and realistic “meaning of experience” (Rejnö, Berg, & Danielson, 2014, p. 618) and to better understand the patients' true perspective of care delivery.
Every nurse is responsible for ensuring that patients get adequate sleep, have emotional support and a voice in the plan of care, and are well-informed about their condition and interventions that improve and/or maintain health outcomes. These are the tenets of patient-centered care and quality nursing practice.
The data from this study suggest that nurses are missing opportunities to improve their practice and the quality of patient care when using technology as an adjunct to care delivery. The analysis of the data shows a lack of nursing competency in some areas of practice that include active listening, interactive communication and sharing of information, assessing possible fears the patient and family might have of equipment failure, preventing assumptions about patient awareness of technology and its use in care delivery, improving patient engagement through eye contact and touch, and encouraging patient involvement and decision making in the plan of care. This gap between nurses' behavior and patient perceptions substantiates the need for change in nursing education and professional development and suggests there is an opportunity for the advancement of new competencies related to nurses' use of technology in care delivery.
- Barnard, A. (2002). Philosophy of technology and nursing. Nursing Philosophy, 3, 15–26. doi:10.1046/j.1466-769X.2002.00078.x [CrossRef]
- Barr, P. (2014, January). Baby boomers will transform health care as they age. Hospitals & Health Networks. Retrieved from https://www.hhnmag.com/articles/5298-Boomers-Will-Transform-Health-Care-as-They-Age
- Buckner, M. & Gregory, D.D. (2011). Point-of-care-technology: Preserving the caring environment. Critical Care Nursing Quarterly, 34, 297–305. doi:10.1097/CNQ.0b013e31822bac0e [CrossRef]
- Huryk, L.A. (2010). Factors influencing nurses' attitudes towards health-care information technology. Journal of Nursing Management, 18, 606–612. doi:10.1111/j.1365-2834.2010.01084.x [CrossRef]
- Johnson, J.A. (2015). Tasks and technology versus compassion and caring in nursing: Are they mutually exclusive?Journal for Nurses in Professional Development, 31, 338–340. doi:10.1097/NND.0000000000000210 [CrossRef]
- Koskenniemi, J., Leino-Kilpi, H. & Suhonen, R. (2015). Manifestation of respect in the care of older patients in long-term care settings. Scandinavian Journal of Caring Sciences, 29, 288–296. doi:10.1111/scs.12162 [CrossRef]
- Locsin, R.C. (2001). The culture of technology: Defining transformation in nursing, from the “lady with a lamp” to “robonurse”?Holistic Nursing Practice, 16, 1–4. doi:10.1097/00004650-200110000-00004 [CrossRef]
- Marshall, C. & Rossman, G.B. (2016). Designing qualitative research (6th ed.). Los Angeles, CA: Sage.
- Nash, B.A. (2014). Maintaining the art of nursing in an age of technology. Ohio Nurses Review, 86(6), 12–13.
- Nightingale, F. (1914). Florence Nightingale to her nurses: A selection from Miss Nightingale's addresses to probationers and nurses of the Nightingale school at St. Thomas's Hospital. London, United Kingdom: Macmillan.
- Rejnö, Å., Berg, L. & Danielson, E. (2014). The narrative structure as a way to gain insight into peoples' experiences: One methodological approach. Scandinavian Journal of Caring Sciences, 28, 618–626. doi:10.1111/scs.12080 [CrossRef]
- Richards, J., Agger-Gupta, D. & Agger-Gupta, N. (2012). [Partnering with patients to understand and improve their healthcare experiences.] Unpublished raw data.
- Sandelowski, M. (1997a). (Ir)reconcilable differences? The debate concerning nursing and technology. Image: Journal of Nursing Scholarship, 29, 169–174.
- Sandelowski, M. (1997b). “Making the best of things”: Technology in American nursing, 1870–1940. Nursing History Review, 5, 3–22. doi:10.1891/1062-8061.5.1.3 [CrossRef]
- Sandelowski, M. (2000). Devices and desires: Gender, technology, and American nursing. Chapel Hill: University of North Carolina Press.
- Sitzman, K. & Watson, J. (2013). Caring science, mindful practice: Implementing Watson's human caring theory. New York, NY: Springer. doi:10.1891/9780826171542 [CrossRef]
Semistructured Interview Script and Questions
|Introduction and explanation of purpose of study
Let's start with some questions about your health history and hospitalizations:
1. Tell me how many times you have been in the hospital in the past 10 years.
2. On a scale of 1 to 10, can you rate the best hospital experience?
3. Tell me what made that experience better than others.
Now that I have an idea of your history with hospitals in general, I would like to talk about your impressions of being in a modern, high-tech hospital:
4. Tell me about the differences you see and/or feel about being a patient in such a modern (high-tech) hospital and your experiences in the past.
Now let's talk about your nursing care and your thoughts about the high technology being used to provide your care:
5. Tell me about the differences you see and/or feel about the way that nurses provide your care now and in the past.
6. Do you have any suggestions of how your nurse could improve his/her care while still using the new technology?
7. Are there any final thoughts that you would like to share about your feelings of technology and your nursing care?
Now that we have completed the interview, is there anything from our conversation that you would like me to delete or not include in the final transcripts?