The American Nurses Association (2015) asserted that nursing has the responsibility to protect, promote, and optimize the health of the general public. Nurses need up-to-date knowledge and skills to meet this obligation. Regrettably, the knowledge and skills vital to provide optimal patient care can quickly become obsolete with the release of new research findings or improved technological developments. Johnson (2016) estimated that medical knowledge doubles every 5 to 8 years. The flood of new information and the ensuing perpetual changes present a challenge for nurses to keep up.
Maintaining current knowledge and skills is critically important for nurses. The failure to keep up with new developments in health care may result in the use of old information to provide patient care. However, using outdated information can be detrimental to the patient and may even jeopardize the patient's safety (Orr & Davenport, 2015), emphasizing the need for bedside nurses to keep up with the many changes within the field. One possible alternative is the use of up-to-date technology, such as text messaging, to help nurses retain and apply new information. This research study explored the use of technology, specifically text messaging, to examine whether repeated text messages could influence the retention of information.
How nurses learn and retain information combines several disciplines, including nursing, education, psychology, and neuroscience. Several theories and methods of teaching have been developed over the years, such as adult learning theories (Knowles, 1970), forgetting theory (Ricker, Vergauwe, & Cowan, 2016), and problem-based learning (Walker, Leary, Hmelo-Silver, & Ertmer, 2015). In his classic work, Kolb (1984) developed the experiential learning model (ELM) to understand how adults learn and this model served as the theoretical framework for the study. Learning is a complex process. Information is received through various media (e.g., reading, hearing, or feeling) but also must be retained. Educators have explored how to improve retention for many years. Repetition has been used to enhance retention of information. Repetition has also been used to teach children and adults a new language, as well as gymnastics, baseball, and other activities (Settles & Meeder, 2016). Actors and actresses use repetition to memorize passages of dialogue (Zucker, 2016). Mnemonics (Jangid, Swadia, & Sharma, 2016) and jingles (Putnam, 2015) offer additional alternatives.
The literature review led to consideration of how repetition might be used in the clinical setting to help staff members retain information. The use of e-mail to send reminders was considered at the beginning of this study but was discarded due to e-mail overload that some staff experience. Observations of staff performing work duties led to the idea of using mobile phones to text message as a delivery method for information. Text messaging is a common activity for the staff nurses and clinical partners. In searching the literature for precedence in using text messages, articles were available describing higher education instructors' use of text messaging in the classroom setting but primarily as a communication tool between teacher and student. One study examined the relationship between cell phone use and grade point average (Lepp, Barkley, & Karpinski, 2015), whereas Stephens, Yager, and Allen (2017) used text messaging to reinforce compliance with a weight loss program. Health care organizations have used text messaging to remind patients of medical appointments and even to remind patients to take medication (Nhavoto, Grönlund, & Klein, 2017). However, studies using text messages to improve retention of information were not found in the literature search, thus identifying a gap in the literature.
Method and Design
The purpose of this study was to explore the effect of repetitive text messages on the retention of information. A quantitative, experimental methodology was chosen as the best approach to answer the research questions. The pretest–posttest format provided information before and after the intervention (text messaging) to determine the influence exerted by the intervention (text messages). The study included three research questions:
- What is the effect of repetitive text messaging on the retention of knowledge among clinical staff?
- What is the effect of a staff member's level of education?
- What is the effect of a staff member's years of experience?
Population and Sample
This study took place in a not-for-profit hospital system located in southeast Florida with 10 acute care facilities and more than 50 outpatient and urgent care centers. Recruitment of participants comprised of announcements at staff meetings, council meetings, flyers posted on bulletin boards, group e-mails, and communication with educators and managers. The requirements to participate included employment with the organization as an RN or certified nursing assistant, working in the acute care setting, attendance at a training class, and the ability and means to receive and read text messages in English at work and at home. A total of 142 participants enrolled in the study, attended the class, and completed examination #1. Seventy-two participants completed examination #2 approximately 1 week later via online survey program.
An extensive literature search was performed to seek an instrument for the study. An appropriate instrument would be an examination about preventing patient falls in the acute care setting, based on current standards. An existing instrument could not be procured; therefore, an instrument was created, adhering to the rigorous process described by Nieswiadomy (2012).
The first step in developing an instrument specific to this study was to conduct an extensive literature search on preventing patient falls. The search included Cumulative Index to Nursing and Allied Health Literature (CINAHL®), Education Resources Information Center (ERIC™), EBSCOhost, Nursing@Ovid, The Joint Commission (2019), and the Agency for Healthcare Research and Quality (AHRQ, 2018). The search terms included patient falls, inpatient falls, prevention of patient falls, and polypharmacy in the elderly. Only articles focused on falls within acute care hospitals written within the past 5 years were used.
The process for establishing the validity and reliability of the instrument was followed meticulously (Nieswiadomy, 2012). A class outline and lesson plan were developed. The lesson plan was reviewed by the chair of the hospital falls prevention committee and four subject matter experts for accuracy and appropriateness. Then, an expert panel of four PhD-prepared nurses reviewed the contents and the examination. Revisions were made based on recommendations from each group. The final examination consisted of six multiple choice questions. The final step of development was a pilot test conducted with 10 volunteers (eight nurses and two clinical partners). The participants completed the examination with an average score of 96.8.
The intervention in this study was sending repeated text messages to half the study participants. Text messages, also known as Short Message Service (SMS), have a maximum allowed length of 160 characters, including spaces, letters, numbers, and punctuation. SMS did not perform well during the testing phase of the study; therefore, Multimedia Messaging Service (MMS) was used. MMS allowed more content to be sent at one time and therefore allowed the entire text message to be conveyed at one time although the information was automatically split into several text messages when the maximum length was reached. To decrease the number of messages, only essential words were used to convey key ideas from the class. This decreased the number of messages from an original total of six each time to three each time.
Data Collection and Analysis Procedure
After approval was obtained from the institutional review board, participants attended a class on preventing patient falls. They were provided with a full explanation of the study, any anticipated risks, expectations of their participation, and information on their rights as participants, including the ability to withdraw from the study at any time without any consequences. The confidentiality of the study participants was protected throughout the study, using a personal code on the demographic form, as well as securing the signed consent and demographic surveys in a locked cabinet in the principal investigator's office; further, only aggregate results were reported.
After signing informed consent, participants attended a class on preventing patient falls. The staff then completed a demographic survey and completed examination #1 (paper version). To protect the participants' identity, they were instructed to create a personal code using the instructions included on the survey form (Table 1). The demographic survey included a request for the participants' mobile phone number and carrier, which were necessary to send text messages to the staff member from a hospital computer. Participants were then assigned to the experimental or control group using a randomization table. The experimental group received text messages with key points based on the contents from the class. The group were sent text messages for 6 days with the same information (Table 2). Using Microsoft Outlook®, the text messages were sent using the delayed delivery function, which enabled the delivery date to be synchronized with their attendance in class. The control group did not receive daily test messages with falls prevention information. Seven days after attending the class, all participants were sent a link to an electronic survey and asked to complete examination #2.
Creating Your Personal Code
Analysis and Findings
The demographic questionnaire consisted of six questions: age, job category, years of experience as a nurse or clinical partner, gender, highest level of education, and area of expertise. The demographic categories were coded numerically to enable use of SPSS® version 24 in the analysis and included the mean, median, and standard deviation. The descriptive analysis determined the data were skewed to the right and therefore did not met the qualifications for normal distribution, requiring that a nonparametric test be used for the analysis (Pallant, 2016; Salkind, 2017). Mann-Whitney U Test was used to confirm the homogeneity of both groups.
The first research question explored the effect of repetitive text messaging on retention of knowledge among clinical staff. The Wilcoxon signed-rank test was used to examine the scores of each group of participants at two different times (preintervention and postintervention) (Pallant, 2016). The test revealed a statistically significant difference in the scores between examination #1 and examination #2 for the experimental group with a medium effect size. The test scores revealed no significant differences between examination #1 and examination #2 for the control group (Table 3).
Groups Pretest–Posttest Scores: Wilcoxon Signed-Rank Test
The second research question explored the effect of a staff member's level of education on the retention of knowledge among clinical staff. The Kruskal-Wallis test was used to compare the test scores (continuous variable) on the final examination of those who received repetitive text messages (experimental group) based on the level of education (categorical variable). The test revealed no significant difference between the test results for participants who received the repetitive text messages across nine levels of education.
The third research question examined the relationship between a staff member's years of nursing experience and the retention of knowledge. Pearson correlation (r) was used to calculate the strength of the relationship between the two continuous variables—years of experience and retention of knowledge (as shown by scores on examination #2). Pearson's correlation calculations range from −1 to 1 and indicate the strength of the relationship. A correlation of 0 indicates no relationship and 1 indicates a perfect positive correlation (Pallant, 2016). The experimental group had a positive relationship (r = .278) with medium strength between years of experience and retention of knowledge, as demonstrated by the final examination scores.
The findings demonstrated that the experimental group achieved statistically significant higher scores on the second examination with a medium effect size, whereas the control group (who did not receive repetitive text messages) did not show a significant difference. The level of education did not demonstrate a significant effect on the examination results. Pearson's correlation demonstrated a positive correlation, with medium strength, between years of experience and retention of knowledge as measured by examination #2 scores.
Repetitive text messages can serve as a memory boost for information learned in class (Kahn, 2018). Educators can use text messages to reinforce information on many of the changes in the workplace, such as new research findings, new policies, new procedures, or new regulations. Information from the entire class does not need to be repeated, only key ideas. Nurses simply need to read the text message to improve their retention of information. Although the use of repetitive text messaging needs further investigation, the study demonstrated the potential for text messaging to work in a variety of settings for many disciplines.
Limitations of the study include how some individuals may learn better using different learning styles (Kolb, 1984). However, the focus of this study was the retention of information. To minimize this variable, the study used a combination of delivery methods to engage the participants, including lecture, interactive question-and-answer sessions, and return demonstration. The same facilitator presented the same information to each class to ensure consistency. Another limitation was the inability to restrict participants from one group talking and exchanging information with members of another group.
An additional limitation was language. The presentation and the examination were offered in English. Although all of the participants spoke English, this was a second language for some participants, who may have experienced difficulty with written English while taking the examinations.
Another note for consideration is that the study focus was on retention of information. The changes in examination scores were the main result on which the principal investigator focused. Changes in the patient fall rate was noted as not statistically significant. This was not a surprise finding, given that the percentage of participants was small and exerted a minimal effect on the overall rate.
Nurses have a duty to the public to provide patient care based on the most current information available. This presents a challenge because of the rapidly changing environment of health care. Yet, clinical staff must keep up with the changes in order to provide care that meets professional standards. This study demonstrated that text messaging can be used successfully to provide information repeatedly to improve retention. The use of repetition is not new but the delivery method—text messaging via smartphones—is new. Some hospitals use wireless phones within their facility that can also be used to deliver messages. This process opens a new path for managers and educators to deliver important information to staff while they are on the job. Repetitive text messages can improve retention of new information and has the potential to improve compliance with new policies and new regulations. The goal is to improve patient outcomes by providing bedside staff with the tools to learn and retain information despite the rapid changes within health care.
- Agency for Healthcare Research and Quality. (2018). Agency for healthcare research and quality: A profile. Retrieved from http://www.ahrq.gov/cpi/about/profile/index.html
- American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Springs, MD: Author.
- Jangid, N., Swadia, H. & Sherma, D. (2016). Effectiveness of mnemonic instructions on the thinking strategies of children with learning disability. Journal of Disability Management and Rehabilitation, 2, 22–27.
- Johnson, J.A. (2016). Nursing professional development specialists of the future. Journal for Nurses in Professional Development, 32(3), 158–160. doi:10.1097/NND.0000000000000251 [CrossRef]
- The Joint Commission. (2019). Standards interpretation. Retrieved from http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=450&ProgramId=47
- Kahn, A. (2018). Learning solutions. Retrieved from https://www.learningsolutionsmag.com/author/art-kohn.
- Knowles, M.S. (1970). The modern practice of adult education: Andragogy versus pedagogy. New York, NY: Association Press.
- Kolb, D.A. (1984). Experiential learning: Experience as the source of learning and development. Upper Saddle River, NJ: Prentice Hall.
- Lepp, A., Barkley, J.E. & Karpinski, A.C. (2015). The relationship between cell phone use and academic performance in a sample of U.S. college students. Sage Open, 5, 2158244015573169. doi:10.1177/2158244015573169 [CrossRef]
- Nhavoto, J.A., Grönlund, A. & Klein, G.O. (2017). Mobile health treatment support intervention for HIV and tuberculosis in Mozambique: Perspectives of patient and healthcare workers. PLoS One, 12(4), e0176051. doi:10.1371/journal.pone.0176051 [CrossRef]
- Nieswiadomy, R.M. (2012). Foundations of nursing research (6th ed.). Upper Saddle River, NJ: Prentice Hall.
- Orr, P. & Davenport, D. (2015). Embracing change. Nursing Clinics of North America, 50, 1–18. doi:10.1016/j.cnur.2014.10.001 [CrossRef]
- Pallant, J. (2016). SPSS survival manual. (6th ed.). Berkshire, England: McGraw-Hill.
- Putnam, A.L. (2015). Mnemonics in education: Current research and applications. Translational Issues in Psychological Science, 1(2), 130–139. doi:10.1037/tps0000023 [CrossRef]
- Ricker, T.J., Vergauve, E. & Cowan, N. (2016). Decay theory of immediate memory: From Brown (1958) to today (2014). Quarterly Journal of Experimental Psychology, 69(10), 1969–1995. doi:10.1080/17470218.2014.914546 [CrossRef]
- Salkind, N.J. (2017). Statistics for people who (think they) hate statistics (6th ed.). Thousand Oaks, CA: Sage.
- Settles, B. & Meeder, B. (2016). A trainable spaced repetition model for language learning. Proceedings of the 54th Annual Meeting of the Association for Computational Linguistics, 1848–1858. doi:10.18653/v1/P16-1174 [CrossRef]
- Stephens, J.D., Yager, A.M. & Allen, J. (2017). Smartphone technology and text messaging for weight loss in young adults: A randomized controlled trial. Journal of Cardiovascular Nursing, 32, 39–46. doi:10.1097/JCN.0000000000000307 [CrossRef]
- Walker, A., Leary, H., Hmelo-Silver, C.E. & Ertmer, P.A. (Eds.). (2015). Essentials readings in problem-based learning: Exploring and extending the legacy of Howard S. Barrows. West Lafayette, IN: Purdue University Press.
- Zucker, C. (2016). In the company of actors: Reflections on the craft of acting. New York, NY: Routledge.
Creating Your Personal Code
|Please create your personal code number and place it on this demographic survey. DO NOT write your name anywhere on the survey! Create your personal code by using the first two letters of your first name, then your last two digits of your social security number, then the last two digits of your employee number.|
|Name: Judy Bowling|
|Social Security number: 999-55-0000|
|Employee number: 55555|
|So, the code will be: Ju0055|
Common intrinsic factor is cognitive impairment/mental status.
Common extrinsic factor is unfamiliar environment.
Increased staff knowledge increases critical evaluation and identification of high-risk patients.
Three ways to improve communication: include risk for fall in handoff report, during walking rounds, and put on the white board.
Two most common side effects of polypharmacy are confusion/disorientation and dizziness.
Older adults accrue drugs in their body faster due to decreases in metabolism, kidney function, and liver function.
Groups Pretest–Posttest Scores: Wilcoxon Signed-Rank Test
|Group||N||Z||Asympt. Sig., 2-Tailed||r|
|1||109||−2.214||.027, < .05 statistically significant||.21|
|2||105||−0.535||.593, > .05 not statistically significant||Not calculated|