The expansion of mobile health technology provides an opportunity to improve health knowledge, behavior management, and patient–provider communication, particularly in underserved communities. Of note, the U.S. Department of Health and Human Services (HHS) established a Text4Health Task Force in November 2010 to identify existing text messaging programs and recommend strategies to promote future development and evaluation of text messaging programs in the United States (HHS, 2014). The findings of this task force included efforts by nurses to include text messaging and Short Message Service (SMS) technology as part of a health maintenance plan for their patients.
This use of technology is not surprising, given that nurses have always been leaders in delivering health care services, especially in underserved communities. In 2010, the landmark Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, was released, which offers recommendations on the critical intersection between the health needs of diverse, changing patient populations across the lifespan and the actions of the nursing workforce. The IOM’s (2010) recommendations are intended to support efforts to improve the health of the U.S. population through the contributions of nurses to the delivery of care.
At a time when the nursing workforce has been charged with taking a greater role in the increasingly complex health care system in the United States, it is particularly important to ensure that the nursing workforce is meeting its core competencies, including providing patient-centered care, working in interdisciplinary teams, using evidence-based practice, applying quality improvement, and using informatics (IOM, 2003). It is critical that each of these competencies is achieved so that nurses are able to practice to the full extent of their license. Yet, the education of nurses to meet these goals has been inadequate in some areas. In particular, research has shown that there is variation in whether and how programs have integrated informatics and health information technology content to meet informatics competencies (Fulton, Meek, & Walker, 2014; Manning & Frisby, 2011).
To help improve the integration of informatics content into the Doctor of Nursing Practice (DNP) curriculum, the development of creative and novel strategies for meeting the core competency of using informatics in practice is necessary. As a result of the expansion of mobile health technology, a simulation activity using SMS technology was created to meet the needs of the American Association of Colleges of Nursing’s (2006) Essentials for DNP education to ensure that the nursing work-force meets the current service challenges in the health care system. The goal of the activity was to encourage DNP students to think about innovative approaches to the delivery of health care, using informatics strategies. The aims of the current study were to report on the use of a SMS simulation activity for incorporating informatics knowledge and skills into the DNP curriculum and to understand DNP students’ perceptions of the use of the SMS in their clinical activities.
This project was reviewed by the institutional review board, which determined that it met the regulatory guidelines of categories 1 and 2 for review exemption.
For this activity, students were first introduced to the method of ecological momentary assessment and presented with a description of the past use of ecological momentary assessment for evaluating adolescents’ health information needs in real time (Schnall, Okoniewski, et al., 2013). Ecological momentary assessment is a sampling method developed to assess phenomena at the moment they occur in participants’ natural settings, supporting the ecological validity of this approach (Stone & Shiffman, 1994).
In the first cohort, 13 nurse practitioners (NPs), who were enrolled in the DNP program, participated; the second cohort included 19 NPs in the DNP program. Students were divided into groups of three to four and were given the following instructions:
Create a mock clinical scenario, where, over the next 3 weeks, one of your team members is the clinician and the other two or three members are the patients. This is a completely simulated activity, and no one should report any real health issues or conditions during this activity.
Students were told to (a) identify a health problem or issue that needs regular monitoring; examples include nutrition, hypertension, and diabetes; (b) use text messaging technology to develop a clinical diary to report on the health condition in the scenario; and (c) incorporate components of the clinical diary to include health outcomes, frequency, and messaging. Students were also reminded that SMS and text messaging are not secure mediums to share personal health information.
At the end of 3 weeks, each student wrote a one-page description of his or her experience, lessons learned, what he or she would do differently, and what worked about using this technology as a tool for patient monitoring. Students were also asked to consider whether the SMS was appropriate for the clinical problem chosen by their group. Each group also submitted a report summarizing the clinical problem or health issue, the text messages sent, and the text message responses. In addition to this summary report, each group detailed the challenges or successes of the group. Finally, each student completed a survey based on the technology acceptance model of his or her experience using this technology and completing this project. The technology acceptance model is an information systems theory that is based on principles adopted from social psychology and has been widely accepted as a parsimonious, yet robust, model that explains technology acceptance behavior. The technology acceptance model consists of two constructs that influence technology acceptance—perceived ease of use and perceived usefulness (Davis, 1989).
In the first cohort, the authors used Google Chat® as the text messaging system. Through Google Chat, students could send free SMS text messages directly and without cost. However, in April 2014, sending SMS communications to phone contacts through Google Chat in Gmail was discontinued for all supported mobile operators. As a result, Telerivet™ ( https://www.telerivet.com) was used as the messaging service in the second cohort. Telerivet is a ready-to-use SMS communications platform for sending and receiving the SMS and managing contacts from any Web browser. Telerivet uses a cloud-based management system to route messages to and from mobile telephone numbers. A fee is associated with the use of this product, but it was paid by the author and not charged to the students.
Structured survey items were entered into SPSS® version 20 software. Descriptive statistics were used to calculate the demographics of all participants and the technology acceptance model survey results. Scale scores were created for behavioral intention, perceived usefulness, and perceived ease of use of the SMS in clinical care (Schnall & Bakken, 2011). Then, each of the participants’ responses about their experience were coded, using the PRECEDE portion of the PRECEDE–PROCEED model of public health planning (Green & Kreuter, 2005). Because it is important to address the predisposing, enabling, and reinforcing factors prior to implementing an intervention, the PRECEDE–PROCEED model has been used to understand information technology implementation in health care delivery (Schnall, Clark, Olender, & Sperling, 2013; Schnall, Gordon, Camhi, & Bakken, 2011). A content analysis guide was completed by the predisposing, enabling, and reinforcing factors of students’ reports to understand their experience using SMS technology for promoting health behavior in their patients.
The sample included two cohorts of DNP students, and all participants were practicing NPs. In the first cohort, 13 students participated in the simulation activity. One student was male, two students self-identified as Hispanic/Latino, one as Multi-Racial, one as Black, and one as Other (not all students answered this question). Mean participant age of was 35 years, ranging from 25 to 59 years. In this cohort, the students’ specialties were acute care (n = 2), adult-gerontology (n = 1), family (n = 2), midwife (n = 1), psychiatric/mental health (n = 1), pediatrics (n = 5), and women’s health (n = 1).
In cohort 2, 19 students participated. One student was male, one student identified as being Hispanic/Latino, four (21.1%) reported their race as Asian, one (5.3%) as Black, and 15 (78.9%) as White (some students selected multiple categories). Mean student age was 29 years, ranging from 25 to 43 years. Students’ specialties were adult (n = 1), adult-gerontology (n = 1), anesthesia (n = 2), family (n = 7), psychiatric/mental health (n = 4), and pediatrics (n = 4).
All of the participants in both cohorts indicated that they generally send text messages several times every day and started using text messaging more than 2 years ago.
The Technology Acceptance Survey (Schnall & Bakken, 2011) was used to understand NPs’ perceived ease of use and usefulness of the SMS for clinical management of patients. These findings are reported in the Table. Overall, participants found the SMS to be somewhat useful and easy to use. In cohort 1, participants were neutral regarding where they intended to use the technology with their patients. In cohort 2, participants stated that they were somewhat unlikely to use the technology.
A total of four groups were included in cohort 1. The clinical issues examined included traumatic brain injury, hypoglycemia and Type 1 diabetes in adolescents, and hypertension. Cohort 2 was composed of six groups. The clinical issues examined included newly diagnosed juvenile diabetes, benzodiazepine withdrawal, intestinal transplant, and smoking cessation; two groups focused on physical activity monitoring.
The benzodiazepine withdrawal group used the Short Alcohol Withdrawal Scale (Gossop, Keaney, Stewart, Marshall, & Strang, 2002), which is a validated tool to measure participants’ symptoms related to benzodiazepine withdrawal. The clinician sent an automated text message every 3 days at 7 pm, asking the patients to score their withdrawal. Another group also used a structured format for collecting information. The intestinal transplant group created a text template in which the following question was asked: “In the past 24 hours, please report on: Fever (Yes/No), Nausea (Yes/No), Abdominal distention (Yes/No), Enteral feeds tolerance (Yes/No), Formula rate oral intake (mL), Stoma output (mL or liters).” The remainder of the groups used less-structured formats for communicating with their patients. One clinician asked, “How did your physical activity goals go this weekend?” In another group, the clinician sent reminders to the patients’ about their follow-up appointments.
To better understand the participants’ perception of the use of the SMS for clinical care, each student’s one-page description of their experience, lessons learned, what they would do differently, and what worked using the SMS as a tool for patient monitoring was coded Content using the PRECEED portion of the PRECEED–PROCEED framework and was categorized by predisposing, enabling, and reinforcing factors.
Predisposing Factors. Predisposing factors are antecedent to the use of technology, such as the SMS, and provide the basis for motivation. Predisposing factors include the following categories: perceived ease of use, usefulness, and self-efficacy. Perceived ease of use and usefulness were measured by the survey tool. Further understanding of the predisposing factors was elucidated after reading the students’ reports. One student remarked, “I found the technology very easy to use.” Another student explained, “The system was simple because of my touchscreen phone. I could touch the template to copy it and touch again to paste it.” Finally, one student commented, “Overall, it was easy to communicate with the patient and to give immediate feedback.”
Regarding usefulness, many students thought that SMS was a useful tool in their clinical practice. For example, one student said, “I believe this is a good way to reach out to teens, since they are also very involved with texting and using cell phones.” Another student also thought that SMS communication can be useful and reported that “the use of text messaging should be implemented for laboratory and test results where the results are benign and should be used for routine follow-up care only.” On the other hand, some students were concerned that this technology may not be useful because “tailored text messages to participants are a very difficult task to achieve because each participant had different goals and required different coaching.” Another student also had concerns about the usefulness of SMS communication and said:
Clinical questions that arise regarding physical activities may be too complex to be responded [to] over text. In-depth conversations are limited, and misunderstandings can easily arise due to the absence of verbal and facial cues.
Self-efficacy was reported by many students who felt that, even if they had never used SMS previously in clinical settings, they could still easily adopt this technology and that it may improve how they are able to provide patient care. One participant, who played the role of a patient, reported that:
the texts challenged me to add novel and exciting work-outs in order to report them and to feel accomplished when looking back at the texts and reviewing what I had done that week or weekend.
Another participant, who assumed the clinician role, said, “I enjoyed the process of facilitating a fictional therapeutic relationship with my ‘patients’ in the technological setting, and I found that it was particularly helpful in maintaining rapport.”
Enabling Factors. Enabling factors are antecedents to technology use and are conceptualized as conditions that function to facilitate or create a barrier to the desired outcome. Categories of enabling factors included technical issues and accessibility to the information technology system. Participants were concerned about the technical issues, which may be barriers to SMS use. For example, one student commented:
Patients are not always in a location where they can get a signal, or they are unable to speak freely about the problem, or they are not comfortable verbally expressing what they are feeling.
Another student reported technical issues and said, “I encountered incompatibility of the system [Telerivet] with my mobile phone,” and she was unable to text back to the system-generated SMS message as a result. On the other hand, some participants thought that technology was a facilitator for allowing a somewhat automated communication among clinicians and patients. One participant reported that “the Telerivet technology was useful for initiating the text conversations, allowing me to text both patients the same message at once.”
Another common theme expressed was that participants were concerned about the accessibility of the system. The clinician would not likely have the time or information accessibility to text patients back with individualized treatment plans or clinic appointment time slots. One student reflected on her experience using the system and said:
I had to constantly check in the Web site to see if any responses came through. With no real alert system to my e-mail or personal phone, this was difficult to do while working every day.
Accessibility to the system was compromised when participants did not have ready access to a computer. For example, one participant reported:
SMS works very well when the provider is sitting at his or her computer and the patient responds immediately to the text message. However, if the patient is delayed in answering the message and the provider is no longer online, the message to the provider could be lost. It does not allow the patient to reach out to the provider whenever they choose.
Reinforcing Factors. These factors follow an action and provide an incentive for continuing to use the information technology system. Categories of reinforcing factors include an awareness of the positive attitudes and behaviors of others and remuneration. Reinforcing factors were focused on an awareness of the positive attitudes and behaviors of clinicians, patients, and resources. Following the 3-week experience, many participants were aware of the positive attitudes and behaviors that could potentially result from the use of the SMS.
One participant stated, “The main success of our program was our ability to find meaningful ways to maintain correspondence between the provider and patients throughout the intervention.” Another participant reflected on her role, “As the patient, it was comforting to be able to talk to the provider and should I have any questions, be able to ask.” Another participant explained the use of the SMS for improving the delivery of care, saying:
As a clinician, I value the real-time exchange and the opportunity to act as a resource in the patient’s self-management of chronic illness. I have found in both this exercise and in practice that often patients want to partner in their care.
Another participant said:
Knowing that there was a physical person on the other side who was a health care professional responding to my messages motivated me to stay in touch with her. If I just had an automatic alert to check on my health status, I do not think that I would have been as motivated to address my concerns.
Use of the SMS has the potential to save resources by improving communication and enhancing follow up. One participant said, “This satellite care is very efficient because it saves the patient time and money from having to attend extra office visits, and the providers can utilize their office time more efficiently.” On the other hand, use of the SMS for follow up is not reimbursable, as one participant pointed out, “In clinical practice the disadvantage is that this communication is not reimbursed, although it contributes to patient care.” If the SMS becomes reimbursable, this would be a reinforcing factor for providers to use this technology, especially for ensuring follow-up visits.
Although informatics competencies are a requirement in DNP programs, few programs have strategies to integrate informatics knowledge and skills into their curriculum (Choi & Zucker, 2013). This article reports on a novel approach to integrating informatics skills into the DNP curriculum. At the same time, the simulation activity described provided useful information for the future delivery of care using the SMS and a greater understanding of the factors that need to be addressed and supported to use this technology in health care.
Health text messaging has the potential for addressing many health-related issues, as was demonstrated by the broad range of topics chosen by the participants. Nonetheless, the current evidence for use of this technology is limited to a number of diseases, as reported in the HHS Text4Health task force recommendations (HHS, 2014). Some health conditions are less appropriate for text messaging, but many health conditions can be monitored using the SMS to improve continuity of care. For example, in the case of the current simulation activity, some respondents thought that the questions that can arise are too complex to answer via messaging; however, in many cases clinicians were able to perform basic monitoring and check-in with their patients using this technology.
In particular, one participant commented on the usefulness of the SMS for adolescents, who are high users of this technology. In one study, 92% of pediatricians found that this technology was helpful for their adolescent patients, with 85% of adolescents reporting that the data were accurately reported and that it assisted their pediatrician in understanding them better (Reid et al., 2012). Another study focused on the assessment of the health information needs of adolescents, where 90% of high-risk, underserved adolescents reported on their health information needs during a 30-day study period (Schnall, Okoniewski, et al., 2013). Those studies demonstrated user acceptance of this technology, especially in adolescents.
Overall scores for study participants’ intention to use this technology in their clinical practice were slightly above neutral (3.08) in cohort 1 and slightly below neutral (2.67) in cohort 2. Similarly, scale scores for perceived ease of use and usefulness were also lower in cohort 2 than in cohort 1. Students in cohort 2 may have had more difficulty using the SMS platform, as the interface was more complicated than that used in cohort 1.
Although many students had positive feedback on the perceived ease of use and usefulness of SMS technology and the potential that it has to change health care delivery and health outcomes, they identified barriers to using this technology in clinical care. An important barrier that needs to be addressed to facilitate the use of this technology is its integration into the clinical workflow. Participants in the current simulation activity complained about the need to log on to separate Web-portals to respond to their patients. In an ideal clinical situation, the messages should not only be easily accessible to the clinician but also should not be interruptive. Past research has demonstrated that synchronous communication can be highly interruptive and has the potential to increase errors (Edwards et al., 2009).
Another concern discussed by the participants is the need for reimbursement if this technology is incorporated into their practice. The participants described the usefulness of this technology for improving follow-up and continuity of care, which has the potential to improve patient outcomes and reduce overall costs. Considering the cost-saving potential of follow-up messaging, especially for patients with chronic conditions, reimbursement for providers who use this technology may be a worthwhile investment of health care payers.
Overall, the students who participated in this activity perceived the SMS as being easy to use and useful. Future work could encourage the use of the SMS in the clinical setting, paying close attention to the need to protect health information. Moreover, students who participated in this activity had some difficulty with the platform, and future projects may consider the use of different platforms or spending more time teaching students how to use the technology.
This simulation activity demonstrated the usefulness of SMS technology to communicate with patients. The activity provided DNP students with an opportunity to use the SMS in the context of communication between the patient and the clinician. Students reported that this activity demonstrated the usefulness of informatics tools for helping patients to manage their chronic health conditions. If the SMS becomes reimbursable, this would be a reinforcing factor for providers to use the technology, especially for ensuring follow-up visits.
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