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Mobile revolution: a requiem for bleeps?
  1. Guy Martin,
  2. Pradeep Janardhanan,
  3. Tristan Withers,
  4. Sanjay Gupta
  1. Department of General Surgery, The Lister Hospital, Stevenage, UK
  1. Correspondence to Guy Martin, Department of General Surgery, The Lister Hospital, Coreys Mill Ln, Stevenage SG1 4AB; UK; guy.martin{at}doctors.net.uk, guy.martin{at}nhs.net

Abstract

Objectives Effective communication is a vital part of good clinical care. Traditionally bleep systems have been used as the mainstay of communication. Mobile technology is increasingly seen as a quicker, easier and more reliable method of communication. Our objective was to assess the use of mobile devices within a typical National Health Service (NHS) hospital, discuss potential benefits and pitfalls, and develop suggestions for future improvements.

Methods A survey of 600 hospital doctors was conducted in a large NHS district general hospital between 1 May and 30 June 2015. The questionnaire explored the patterns of use, attitudes and impact of mobile communication, and identified potential risks and benefits of its wider adoption within the NHS.

Results 92% of doctors use their personal mobile for hospital-related work. 95% share their personal number with colleagues, and 64% have it available through hospital switchboard. 77% use their personal mobile to discuss patient matters, and 48% are prevented from communicating effectively due to poor signal within the hospital. 90% are contacted when not at work on a weekly or daily basis regarding patients. 73% feel that traditional bleeps should be replaced with new mobile technologies.

Conclusions Mobile phone usage is very common among doctors, and is the preferred method of communication within the hospital. Mobile technology has the potential to revolutionise communication and clinical care and should be embraced. The introduction of new technology will inevitably change existing hospital dynamics, and consequently may create a new set of challenges that will require further work to explore in the future.

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Introduction

Effective communication within the hospital is a vital part of good clinical care. The traditional method of using pagers as a means of communication is far from ideal; 65% interrupt patient care,1 a quarter are unimportant or unnecessary and only one-third actually result in a change to care.1 ,2 Junior doctors receive on average 60 bleeps per on-call shift, with peaks during nursing handover, increased volumes with reduced nursing workload, and only 16 min between bleeps at peak times.3 To address these problems junior doctors often resort to personal mobile phones, which are carried by 98%, and are used by 67% for work-related matters at an average cost of £14/month for hospital-related calls.4 Mobile phones are seen as quicker, easier and a more reliable source of communication than traditional pagers.5 Group messaging applications such as WhatsApp are widely used as an effective means of communication within medical teams. While such applications may improve ease of communication, they have inherent risks, namely the potential for breach of patient confidentiality. Surprisingly there seems to be a paucity of literature on the use of mobile phones by NHS doctors in UK.

In light of this we conducted a survey of doctors of all grades working in a large English District General Hospital to assess the use and impact of communications devices at work, and develop suggestions for future improvements.

Methods

A cross-sectional online survey (SurveyMonkey) of 600 full-time doctors of all grades and specialties was conducted from 1 May to 30 June 2015 at The Lister Hospital, a large UK District General Hospital. All doctors within the hospital were invited to complete the questionnaire vie email correspondence, and received a number of reminders during the study period to improve the response rate. The results were then analysed to assess the use of communications devices at work, and develop suggestions for future improvements. The hospital in which the study took place currently uses traditional pagers or bleeps as the standard method of communication, and has no facility for clinicians to access a WiFi network for Internet or data connectivity.

Results

The overall response rate was 34% (206), and included a broad range of grades (66 foundation trainees, 11 core trainees, 25 specialty trainees, 8 associate specialists and 96 consultants), and both medical (71%) and surgical specialties (29%).

Seventy (34%) doctors surveyed carried a bleep, the majority of whom were in training grades and principally foundation trainees. The mean number of bleeps received on a normal working day by each doctor was 3.6, with 40% reporting being bleeped more than 6 times per day. The mean time spent waiting for a response to a bleep was 8.7 (0–60) minutes.

The vast majority of those surveyed (92%) use their personal mobile phone for work-related calls, 88% (181) for work-related text or data messaging and 82% (169) for access to work email accounts. Eighty-three per cent (171) used their personal phones to access online medical resources or applications including National Institute for Health and Care Excellence Guidelines and the British National Formulary (BNF) while at work (figure 1). Ninety-five per cent (196) of respondents share their personal mobile numbers with work colleagues, while 64% (132) stated that the hospital switchboard has their personal mobile number that may be used to connect them to any caller. When questioned, a further 66% (136) stated that their preferred method of communication for work-related matters was via a phone call, 17% (35) via text message, 11% (23) via a messaging application and only 6% (12) via a hospital-issued bleep (figure 2).

Figure 1

Reported use of personal mobile phones while at work.

Figure 2

Doctors’ preferred method of communication at work.

Three-quarters (77%) of respondents surveyed use their personal mobile phone to discuss patient information and 13% (27) have used their phones to send picture messages containing clinical information such as wounds or X-rays. Thirteen per cent (27) of mobile phones used in the survey were not password protected.

Ninety-nine (48%) respondents stated that they were prevented from communicating effectively with colleagues due to a lack of mobile phone signal within the hospital, often in newly built areas. When asked to rate the availability of phone signal while at work, 33% (68) rated it as poor, 26% (54) as neutral, 17% (35) as good and only 4% (8) excellent. Sixty-five per cent (134) of respondents reported the quality of 3G/4G reception required for the use of mobile applications or data download as poor or very poor.

When not at work, only 10% (21) of doctors reported that they are never contacted on the personal mobile about work-related matters, while 32% (66) reported being contacted on a weekly basis, 36% (74) a few times a week, 16% (33) on a daily basis and 5% (10) several times a day (figure 3). The frequency of contact was unsurprisingly correlated to grade and seniority, with consultants most frequently contacted when not at work, and foundation trainees rarely contacted at all.

Figure 3

Frequency of contact by mobile phone regarding hospital-related matters when not at work or on call.

The majority (68%) of doctors support the use of personal mobile phones for NHS work, despite 71% (146) feeling that they subsidise the NHS through their use. Eighty-six per cent (177) would be supportive of the introduction of NHS-provided mobile phones to be used for work-related matters. Seventy-three per cent (150) felt that traditional and outdated bleeps should be largely replaced, except in specific emergency situations. Ninety-nine per cent (204) felt that access for staff to an on-site WiFi network would be beneficial to their day-to-day work.

Discussion and conclusions

Virtually all doctors use their personal mobile phones for work-related matters, and the majority prefer to use their mobile phone as their principal method of communication, despite potential information governance concerns, finding traditional bleeps to be antiquated and obsolete, despite distinct advantages in terms of accessibility and signal coverage.

Effective communication is critical to the delivery of high-quality patient care, and failures of communication remain a leading cause of patient safety events, yet despite this there remain significant challenges. A number of different solutions have been trialled involving smartphones and web-based tools; however, the evidence underpinning them remains limited, and many challenges and barriers still exist.6–8

Previous studies have suggested that traditional bleep systems often interrupt patient care, with only a minority actually requiring a response from the clinician within an hour of them being placed.1 In addition they have been shown to frequently disrupt sleep when used overnight, as well as directly interrupting patient contact on a regular basis.9 These findings are likely to be key influencing factors for the 73% of doctors in our study who felt that traditional bleeps should be replaced by more modern technology, although given that junior doctors are the principal users of bleeps this may have had a significant impact on this finding. A key potential advantage of the use of smartphone technology would therefore be to allow the transfer of information, particularly in non-urgent cases, without requiring a direct response as is required with traditional bleeps; for example, via instant messaging or email communication. This would allow doctors to more effectively triage and prioritise tasks, as well as providing a clear and precise method of data collection for quality assurance and audit purposes. This may not be completely straightforward, however, with conflicting evidence on its impact; the replacement of pagers with a web-based messaging system to facilitate coordination of patient care resulted in a 233% increase in interruptions of patient care in one study,10 despite user surveys and focus groups suggesting a high level of satisfaction and a perceived decrease in interruptions to the workflow of both nurses and physicians with such systems in another.11 To help resolve this paradoxical challenge of providing clinicians with the means for communicating effectively while reducing potentially dangerous interruptions, the ability for smartphones to become ‘silent’ and filter out non-urgent issues when the user is engaged in safety-critical tasks is therefore crucially important.

It is also important to remember that multiprofessional teams are complex, and require much more than simple methods of electronic communication to function effectively. Improvements in communication must therefore not be at the expense of other aspects of work and human interactions that, if ignored, can also severely impact patient safety.12 In addition, when introducing new technology it is imperative to streamline and consolidate, rather than just add new layers and complexity, as this may lead to increased confusion around which of the multiple communication channels to use.13

The majority of doctors (83%) in our study already use their smartphones to access online resources such as the BNF, 77% to discuss confidential patient information and a significant minority (13%) also use their personal phones to share important clinical information via photo messaging. Embracing the use of smartphones therefore may have the potential to improve patient safety through strengthening the provision of easy access and trusted online resources, which have been shown to save time in performing clinical activities, as well as increasing adherence to hospital-specific protocols.14 In addition, the ability to remotely and securely access hospital applications and electronic records may provide a secure and efficient way to capture and upload relevant clinical images,15 and also aid in the development of innovative methods that allow the rapid communication of critical results to targeted physicians, facilitating rapid and timely interventions that may improve patient safety.16

Currently the majority of work is conducted on personal mobile phones that lack appropriate information governance and security arrangements; indeed 13% of those surveyed did not even have password protection on their mobile phone. It is therefore imperative that organisations and institutions take ownership and embrace the provision of ‘in-house’ technology in order to have control and oversight of it, and provide assurance for the necessary security and information governance arrangements. This will improve security and oversight, and potential organisational concerns that the wholesale adoption of smartphones within hospitals may lead to the distraction of staff are unfounded; handheld smart technology does not increase the frequency of use, or significantly change the range of tasks devices are used for compared with devices that are privately owned.17 In addition, if smartphones were issued by an organisation then there could be strict controls on their use for non-work-related matters to avoid distractions, and it would also serve the dual purpose of allowing staff to reduce unnecessary and inappropriate contact and disturbance when not a work, which has also been highlighted as a key concern and frequent occurrence in our study.

This study has highlighted the potential benefits and pitfalls in introducing new forms of mobile communication. It is important to remember, however, that the hospital setting is an extremely complex system involving a multitude of interactions and relationships; the introduction of new tools to aid with communication in such a complex environment may result in unforeseen issues that could lead to both positive and negative impacts on patient safety and the delivery of effective care. A key limitation of this study and an area for future investigation therefore would be to further understand the complex nature of multidisciplinary team communications and dynamics, as it would be a prerequisite to assess nursing and allied health professionals’ views on the use, ease and effectiveness of mobile communication technologies prior to any radical change being undertaken. In addition, this study has only looked at the experiences of medical staff within a single hospital and is therefore heavily influenced by individual institutional factors; in order to gain a deeper understanding of the problem it would therefore be helpful to look at the patterns of use, attitudes and impacts of mobile communication technologies in other institutions and contexts.

Mobile technology has the potential to revolutionise communication and clinical care within the hospital setting. Doctors are commonly early adopters of new technology and already use their own personal smartphones for a wide variety of critical tasks within the hospital. The use of personal phones while easy and straightforward does not allow for corporate ownership in terms of security, information governance and assurance of the clinical applications and guidelines that may be used. In addition, it does not provide scope to widen the use of smartphone technology within the hospital such as through the adoption of multidisciplinary messaging applications, or the provision of remote access to hospital systems. If the NHS is to take advantage of the many benefits that smart technology may provide, it must embrace it, and work to facilitate it as much as possible such as through the provision of hospital-specific applications, hospital-issued smart technology and secure WiFi networks rather than fight against it and be institutionally obstructive as is commonly seen at the moment. The introduction of new communication technology will inevitably change existing dynamics that exist within the workplace, and consequently may create a new set of challenges and difficulties that will require further work to explore and understand in the future.

Main messages

  • Effective communication within the hospital is a vital part of good clinical care. The traditional method of using pagers as a means of communication is far from ideal, frequently interrupting patient care, plagued by inappropriate use and taking up a significant amount of clinicians’ time. The vast majority of doctors use personal mobile phones for work-related matters as they are seen as quicker, easier and a more reliable source of communication than traditional pagers. Despite this rapid uptake of technology there seems to be a paucity of literature on the ad-hoc use of mobile phones and technology by NHS doctors in UK.

  • A number of different solutions have been trialled involving smartphones and web-based tools to improve communication in hospitals; however, the evidence underpinning them remains limited, and many challenges, barriers and institutional reluctance still exist to their widespread adoption.

  • If the NHS is to take advantage of the many benefits that smart technology may provide it must embrace it, and work to facilitate it as much as possible rather than fight against it and be institutionally obstructive as is commonly seen at the moment

  • Multiprofessional teams are complex and the introduction of new communication technology will inevitably change existing dynamics. Improvements in communication must therefore not be at the expense of other crucial aspects of the hospital environment, and the other interactions and relationships that if ignored will create a new set of challenges and difficulties that may also severely impact patient safety.

Current research questions

  • What legal, technological and cultural barriers underpin the institutional reluctance to embrace new mobile technology that may improve multidisciplinary communication within the hospital setting?

  • To what extent may the ad-hoc use of personal mobile communication devices within the hospital setting compromise patient confidentiality and information governance arrangements? Is this an institutional risk that must be addressed, or is it the responsibility of the individual clinician?

  • Will the widespread adoption of new communication technologies compromise fundamental human interactions and team dynamics that are crucial to the effective and safe delivery of healthcare? In the age of new technology, does rapid adoption have only positive effects?

Acknowledgments

Daisy Clegg, Aishani Sachdeva and Richard Hughes, Department of General Surgery, The Lister Hospital, Stevenage, UK.

References

View Abstract

Footnotes

  • Contributors All authors contributed to the study design, data collection and analysis of results. GM was the principal author of the submitted article with input from all other authors in the process.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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