Digital engagement in nursing: the benefits and barriers

Introduction

In 2016, at the annual Royal College of Nursing (RCN) Congress, it was agreed that the college should lobby for every nurse to be an ‘e-nurse’, able to use data, information, knowledge and technology to its full potential for patients, carers and service users. These were no longer to be regarded as specialist issues; they affected the whole of the nursing profession, which needed to be supported to practise in new ways. The message was clear: the future of nursing was digital (Clever Together, 2018).

In 2018, the RCN published a report written by Clever Together on a consultation that had asked participants – both online and in focus groups – to consider what the digital age would look like, and the enablers and barriers to making it happen. Perhaps unsurprisingly, most of the nurses who contributed to the consultation were digital enthusiasts: more than half (58.3%) used technology or data “all the time in their everyday practice”; “nearly two out of five (39.6%) described themselves as digitally leading” in comparison with the rest of the nursing community; and “four out of five (81.4%) felt that data, information, knowledge and technology would make a large positive contribution to nursing and midwifery” (Clever Together, 2018).

Despite this openness to technology, the participants were not finding it easy to embrace the digital revolution, and fewer than half (45.9%) felt their organisation was doing a good job of supporting them to develop their digital capabilities. Many of the barriers were, from a technological point of view, mundane. They included:

• Difficulties with passwords;
• Inadequate computers;
• Lack of support;
• Over-complicated systems (Clever Together, 2018).

Comments from participants revealed a deep frustration at the gap between how things should work, and the day-to-day reality. One said: “The single, most fundamental problem in our trust is the inadequacy of our IT systems… I hate to think how much nursing time is wasted each day waiting for computers to switch on, load emails, bring up blood results etc. And that is if you can find one that is free. Since IT systems are now at the heart of day-to-day clinical practice, there are rarely enough computers to match demand…” (Clever Together, 2018).

The report concluded that, to suggest nurses and midwives lack enthusiasm about technology or the skills to use it (“a common perception”), while failing to give them the tools they need, “unfairly lays blame at their door and does them a great disservice”. It called for a re-shifting of priorities, with less attention paid to “exciting” but small developments, and more given to “getting the basics right” (Clever Together, 2018).

A recent analysis of how the nursing profession should adapt for a digital future suggested that nurses “still commonly use practice systems that are lacking basic usability”; this can lead to alert fatigue and reinforcing disruptive work processes, or increasing the burden of documentation (Booth et al, 2021). The authors called on nurses and their leaders to demand digital systems better suited to current and emerging needs.

Community nursing

The problems that nurses experience in the acute sector may be an even greater barrier to engagement for nurses who work alone in the community and are dependent on mobile technology.

A 2018 report by the Queen’s Nursing Institute (QNI) noted the progress that had been achieved: respondents to a survey described the diverse ways in which technology was helping them to deliver services, including electronic prescribing, diagnostic tools, data collection and updating patient records. Nurses were also monitoring wounds via photography and using eClinic instant messaging and virtual consultations. However, 29% of community nurse respondents were still largely working with paper-based systems and older technologies, such as fax machines, were used often.

The upfront cost of new technology in a difficult financial climate – with potential savings taking time to materialise – was identified as a significant barrier. Nurses were struggling with outdated systems that were prone to crashing, which forced them to work on paper. Poor connectivity also meant they had to write up paper records while on visits and then duplicate the information onto the IT system when they were back at base. There was also the problem of systems having been adapted from those in use elsewhere in the health service and applied to community nursing, without consideration for the complexity and specific needs of the sector.

Some community nurses who responded to the survey were resistant to using IT, even when considerable efforts had been made to engage them. Their reasons included:

• Heavy workloads, which left little time to use the technology;
• Concerns about patients’ perception;
• A “general reluctance to use IT”.

Lack of nursing leadership in technology and digital innovation is a major barrier to nurse engagement. The QNI survey found that few senior nurses were given a leadership role to support innovation in this area, and roles were sometimes cut after a particular innovation was implemented. Where these roles did exist, they enabled nurses to understand the technology and influenced it as it was being developed, thereby ensuring it would be fit for purpose.

One nurse quoted in the QNI’s (2018) report explained: “We do have a team of senior nurses who have worked with IM&T [information management and technology] on technology to improve systems and we do feel we have pushed for advances and improvements that we otherwise wouldn’t have.”

Another commented that the nurse lead was “someone who speaks the same language/does the same job to explain it to us without making us feel inferior, stupid, and also enhances it by relating it to patients and how we can use it to improve patient outcomes” (QNI, 2018).

“At the 2016 Royal College of Nursing Congress, it was agreed that the college should lobby for every nurse to be an ‘e-nurse’”

Artificial intelligence

Nursing leadership is important to help nurses navigate exciting but complex areas, such the use of artificial intelligence (AI) and predictive analytics – two of the “hottest topics in healthcare” (Drake, 2019). Existing informatics technologies – such as clinical decision support systems, electronic health records and mobile technologies – are likely to have increasing levels of AI functionality. Having a “critical mass” of nursing leaders who understand the consequences and opportunities of these developments will be vital to ensure the “quality and safety of nursing” (Booth et al, 2021).

The increasing recognition of the importance of the chief nursing informatics officer role is helpful, but more nurses from all specialties should have the opportunity to contribute to the development of digital health policies, locally and nationally; this could increase nurses’ future use of digital technologies (Booth et al, 2021).

Booth et al’s (2021) analysis suggested the profession should “revisit cultural interpretations” of technology such as robots and AI-enabled systems, so they are viewed as complementary to nursing practice, rather than as competition. Success will depend on nurses collaborating with technology developers, providers alongside patients (Booth et al, 2021).

“Nurses’ resistance to technology is often not based on fear or dislike of technology itself, but on a concern that it will damage or reduce their interactions with patients”

Improving care

Technological innovations that are well designed with nursing input from the beginning, and implemented by adequately supported staff, can deliver improvements in patient care and safety.

Watson and Carberry’s (2021) study of nurses’ experiences on four acute wards of using Patientrack, an electronic system that records patients’ vital signs, found a significant improvement in the reliability and accuracy of the National Early Warning Score tool. Nurses found the system easy to use and helpful – although a few highlighted that it did not replace the need for critical thinking and clinical assessment. The study authors commented that if the electronic system was to be rolled out across the hospital – a move supported by 66% of the trial’s participants – then staff should be trained not only in the new skills needed to use it, but also in how to complete a competent airway, breathing, circulation, disability and exposure (ABCDE) assessment.

In that instance, as is the case with many successful innovations that engage nurses, the technology acted as a support to nurses’ skills, not a replacement.

Resistance to change

Nurses’ resistance to technology is often not based on a fear or dislike of technology itself (although that can be a factor for some), but on the concern that it will damage or reduce their interactions with patients, leading to depersonalised care. Digital technologies can be viewed as a “distraction” from, or an “intrusion” into, therapeutic relationships (Booth et al, 2021; Robichaux et al, 2019).

If technology is viewed as incompatible with traditional nursing ideals, such as compassionate care, it may, understandably, make nurses reluctant to adopt it in their practice. This concern may be alleviated by making sure that technology, such as electronic observation systems, free up nurses’ time so they have more (caring) time to spend with patients (Watson and Carberry, 2021).

“I hate to think how much nursing time is wasted each day waiting for computers to switch on, load emails, bring up blood results etc”

Using data

Many new technologies with the potential to improve workforce modelling and patient care, such as AI, depend on large amounts of data. Combining data on staffing, vital signs and safety can capture the work of nurses – which is often drastically underestimated – and reveal how to make patient care better and safer (Leary and Dix, 2018; Leary et al, 2016).

As Leary and Dix (2018) explained, advances in mathematics and computer science mean it is now possible to make multiple calculations on huge amounts of information; these “big data techniques… help us understand and even predict complex situations and what resources will be needed”. For example, research in which Leary was involved analysed data from more than 100,000 people with lung cancer and the work of more than 200 nurses; it showed that receiving care from a lung cancer nurse specialist was fundamental to better outcomes for patients (Thorne, 2018).

Unfortunately, healthcare’s use of big data lags far behind sectors such as retail and banking (Leary and Dix, 2018). Nurses often get little return for the considerable time and effort they put into collecting data; they are not enabled to use it and “find it hard to engage in the process” (Leary and Dix, 2018). Nurse leaders should be asking their trusts:

• What data is being collected and why;
• How it will be used;
• How it captures the nurses’ work;
• What nurses can expect to see from it (Leary and Dix, 2018).

As technology advances, there is the potential for increased benefits; however, there is also a risk that it becomes so complex that it is incomprehensible to most staff members.

The increasing sophistication of e-rostering systems, with acuity measurement systems synchronised to hand-held devices, can give ward managers and nursing staff more information about their staffing needs than at any time in the past (Drake, 2019). However, many aspects of e-rostering systems are “obscure and difficult to use” and, instead of empowering staff, many nurses associate them with management control and monitoring (Drake, 2019).

Ironically, it may be helpful to make the technology even more sophisticated – for example, by moving to machine learning (which enables systems to learn and improve automatically without specific instructions) – as ‘smarter’ technology can be more user friendly (Drake, 2019).

Staff development

The 2019 Topol review, Preparing the Healthcare Workforce to Deliver the Digital Future, stated that “the healthcare workforce needs expertise and guidance to evaluate new technologies”, and called on NHS organisations to invest in their staff’s development of specialist digital skills through the Digital Academy, continuing professional development, sabbaticals and secondments (Topel, 2019).

Booth et al (2021) argued there was an urgent need to “create educational opportunities at undergraduate and graduate levels in informatics, digital health, co-design, implementation science, and data science”. They warned that, without immediate action to upskill nurses and invest in and lead digital health developments, the profession was in danger of not only missing out on opportunities in future health systems, but also becoming less relevant to “societies saturated by digital technologies”.

Effect of the Covid-19 pandemic

Before January 2020, the promised digital future of the NHS appeared to be quite a long way away. Despite a plethora of initiatives and government support – including the Global Digital Exemplar programme, an NHS funding programme to enable innovative trusts to accelerate their digital programmes and share best practice, and the 2019 establishment of NHSX (nhsx.nhs.uk), a government unit tasked with leading the digital transformation of health and social care – progress was patchy, held back by outdated systems and underinvestment (Hutchings, 2020).

A great leap forward came with the arrival of Covid-19. The pandemic triggered an unprecedented, rapid adoption of digital technology in the NHS to free up capacity in hospitals, enable remote working, and reduce face-to-face contacts and the risk of infection transmission (Hutchings, 2020).

Many nurses in the community have taken the lead in embedding and accelerating the use of digital technology. Tips on improving nurse engagement with digital technology are given in Box 2.

Help or hindrance?

Much of the leap forward in the use of technology in nursing has been driven by necessity, and the desire to avoid hospital admissions and prevent the NHS from being overwhelmed. The quality of care that patients are receiving via digital technologies is unclear, as is the impact on nurses who have risen to the challenge and transformed how they work.

Virtual wards do not provide 24-hour care, and there are some concerns that patients are not only receiving different nursing care, but less nursing care. Part of the promise of the digital revolution was to free up time for health professionals so they could spend more time on direct patient care. However, it is not clear that the shift to remote consultations has delivered this – indeed, for some staff, the reverse may be true (Hutchings, 2020).

Conclusion

Technology is changing how care is delivered and the Covid-19 pandemic has accelerated the adoption of systems that allow remote monitoring and facilitate patient self-management. However, nurses need to be at the heart of technological developments and implementation to make sure changes facilitate and enhance patient care, and deliver on promises to free up clinician time and improve patient safety.