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The 2017 Australian Digital Health Agency (ADHA) Strategy is based on the underlying assumption that digital technology in health care environments is ubiquitous. The ADHA Strategy views health professionals, especially nurses, as grappling with the complexity of installing and using digital technologies to facilitate personalized and sustainable person-centered care. Yet, ironically, the 2018 debate over how to enroll Australians into the national electronic health record system and its alteration from an opt-in to an opt-out model heightened public and professional concern over what constituted a “safe, seamless and secure” health information system. What can be termed a digital technology paradox has emerged where, although it is widely acknowledged that there are benefits from deploying and using digital technology in the workplace, the perception of risk renders it unavailable or inaccessible at point of care. The inability of nurses to legitimately access and use mobile technology is impeding the diffusion of digital technology in Australian health care environments and undermining the 2017 ADHA Strategy.
This study explored the nature and scope of usability of mobile technology at point of care, in order to understand how current governance structures impacted on access and use of digital technology from an organizational perspective.
Individual semistructured interviews were conducted with 6 representatives from professional nursing organizations. A total of 10 interview questions focused on factors that impacted the use of mobile technology for learning at point of care. Seven national organizations and 52 members from the Coalition of National Nursing and Midwifery Organisations were invited to participate. Interviews were recorded and transcribed verbatim. Data analysis was systematic and organized, consisting of trial coding; member checking was undertaken to ensure rigor. A codebook was developed to provide a framework for analysis to identify the themes latent in the transcribed data. Nurses as stakeholders emerged as a key theme.
Out of 6 participants, 4 female (67%) and 2 male (33%) senior members of the nursing profession were interviewed. Each interview lasted between 17 and 54 minutes, which reflected the knowledge of participants regarding the topic of interest and their availability. Two subthemes, coded as
Nurses are inadequately prepared for the digital future that has now arrived in health care environments. Nurses do not perceive that they are leaders in decision making regarding digital technology adoption, nor are they able to facilitate digital literacy or model digital professionalism.
The rapid evolution of health technology and informatics has significantly altered health care delivery and impacted the health care workforce in Australia and internationally [
Increasing awareness of the need for change is evident in a number of initiatives. The release of the Australian Digital Health Agency (ADHA) Strategy [
Other recent initiatives include the development of national nursing informatics competency standards to provide guidance to nurses about the expected level of understanding of computer and information literacy and management [
The release of the Nursing Informatics Position Statement [
Individual semistructured interviews were undertaken with 6 representatives from professional nursing organizations. Purposive sampling was used to recruit participants who were able to represent organizations from a policy or guideline perspective and who had expertise in nursing practice. Seven national organizations were identified and a further 52 members from the Coalition of National Nursing and Midwifery Organisations (CoNNMO), who had email addresses available on their website, were invited to participate. Follow-up emails 2 weeks after the initial invitation and a reminder email were sent 1 month after the first invitation. Those organizations that listed telephone details were also contacted via telephone. An information sheet was provided with the invitation to participate, and consent was recorded using Skype for Business prior to the beginning of each participant interview. Participants chose the venue and time for the interview. The University of Tasmania Social Sciences Human Research Ethics Committee granted approval (approval number: H0016097) prior to initiating this study.
A total of 10 interview questions were developed (see
Data analysis was a systematic and organized process consisting of trial coding; constant member checking was undertaken to ensure rigor. A codebook was developed to provide a framework of codes. Fidelity of application of labels across interviews to ensure consistency was undertaken during coding. Microsoft Excel 2016 was used to tabulate
Coding process.
Six interviews were conducted during the data collection period. Of the 6 participants, 4 were female (67%) and 2 were male (33%). All participants identified themselves as senior members of the nursing profession with extensive clinical, educational, research, or administrative experience in a range of health care environments (see
These nurses were paid employees or were associated with CoNNMO as volunteers within Australian nursing specialty professional bodies. Each interview lasted between 17 and 54 minutes. The length of each interview was related to each participant’s available time and knowledge regarding the topic of interest. Two subthemes coded as
Participant demographics.
Interview # | Gender | Source of recruitment | Nursing organization | Nurse role |
1 | Female | Direct email to organization | National representative (executive) | Administration |
2 | Male | Email from CoNNMOa secretariat | Specialty nursing executive position (volunteer organization) | University academic and clinician |
3 | Female | Direct email to organization | National representative (executive) | University academic |
4 | Female | Email from CoNNMO secretariat | Specialty nursing executive position (volunteer organization) | Clinician |
5 | Male | Email from CoNNMO secretariat | Specialty nursing executive position (volunteer organization) | Administration and clinician |
6 | Female | Direct email | National representative (executive) | Administration |
aCoNNMO: Coalition of National Nursing and Midwifery Organisations.
Participants provided examples of how nurses behaved in relation to accessing and using digital technology in the workplace. These nurses highlighted the risks, challenges, barriers, and benefits of accessing and using digital technology in health care service provision and for learning and teaching. Participants indicated that the capacity for digital technology adoption by nurses was affected by contributing factors related to actions linked to work-arounds, attentiveness, and experiences. Each is explained in detail below.
When listening to and coding their conversations, it became apparent that participants often perceived that they did not have a voice in decision making regarding access and use of digital technology. The lack of inclusion resulted in unintended consequences. Nurses developed work-arounds to accommodate perceived workflow issues [
I did a survey of about 10 [city] hospitals, [specialty] departments, and less than half the staff had Internet access and when you take out the senior staff in that survey, there was, you know, most of the staff, the direct care nurses didn't have Internet access. So, people are using their mobile phones for Internet access and to find evidence and to source, you know, information, which is just terrible.
Another participant stated that due to funding constraints, using a mobile device enabled improved efficiency of health care service delivery by facilitating access to information:
You know, they’re taking away massive amounts of funding and things are very privatized, so these facilities are kind of left to their own devices as far as how many RNs [registered nurses], if they have RNs at all now. So, I think that one way—and I don’t know how to combat that—but one way to ensure better patient care is by allowing staff to have that kind of information where they can look at a patient and put symptoms or use education that’s right there and then on their phones and that will probably lead to better patient care and identification of deterioration or issues. I think that’s an area that could be incredibly useful.
There were divergent views about accessing digital technology in relation to attentiveness. Participants provided examples of how mobile devices can be used in real time for improving efficiency of health care delivery. For example, one participant outlined a benefit of integrating digital technology into nursing practice:
But if you’re actually learning in real time as you’ve got an actual issue happening, it’s great. I think there’s also potential to use downtime better. I was going to say like everything that’s mobile, it just becomes integrated more into people’s lifestyle.
However, there was also the view that there needed to be a minimum standard of capability of nurses rather than relying on digital technology when there was the potential to negatively impact safe health care delivery:
...you know, you’re not going to be sitting there in the middle of a [cardiac] arrest going, “Okay, wow, the doctor’s just asked for adrenalin, hold on let me just quickly Google adrenalin and find out how fast I should push it and is the actual correct dose and, oh, what’s its indication, oh, what’s its mode of action?”
Another participant indicated that there were perceived risks associated with distraction when using mobile technology:
People will get enamored or caught up on what's going on in their phone and not be paying attention to what's going on with their patient.
Nurses provided examples of how digital technology could change behavior to enhance nursing practice and support learning by students while undertaking work-integrated learning:
Particularly, I worked in rural and remote-type areas so where you didn’t have someone else that you could ask for help, and just for the students I've found that if they can look something up then and there, that they learn it because it makes sense to them, that they need to know it.
Additionally, participants were aware that the digital revolution was imminent. They could foresee the benefits of enabling personalized learning that could contribute to supporting person-centered care. One participant stated the following:
I think it’s got huge potential for really looking at being able to adapt to different learning styles and being able to bring that, the ideal situation where you’ve got theory with experience at the same time, and you can look at what you’ve assessed and then put that into mobile learning technology and find out what you’ve missed or how that measured up against the theory on the information.
Participants acknowledged that the role of nurses included experiences that promoted engagement and improvement in health literacy, digital literacy, and health education of consumers. One participant indicated the following:
I think too that a lot more consumers are going to the Internet for information these days; to be able to show them what is a useful site or is a safe site for them to go to so they're not getting false information about things would be quite useful as well. So, I think there's significant benefits there.
The second subtheme that emerged was
Nurses raised the issue of balancing person-centered health care delivery, learning, and integrating digital technology within nursing practice. One participant stated the following:
I think there's an issue on duty in that the staff will say they've got enough to do without having to sit down at the computer...if they are allocated time in their workday to do it, well then that's probably okay. But if they're just expected to fit it on around everything else, I'm not sure how much focus they'll give it.
However, participants also acknowledged there was a range of attitudes about nurses using digital technology in health care environments. An example quotation about nurses being viewed negatively by other stakeholders is shown below:
...all the nurses seem to do is pay attention to the computer even where they've got electronic health records and order entry systems and all that they have now. And you do hear at times members of the community see that the nurses are tied more to the computers than they are tied to the people.
In stark contrast, a participant whose attitude was positive regarding implementation of digital technology into nursing practice stated the following:
We're just burying our head in the sand saying, you know, let's just say no phones, well that's not happening. Anyway, it's actually detrimental because it's a really useful tool, these mobile devices, for our staff. We can just train people better in how to use their phone.
Implementation of digital technology will require support at systems and organizational levels before stakeholders will be influenced to adopt it to advance nursing practice. One participant indicated the following:
So, I think there’s a lot going on but there’s not—as far as I’m aware—there’s not a really big push from the government to use technology, or funding from the government to use technology well. And there’s lots of, I guess, private and smaller initiatives taking off, but I think the drive has to be from the health district as well, but there has to be government funding and incentives to be implementing technology and, particularly, mobile technology.
At an individual level, one participant indicated that nurses have the capacity to change their views when exposed to the benefits of using digital technology. However, others are also influenced, which impacts on nurses’ capacity to use digital technology within their workplace. The following quotation illustrates this view:
I've certainly had clinical facilitators in the past make comments that, you know, it has been changing and that they'd seen students with mobile technology and gone to them with the idea of criticizing them for using it and then discovered that they were using it for very relevant purposes. And their attitudes were changing due to that type of thing, so I'd been supportive of that type of learning and the success they were having. But now it's very different, we’ve got an edict from above and we're not allowed to do it [use digital technology].
Findings from this research indicate that nurses within the profession’s organizations do not perceive that they are leaders in decision making regarding digital technology. Participants believed that nurses’ access to, and use of, the Internet within health care environments is decided by others. This perception shapes their ways of acting and thinking, which impacts on their capacity to advocate for being included as stakeholders regarding health technology and health informatics at systems, organizational, and individual levels.
Participants realize that there is a mobile learning paradox where, although it is acknowledged that there are benefits to using digital technology, they are unable to access it [
When undergraduate nurses are educationally prepared to use health technology and health informatics, and to undertake work-integrated learning, they will be better able to challenge the status quo arrangements that marginalize them and to request inclusion in accessing and using digital technology. For example, registered nurses are permitted password access, whereas in the future, supervising nurses and undergraduate students conversant with policy and guideline documents [
This research supports the need for a digital health strategy as proposed by the ADHA [
Fixsen and colleagues [
Stages of implementation (modified from Fixsen et al, 2005).
Limitations of this study include the timing of the interview period, which spanned the traditional end-of-year Christmas and summer holiday period; this may have contributed to the low participation rate. Interviews ceased with the publication of the Nursing Informatics Position Statement [
A larger international comparative study could be undertaken to replicate this research. Findings may determine whether registered nurses in other countries experience similar perceptions or whether the Australian context is unique.
There is still much work to be undertaken to engage all stakeholders, including nurses, in embracing the digital future in health care. This research demonstrates that nurses from professional organizations understand their health workforce but lack the agency to demand inclusion in decision making that impacts nurses at organizational and individual levels. To enable implementation of health technology and informatics in health care environments more effectively, it is crucial for nurses to become stakeholders at every level. Doing so will not only mitigate the risk of implementation failure, but engagement of nurses as frontline health professionals will assist the Australian Government in achieving its goal of a “safe, seamless and secure” digital health system for all.
Nursing profession organization interview schedule.
Australian Digital Health Agency
Australian Nursing and Midwifery Accreditation Council
Coalition of National Nursing and Midwifery Organisations
continuing professional development
registered nurse
We would like to acknowledge the representatives from the nursing profession organizations who agreed to be interviewed and contribute to this research.
CM was involved in all aspects of this research, including study design, the ethics application, recruitment, data collection, analysis, preparation, and review of the manuscript. EC was involved with study design, ethics, analysis, and review and editing of the manuscript. FG was involved with analysis and with review and editing of the manuscript.
None declared.