Generally, nurses should use technologies provided by their hospitals for work. Although technologies were limited in most hospitals where the focus groups were conducted, participants shared that their hospital provided a few technologies that they could use to facilitate communication with colleagues. However, such technologies were deemed unreliable and inferior compared with the smartphones that nurses possess. Therefore, nurse administrators were inclined to allow their nurses to use their personal smartphones for work purposes.

Every private and government hospital had landline telephones considering that it is one of the most fundamental communication technologies one would have. However, most participants reported that although their hospitals provide landline telephones, staff nurses cannot use them to call mobile phones because these are limited to communication with other landline telephones within the hospitals. As a result, most of the participants allowed nurses to use their smartphones to communicate with members of the health care team:

Hospital 8 was an exception because participants shared that their staff nurses could make mobile phone calls by using hospital landline telephones that connected them to mobile phones through the operator. This is generally useful, but a participant from Hospital 8 noted that when operators were unavailable, nurse administrators would allow their nurses to use smartphones to contact doctors:

Participants from Hospital 3 and Hospital 5 described their intercom system as a local two-way communication system in which a microphone and a loudspeaker were installed in every nursing area. Although this was deployed to help facilitate communication among health care staff within the hospital, some of them noted several problems when using the intercom system that consequently reduced its usefulness. For instance, one participant noted that “it is difficult to use” the intercom system (H3P3, Nurse Manager), and another shared that “sometimes it is busy” (H3P1, Nurse Manager). Conversely, a participant stated that such technology “is actually good” but lamented that it was also an inefficient form of communication technology as it is an indirect means of communication:

Consequently, the problems experienced by the participants with their intercom system served as a cue for them to allow staff nurses to use their smartphones for work purposes. For instance, one participant stated that they could “directly call the doctors for a referral” using their staff nurses’ smartphone and they “need not bother to press anything on our intercom” (H3P3, Nurse Manager). Similarly, when the intercom system was busy, one participant was relatively fine when her nurses “made calls or texted” (H3P1, Nurse Manager) using their smartphones just to contact their patients’ doctors. Conversely, one participant explained that communication via mobile phones is faster than an intercom system, to the extent that they requested their management to provide them with a unit phone:

Participants described the desktop-based text messaging software as a software that allowed nurses to send and receive text messages to and from mobile phones regardless of the service provider. In most situations, staff nurses used them to send patient referrals to doctors. In Hospital 1, participants mentioned that their hospital installed Maxxtext in each desktop computer. Similarly, Hospital 17 also has a similar software called Infotext.

Despite being an alternative to mobile phones for sending text messages, a major problem with this technology is the difficulty in receiving replies. For instance, one participant shared that her staff nurses in the intensive care unit used Infotext, but they were bothered because “the problem with Infotext is we cannot immediately receive the reply” (H17P5, Head Nurse). She also noted that doctors were familiar with this problem, and “it is not guaranteed that they will reply [in the Infotext]” considering that there was a “feedback problem” (H17P5, Head Nurse).

The feedback problem associated with this technology was a strong concern because a patient’s life in the intensive care unit depends on the speed of coordination among the health care team. Considering this problem, one participant shared that instead of using Infotext, she allowed her staff nurses to use their smartphones when making referrals to doctors, especially during emergencies:

Participants in Hospital 1 also noted the feedback problem with Maxxtext and why it became unpopular among staff nurses and doctors. According to one participant, Maxxtext was quite useful until it had the same feedback problem, and this led to the termination of the software and the deployment of mobile phones in their hospital:

During the focus groups, most participants were highly vocal about unit phone problems, which suggested their importance and relevance. This is understandable as most of the participants came from hospitals where unit phones were mostly not provided to staff nurses. In situations where unit phones were not provided, they were insufficient, or credits were lacking, nurse administrators were inclined to allow their nurses to use their smartphones for work purposes.

Focus groups with the participants revealed that all government hospitals (ie, Hospital 3, Hospital 14, and Hospital 16) did not provide unit phones, and a few private hospitals provided them (eg, Hospital 1 and Hospital 13). Considering that most of the hospitals did not provide mobile phones to their nurses, participants from those hospitals shared that the smartphones of their staff nurses were very useful, and they allowed their use for work purposes. For instance, one participant shared that she allowed her nurses to use their smartphones “to do research on the case of the patient” because she believed that it is “the fastest way for them to look for information regarding the case of the patient that they are handling” (H5P1, Nurse Manager). Similarly, another participant shared that her area was not provided with a unit phone; as a result, she allowed her nurses to use their smartphones considering their usefulness for communication purposes:

Apart from the usefulness of smartphones, some participants also shared that smartphones contributed to improving the quality of care rendered to patients. This occurred when smartphones helped nurses to immediately cater to their patients’ needs. As a result, the absence of a unit phone served as a cue for the participants to support their staff nurses’ use of smartphones for work purposes. For example, one participant stated that “the patient benefits from it because they [staff nurses] can facilitate immediate interventions to the patient” (H14P2, Infection Control Nurse). Moreover, one participant shared that although mobile phones can be “a double-edged sword,” he argued that:

Nurses would need to find ways to provide the best possible service to their patients despite resource constraints. This meant even using their smartphones just to accomplish their task. According to some participants, their staff nurses’ use of smartphones for work purposes is a manifestation of their capability to adapt in a situation where such technology is not provided by their hospitals. For one participant, the absence of a unit phone made him decide to allow its use because it is a way for staff nurses “to gather technical or clinical information outside of our norm or usual routine” (H5P4, Head Nurse). Moreover, another participant explained how nurses adapt to perform their work in the absence of unit phones:

Although most participants supported their staff nurses’ use of smartphones for work purposes because of the absence of unit phones in their workplace, a few of them recognized that, in the long term, hospitals should provide unit phones so that nurses would not use their smartphones. This sentiment is best described by a participant from Hospital 5 as he believed that his nurses need a unit phone and having it would result in an outcome where “the personal phone [of the nurses] can be kept away and the unit phone is the one outside to be used” (H5P3, Head Nurse). More importantly, another participant expressed that providing her staff nurses with unit phones would be “for the good of the patient” (H16P1, Head Nurse). She added:

Interestingly, the participants also provided details on what mobile phone should hospitals provide to as a unit phone. However, participants were divided on whether a smartphone or a feature phone (nontouchscreen) should be provided. For some participants, providing a feature phone was ideal because it is more durable than a smartphone, and it is not susceptible to theft considering its low value. For instance, one participant shared that her area in the operating room needs “just a keypad cellphone. Like this [points to a feature phone]. It would not get easily destroyed or lost” (H10P1, Nurse Manager). In addition, feature phones could cover most of the staff nurses’ needs because they only frequently used their smartphones to make calls and send text messages to colleagues:

More importantly, feature phones are less likely to be used for nonwork purposes. According to one participant, she preferred a feature phone because this cannot be used to access social media or play mobile games:

On the contrary, some participants indicated a preference to have a smartphone as their unit phone because they intended to use it for documentation purposes. For these participants, being able to take pictures as a means of documentation can reduce their workload and provide visual evidence of certain conditions or events that need to be shown to colleagues as evidence. For instance, one participant shared that “we prefer a touchscreen [smartphone unit phone] because we have referrals that involve pictures and we send them” (H17P5, Head Nurse). Moreover, a participant shared the importance of having a smartphone for documentation in the emergency room:

Among the focus group sites, only 2 private hospitals (ie, Hospital 1 and Hospital 13) provided most of their staff nurses with a unit phone. These phones were all feature phones that were limited to making voice calls and text messages. However, despite the presence of unit phones in these hospitals, some participants shared that there were occasions on which their staff nurses needed to use their smartphones because not all of them can use the unit phone at the same time. For example, one participant shared that she has more than 17 staff nurses in the telemetry unit, and “nurses could not use the unit phone at the same time. That’s why they use their personal phone” (H1P1, Head Nurse). Likewise, another participant argued that staff nurses’ smartphones are much more accessible to use than the hospital’s unit phones:

Considering that Hospital 13, a private hospital, also had problems with insufficient unit phones in their hospital, one participant suggested that 3 staff nurses can share a unit phone:

Likewise, when asked how many unit phones might be sufficient for staff nurses in government hospitals, one participant indicated the “three nurses per one unit phone” ratio when she stated that:

Although Hospital 1 and Hospital 13 provided unit phones as a strategy to reduce staff nurses’ reliance on their own smartphones, participants from these hospitals noted that their hospitals do not necessarily provide them with sufficient credits to use the unit phone. In most cases, unit phones were under prepaid subscription, and credits should be added if consumed completely. Without any credits, unit phones become useless to contact colleagues. As a contingency, participants from Hospital 1 and Hospital 13 allowed their staff nurses to use their own smartphones when their unit phones ran out of credits:

Similarly, another participant shared that as they are working in the emergency department, they need an immediate response from doctors. Unfortunately, their unit phone “does not always have a load [credits]. It is seldom that it has a load. So, we use our own cellphone” (H1P3, Head Nurse).

Some participants who had unit phones also noted that their hospitals only provided credits through prepaid cards every start of the month, and all of them expressed that this arrangement is not feasible because they can easily consume the credits within a couple of weeks. In most situations, some participants used their own money to purchase credits for the unit phone:

An important reason on why credits are consumed quickly is that they often called a member of the health care team (mostly doctors) who had a different service provider. According to one participant, “It is expensive if you are subscribed in Globe to call someone who is subscribed to Smart” (H1P2, Head Nurse). In the Philippines, service providers charge more when users make voice calls to other service providers. For example, Globe Telecom [52] and Smart Communications [53] charge PHP 6.50 (about US $0.13) per minute for calling those with the same service provider and PHP 7.50 per minute (about US $0.15) to others. To avoid potential costs, some participants would ask who among their staff nurses has a smartphone with the same service provider as the one used by the intended recipient of the message or voice call. For example, one participant shared that they “use the cellphone provided by the management but sometimes we use our own cellphone because the line [service provider] is different” (H13P2, Head Nurse).

All 9 hospitals had policies on the use of mobile devices, which were written in hospital memos. Accordingly, hospitals can be divided based on the level of restriction placed on mobile devices. The first group is composed of 4 hospitals (ie, Hospital 5, Hospital 10, Hospital 13, and Hospital 17) that implemented a ban on the use of any mobile devices (whether for work or nonwork purposes) during working hours. It is interesting to note that all these hospitals were private institutions, and only Hospital 13 provided most of their nurses with unit phones. Conversely, the second group comprised 5 hospitals (ie, Hospital 1, Hospital 3, Hospital 8, Hospital 14, and Hospital 16) where the use of smartphones is banned for nonwork purposes but is allowed for work purposes.

Although Hospital 5, Hospital 10, Hospital 13, and Hospital 17 placed a ban on the use of any mobile devices, participants from these hospitals stated that they make an exemption by allowing staff nurses to use their smartphones for work purposes. This could be attributed to the fact that such policy was unrealistic considering that their hospitals did not provide staff nurses with relevant work-related technologies, such as mobile phones. According to one participant, although their hospital banned the use of any mobile devices, she shared that “you cannot avoid not to use it [smartphones] because it is a big help for nurses in terms of communication, especially when the doctors are not here” (H13P1, Head Nurse). Similarly, another participant shared that “we allow [the use of smartphones] if [it is] related to work, but it is not allowed if you would just use Instagram” (H17P5, Head Nurse).

For most participants, a blanket ban on smartphone use is difficult to implement as these devices were useful and necessary at work. One participant argued that “it is not absolute that we cannot use our phone” considering that “there is a need for us to use the phone [for work purposes]” (H5P3, Head Nurse). Moreover, another participant shared that a blanket ban on smartphones “is not realistic even there is a memo because it is difficult to enforce it” (H17P2, Nurse Supervisor). In Hospital 10, although they strictly implemented a ban on using mobile devices at work (this hospital has one of the lowest mean scores for perceived organizational support), a participant from that hospital argued that:

Overall, there was a consensus among participants that the only time that they can implement a blanket ban on the use of mobile devices is when hospitals can provide sufficient technologies for staff nurses. An indication for this is when staff nurses need not use their smartphones completely for work purposes:

On the contrary, 5 hospitals (ie, Hospitals 1, Hospital 3, Hospital 8, Hospital 14, and Hospital 16) had memos where the use of smartphones is banned for nonwork purposes but is allowed for work purposes. Of these hospitals, 2 are private (Hospital 1 and Hospital 8) and 3 are government hospitals (Hospital 3, Hospital 14, and Hospital 16).

Interestingly, although private hospitals such as Hospital 1 and Hospital 8 provided most of their nurses with unit phones, participants noted that their hospital still allowed staff nurses to use their smartphones for work purposes. Even though the participants described that their memos do not provide a definite list on how it should be used for work purposes, nurses could use their smartphones when there is an urgent need to communicate with colleagues (eg, sending text messages or making calls to colleagues). For example, one participant noted that their hospital issued a Doctor’s Notification Protocol (H8P1, Head Nurse) as a basis for them to use their smartphones for work purposes. A colleague of that participant clarified that this protocol allowed nurses to use their smartphones to “inform doctors thru text [messages]” as the hospital had revised the old protocol “by including SMS messaging” as part of the protocol (H8P3, Head Nurse).

In Hospital 1, although unit phones were provided, a participant expressed that their staff nurses can still use their smartphones “if there are important calls or emergencies” related to work (H1P4, Nurse Supervisor). Furthermore, another participant from Hospital 1 shared a policy that allows them to use their smartphones aside from unit phones in the emergency room:

Considering that government hospitals lack adequate technologies for nurses to use, participants from Hospital 3, Hospital 14, and Hospital 16 noted that their hospital allowed the use of smartphones for work purposes and only prohibits their use for nonwork purposes. Although some participants noted that this is not an ideal policy and is the result of their hospitals’ lack of health information technologies, they noted that it is a policy that enables health care staff to properly perform their duty despite resource constraints:

Although the participants allowed staff nurses to use their smartphones for work purposes, they were equally concerned that some were abusing such considerations by secretly using their smartphones for nonwork purposes. This eventually led them to inhibit support to staff nurses’ use of smartphones for work purposes.

When participants discussed details on staff nurses’ use of smartphones for nonwork purposes, most of them showed a facial expression akin to frustration. This is expected because participants mostly shared statements that reflected frustration when discussing this issue. For instance, one participant shared her frustration over the non–work-related use of smartphones by staff nurses:

Apart from feelings of frustration, some participants felt that such behavior did not look like what a staff nurse ought to be doing during the performance of his or her duty. As mentioned by one of the participants, although it is fine for staff nurses to use smartphones for work purposes, its use for nonwork purposes “does not look professional” (H14P1, Nurse Supervisor).

Staff nurses’ use of smartphones for nonwork purposes can lead to negative outcomes. Some participants shared that there were times that they did not want their nurses to use their smartphones because they become distracted. This sentiment is described by one participant:

Another outcome that participants were concerned regarding the use of smartphones for nonwork purposes is reduced work productivity. This concern was reasonable because all of them believed that smartphone use for nonwork purposes is highly distracting and can result in productivity loss:

For some participants, its use for nonwork purposes also reduced the quality of care because smartphones take away the attention that should have been given to patients. One culprit for this is the use of social media during working hours:

Participants noted that they enforced disciplinary actions when they caught staff nurses using their smartphones for nonwork purposes. For most of the participants, the first thing that they did was to give verbal reminders that included some counseling. For instance, one participant shared that “if I caught them playing games, I remind them that we have a memo that using cellphone is not allowed in the operating theatre” (H10P1, Nurse Manager). Similarly, another participant mentioned that she usually calls the attention of her nurses and reminds them that they “have a policy that cellphones are not allowed during their tour of duty” (H17P2, Nurse Supervisor).

Consequently, some participants shared that they implemented preventive measures, such as asking nurses to place their smartphones inside lockers or cabinets. By asking the nurses to put it inside lockers prevented them from placing it in their pockets, which then reduced the tendency for it to be used for nonwork purposes. For instance, one participant mentioned that “their phone should not be even in their pockets. It should be in the locker” (H1P1, Head Nurse). In situations that there is a need for nurses to use their smartphones, they can get it from their locker:

To some extent, some participants shared that their hospital ordered nurse administrators to implement harsh disciplinary actions. Accordingly, if verbal reminders were not enough for repeat violators, nurse administrators could confiscate the smartphone as the next step:

Aside from confiscation, participants in Hospital 10 asked violators to pay a fine when caught using smartphones for nonwork purposes. As mentioned by a participant from Hospital 10, “We have a fine of 100 pesos [about USD 2] then we confiscate the cellphone. They can get that after duty” (H10P1, Nurse Manager). Nonetheless, the hospital also made a record of such violations by asking staff nurses to file an incident report. For instance, another participant from Hospital 10 shared that “in our area, there is [a need to file] an incident report” (H10P2, Head Nurse). These findings somewhat indicate why Hospital 10 had one of the lowest perceived organizational support scores among all hospitals. Finally, there were instances that staff nurses were suspended from work as they were caught using smartphones for nonwork purposes:

Most of the participants shared that they cautioned staff nurses when using smartphones in front of patients as there is a tendency for patients to interpret that staff nurses use their smartphones for nonwork purposes. This issue was expressed mostly by participants from private hospitals because they cater to pay patients. Accordingly, pay patients tend to expect a higher standard of service than patients admitted in government hospitals where most are subsidized. This means that patients in private hospitals are relatively observant on how staff nurses conduct their work. For instance, a participant from Hospital 17 (a private hospital) shared that:

On the contrary, patients who are sick or in pain are generally sensitive, and they may easily complain when they feel neglected, especially when staff nurses use their smartphones, regardless of whether it is for work or nonwork purposes. For example, one participant shared that her patients in the delivery room “are in labor...in pain, so they are really sensitive,” as a result, “if they see that you are holding your cellphone and you did not immediately address their need, these result in complaints” (H5P5, Nurse Manager).

Although it is difficult for the participants to oblige their staff nurses not to use their smartphones considering how necessary it is in their work, they advised them to use it discreetly and outside the view of patients. The aim of this advice is to ensure that patients do not feel neglected when staff nurses use their smartphones even it is for work purposes. For instance, one participant advised her staff nurses to use their smartphones “not in front of the patient” and should there be a need to use it, “they should hide so that the patient would not see them” (H14P3, Nurse Supervisor). In addition, another participant shared a vivid explanation of some considerations when staff nurses use their smartphones for work purposes: